Anti-craving pharmacotherapy — structured clinical viva

Immediate safety. Stop naltrexone while opioids (codeine) continue — risk of precipitated withdrawal and blocked analgesia. Assess for withdrawal symptoms and pain plan with non-opioid strategies / specialist pain input. Mouthwash alcohol exposure is a red flag for impulsive testing; explore readiness and risk, not shame.^[1][5]

Agent gates.

• Naltrexone: restart only after confirmed opioid-free interval, consent, medical alert, and LFT-informed caution (elevated enzymes require clinical liver assessment — not automatic forever ban, but not casual start in active hepatitis/failure).^[1][5]
• Acamprosate: eGFR 42 suggests dose reduction or avoidance per product guidance — do not add full 666 mg TDS blindly.^[1][3]
• Disulfiram: do not stack 'for cover'; requires separate consent, supervision, alcohol education; impulsive mouthwash testing is a relative warning against aversive therapy until stability improves.^[1][4]

COMBINE pearl. Naltrexone and medical management helped; acamprosate null in that design — combination is not automatic 'antibiotic cover'.^[2]

Revised plan. Stabilise opioids/pain; psychosocial package (CBT/MET); choose one suitable agent after gates clear; early review; dual diagnosis and suicide risk screen.^[1][6]