Opioid, Benzodiazepine and Alcohol Withdrawal — Written Clinical Reasoning

SAQ 1 — Inpatient alcohol withdrawal (12 marks)

Prompt: A 52-year-old man who drinks about 30 units of alcohol a day is admitted with community-acquired pneumonia. He is thin and had a withdrawal seizure during a previous assisted withdrawal programme. Twelve hours after admission he is tremulous and sweating. Outline your management of his withdrawal and the plan at discharge. ^[1]

Model Answer

Setting and assessment (3 marks):

• NICE advises admission for medically assisted withdrawal for people with, or at high risk of, withdrawal seizures or delirium tremens. ^[1]
• NICE CG115 lists withdrawal-related seizures during previous assisted withdrawal programmes, and drinking over 30 units a day, among the criteria for considering inpatient withdrawal. ^[2]
• He should be assessed immediately by a professional skilled in managing alcohol withdrawal, with a tool such as the CIWA-Ar as an adjunct to clinical judgement. ^[1]

Drug treatment (3 marks):

• In hospital NICE advises a symptom-triggered regimen, using a benzodiazepine or carbamazepine. ^[1]
• If he has a seizure, consider a quick-acting benzodiazepine such as lorazepam. Do not offer phenytoin. ^[1]
• If delirium tremens develops, oral lorazepam is first-line, then parenteral lorazepam or haloperidol if symptoms persist or oral medication is declined. ^[1]

Thiamine (3 marks):

• He is admitted with an acute illness and is at risk of malnourishment, so NICE advises prophylactic parenteral thiamine followed by oral thiamine. ^[1]
• If Wernicke's encephalopathy is suspected, give parenteral thiamine for a minimum of 5 days unless it is excluded. ^[1]

Relapse prevention (3 marks):

• After successful withdrawal, consider acamprosate or oral naltrexone with an individual psychological intervention. ^[2]
• Acamprosate is 666 mg three times daily, reduced to 333 mg three times daily when creatinine clearance is 30 to 50 mL/min, and contraindicated at 30 mL/min or less. ^[6]
• In a 2023 meta-analysis, the number needed to treat to prevent one return to any drinking was 11 for acamprosate and 18 for oral naltrexone 50 mg/day. ^[5]