Can Lithium Be Prescribed to a Patient with Alcohol Use and Impulsivity?
Yes, lithium can be prescribed to this patient, but it requires extremely careful supervision, close monitoring, and addressing the alcohol use disorder first is strongly preferred. The combination of alcohol use and impulsivity creates significant safety concerns that must be managed proactively.
Critical Safety Considerations
Contraindications and Warnings
The FDA label does not list alcohol use or impulsivity as absolute contraindications to lithium 1. However, lithium must be used with great care if there is a history of drug abuse, and is contraindicated in patients with a history of illicit use or abuse of stimulants unless the patient is being treated in a controlled setting or can be supervised closely 2.
The primary concern is toxicity risk. Lithium has a narrow therapeutic index, and alcohol use can complicate this in several ways:
- Alcohol-related dehydration and electrolyte disturbances significantly increase lithium toxicity risk 1
- Impulsivity raises the risk of intentional or unintentional overdose, which can be lethal 2
- Alcohol use disorder often involves poor medication adherence, making therapeutic monitoring difficult 2
Addressing Alcohol Use First
Before initiating lithium, the patient's alcohol use disorder should be actively managed 2. The WHO guidelines recommend:
- Screening for hazardous and harmful alcohol use using validated instruments (AUDIT) 2
- Patients with alcohol dependence should receive supported withdrawal with benzodiazepines as front-line medication 2
- Psychosocial support should be routinely offered, with consideration of medications like acamprosate, disulfiram, or naltrexone to prevent relapse 2
Importantly, lithium itself is not effective for treating alcohol use disorder. Multiple controlled studies have failed to demonstrate that lithium decreases alcohol intake, craving, or depressive symptoms in alcoholics 3.
When Lithium May Still Be Appropriate
Psychiatric Indication Must Be Compelling
If the psychiatric indication is life-threatening (such as severe bipolar disorder with suicidality), lithium treatment may be undertaken with extreme caution 1. The evidence supports lithium's unique benefits:
- Lithium is a first-line treatment for bipolar disorder with Level I evidence for efficacy in acute mania, maintenance treatment, and as an adjunctive antidepressant 4
- Lithium has demonstrated efficacy in decreasing suicide attempts and suicides, likely through effects on impulsivity and aggression 5, 6
- Lithium may specifically reduce impulsivity through its effects on GSK3β inhibition and regulation of serotonergic and dopaminergic systems 6
Required Safety Measures
If you proceed with lithium in this patient, the following are mandatory 1:
- Daily serum lithium determinations initially and frequent monitoring thereafter 1
- Hospitalization is a necessity if the patient has significant risk factors 1
- Adjustment to usually low doses ordinarily tolerated by at-risk individuals 1
- Third-person supervision of medication administration to prevent overdose 2
- Ensure the patient maintains normal diet including salt and adequate fluid intake (2500-3000 mL daily) 1
Baseline and Ongoing Monitoring
Before starting lithium 7:
- Complete blood count, thyroid function tests, renal function tests, serum calcium, and urinalysis 7
- Assess for cardiovascular disease, renal disease, or dehydration 1
During treatment 7:
- Renal function tests, thyroid function tests, and urinalysis every 3-6 months 7
- Serum calcium annually 7
- Watch for early signs of toxicity: tremor, nausea, diarrhea, polyuria-polydipsia 7
Practical Algorithm for Decision-Making
Assess severity of psychiatric condition: Is this life-threatening bipolar disorder or severe mood instability with suicidality? If yes, proceed to step 2. If no, consider alternative mood stabilizers 1, 4.
Evaluate alcohol use severity: Use AUDIT screening 2. If severe alcohol dependence, initiate alcohol withdrawal management and stabilization first 2.
Assess supervision capacity: Can the patient be hospitalized or have daily third-party medication supervision? If no, lithium is too dangerous 2, 1.
Address impulsivity risks: Ensure firearms and large quantities of medications are removed from the home 2. Consider that lithium itself may help reduce impulsivity over time 5, 6.
If proceeding: Start with low doses, obtain daily lithium levels initially, and maintain intensive monitoring 1.
Common Pitfalls to Avoid
- Do not assume lithium will help the alcohol problem - it won't 3
- Do not prescribe lithium for outpatient use without ensuring third-party supervision in a patient with impulsivity and substance use 2, 1
- Do not forget that alcohol-related dehydration dramatically increases toxicity risk 1
- Do not overlook the need for concurrent alcohol use disorder treatment 2