Question 1

A 52-year-old man with a history of daily heavy alcohol use (a pint of whiskey daily for 15 years) is admitted for elective surgery. On postoperative day 2, he develops tremor, diaphoresis, tachycardia to 110, and anxiety. His CIWA-Ar score is 22. He has a history of one prior withdrawal seizure three years ago. What is the most appropriate management?

Accepted Answer

A CIWA-Ar score of 22 indicates severe withdrawal requiring benzodiazepine treatment. The prior seizure history is a critical risk factor — the kindling phenomenon means each subsequent withdrawal episode tends to be more severe, and this patient is at high risk for seizures and progression to delirium tremens. Symptom-triggered benzodiazepine dosing guided by serial CIWA-Ar monitoring is the standard protocol. Phenytoin is not effective for alcohol withdrawal seizures — benzodiazepines are the treatment of choice. Thiamine should be given parenterally. This patient needs a monitored bed. The most common setting where withdrawal is missed is the postoperative patient whose home drinking history was never obtained on admission.

Question 2

A 38-year-old woman presents with depressed mood, insomnia, anhedonia, poor concentration, and passive suicidal ideation. She reports drinking 6-8 drinks nightly for the past two years. She says she drinks because she's depressed. Her husband says the heavy drinking started first and the depression followed about six months later. She has no psychiatric history prior to the onset of heavy drinking. What is the most appropriate diagnostic approach?

Accepted Answer

The collateral history suggesting drinking preceded depression, combined with no prior psychiatric history, raises high suspicion for alcohol-induced depressive disorder. However, you cannot definitively make this distinction during active use. The pragmatic approach is to treat both conditions concurrently — address safety given the suicidal ideation, initiate AUD treatment, and then reassess the mood picture after a period of sustained abstinence. Depressive symptoms that remit within 2-4 weeks of sobriety were likely alcohol-induced. Symptoms that persist suggest independent MDD requiring antidepressant treatment. Withholding all depression treatment while the patient is actively suicidal is dangerous; siloing the conditions to separate providers fragments care.

Question 3

A 45-year-old man with severe AUD has completed inpatient detoxification and is now 10 days sober. He is motivated to maintain abstinence. His medical history includes compensated alcoholic cirrhosis (Child-Pugh class B). He reports strong cravings and is requesting medication to help prevent relapse. What is the most appropriate pharmacotherapy?

Accepted Answer

This patient has two features that point toward acamprosate: (1) he has achieved initial abstinence and wants to maintain it, which is where acamprosate has its best evidence, and (2) he has significant liver disease (Child-Pugh B cirrhosis), which makes naltrexone relatively contraindicated due to hepatotoxicity risk. Acamprosate is renally eliminated and safe in hepatic impairment — this is exactly the clinical scenario it was designed for. Disulfiram is also hepatotoxic and a poor choice in cirrhosis. Naltrexone would be a reasonable first-line agent in a patient without liver disease, but hepatic impairment shifts the risk-benefit calculation toward acamprosate. Delaying pharmacotherapy serves no purpose and leaves the patient unprotected during the highest-risk period for relapse.

Alcohol Use Disorder

Red Flags & Key Clinical Considerations

Wernicke's Encephalopathy

Withdrawal Seizures

Delirium Tremens

Suicidality During Intoxication and Withdrawal

Related Medications

Practice With Related Cases

References & Further Reading