Addiction Medicine · Supplementary · from Addiction Medicine

Case 2: Alcohol Use Disorder with Withdrawal Management

Patient Presentation

Demographics: 48-year-old male divorced accountant

Chief Complaint: "I had a seizure at home and my roommate called 911"

History of Present Illness: This 48-year-old male is brought to the emergency department by EMS after a witnessed generalized tonic-clonic seizure at his apartment. His roommate reports the seizure lasted approximately 2 minutes and was followed by a 5-minute postictal period. There was no tongue biting, urinary incontinence, or head trauma. The patient regained full consciousness en route to the hospital.

His roommate reports the patient has been drinking heavily for the past 3 months following a job loss. He estimates the patient has been consuming approximately one fifth of vodka (750 mL, approximately 17 standard drinks) daily. The patient's last drink was approximately 18 hours ago when he ran out of vodka and was unable to obtain more due to financial constraints.

The patient has a 20-year history of heavy alcohol use with two prior hospitalizations for alcohol withdrawal: the first was 5 years ago (treated with benzodiazepines, no seizure, no delirium) and the second was 2 years ago (complicated by withdrawal seizure). He has never completed a formal alcohol treatment program and has not tried any medications for alcohol use disorder. He has had several unsuccessful attempts at self-directed quitting.

He reports his drinking escalated significantly after his divorce 3 years ago and again after losing his accounting position 3 months ago. He acknowledges drinking has caused his divorce, job loss, a DUI conviction, and estrangement from his two teenage children.

Past Medical History:

• Alcohol use disorder, severe (20-year history)
• Two prior alcohol withdrawal hospitalizations (one with withdrawal seizure)
• Hypertension
• Alcoholic fatty liver disease
• Gastritis
• Peripheral neuropathy (alcohol-related)
• DUI conviction (1 year ago)
• Depression
• No prior seizure disorder

Medications:

• Lisinopril 20 mg daily (has not taken in 2 weeks)
• Pantoprazole 40 mg daily (has not taken in 2 weeks)
• No psychiatric medications

Social History:

• Divorced 3 years ago
• Two teenage children (limited contact)
• Former senior accountant (lost job 3 months ago)
• Lives with a roommate in a rented apartment
• Currently unemployed, running out of savings
• Drinking one fifth of vodka daily (~17 standard drinks/day) for past 3 months
• 10-pack-year smoking history (1/2 pack per day, current smoker)
• No illicit drug use
• No prior completion of addiction treatment
• DUI 1 year ago (license restricted)

Family History:

• Father with alcohol use disorder (died of alcoholic cirrhosis at age 58)
• Mother with depression and anxiety
• Brother with alcohol use disorder (in recovery)
• Paternal grandfather died of alcohol-related causes

Physical Examination

• Vital Signs: BP 168/102 mmHg, HR 118 bpm, RR 22/min, Temp 38.0°C (100.4°F), SpO2 97% on room air, BMI 26.4
• General: Diaphoretic, tremulous, anxious-appearing male. Alert and oriented x3. Agitated, pacing in the room
• HEENT: Injected sclera. Moist mucous membranes. No tongue laceration. Mild facial flushing
• Cardiac: Tachycardic, regular rhythm, no murmurs
• Lungs: Clear to auscultation bilaterally. Tachypneic
• Abdomen: Soft, mild epigastric tenderness. Liver edge palpable 2 cm below right costal margin (smooth, non-tender). No ascites. No splenomegaly
• Neurologic: Alert, oriented x3. Bilateral hand tremor (coarse, large-amplitude, worse with intention). Hyperreflexia (3+ patellar and Achilles bilaterally). No clonus. Decreased vibration sense in bilateral feet (stocking distribution). No focal motor weakness. No nystagmus at this time
• Skin: Diaphoretic. No spider angiomata. No palmar erythema. No jaundice. No signs of chronic liver disease
• Psychiatric: Anxious, hypervigilant. No visual or auditory hallucinations at this time. No paranoid ideation. Denies suicidal ideation
• CIWA-Ar Score: 24 (severe withdrawal)
• Nausea/vomiting: 3
• Tremor: 5
• Paroxysmal sweats: 4
• Anxiety: 4
• Agitation: 3
• Tactile disturbances: 0
• Auditory disturbances: 0
• Visual disturbances: 0
• Headache: 3
• Orientation/clouding: 2

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• CT Head (non-contrast): No acute intracranial pathology. No subdural hematoma. No mass lesion. Mild diffuse cerebral atrophy
• Chest X-ray: Clear lung fields. No cardiomegaly
• ECG: Sinus tachycardia 118 bpm. QTc 440 ms. No ST-T wave changes
• Liver ultrasound: Hepatomegaly (17 cm). Diffusely echogenic liver consistent with fatty infiltration. No focal lesions. No ascites. Patent hepatic and portal vasculature
• AUDIT Score: 32 (out of 40, indicates severe alcohol use disorder)
• PHQ-9: Score 18 (moderately severe depression — to be reassessed after withdrawal management and sobriety)

Clinical Image

Diagram illustrating the timeline of alcohol withdrawal symptoms (6-72+ hours), CIWA-Ar scoring system, and symptom-triggered benzodiazepine therapy protocol. Source: Educational illustration.

Diagnosis

Alcohol Use Disorder, Severe (DSM-5), with Alcohol Withdrawal Seizure and Severe Alcohol Withdrawal (CIWA-Ar 24)

Key Diagnostic Criteria:

• Severe alcohol use disorder meeting >=6 DSM-5 criteria (tolerance, withdrawal, larger amounts/longer than intended, unsuccessful efforts to cut down, craving, social/occupational impairment, continued use despite consequences)
• Alcohol withdrawal seizure (generalized tonic-clonic, 18 hours after last drink)
• CIWA-Ar score 24 indicating severe withdrawal requiring pharmacologic management
• Prior history of complicated withdrawal (kindling effect increases severity with each successive withdrawal episode)

Treatment Plan

1. Acute withdrawal management (ICU or monitored bed):

• Symptom-triggered benzodiazepine protocol: Diazepam 10-20 mg IV/PO every 1 hour for CIWA-Ar >=10 (or chlordiazepoxide 50-100 mg if stable for oral). Reassess CIWA-Ar every 1 hour during active withdrawal. Given prior withdrawal seizure, consider front-loading with diazepam 20 mg IV every 2 hours x3 initial doses, then symptom-triggered
• Seizure precautions: Padded side rails, suction at bedside, no seizure prophylaxis with phenytoin (ineffective for alcohol withdrawal seizures; benzodiazepines are both treatment and prophylaxis)
• Thiamine: 500 mg IV three times daily for 3 days (high-dose protocol for Wernicke encephalopathy prophylaxis — ALWAYS give thiamine BEFORE glucose), then 100 mg IV/PO daily
• Electrolyte correction: IV magnesium sulfate 2 g, oral magnesium oxide 400 mg BID. IV potassium chloride 40 mEq. Phosphorus repletion. Monitor and replete every 6-12 hours
• IV fluids: D5NS with multivitamins and folate at 125 mL/hr (avoid overhydration)
• Monitoring: Continuous telemetry, CIWA-Ar every 1 hour until score <10 for 24 hours, then every 4-8 hours. Monitor for delirium tremens (typically onset 48-72 hours after last drink)

1. If delirium tremens develops (48-96 hours): Escalate to IV diazepam or midazolam infusion in ICU. Consider phenobarbital 130-260 mg IV as adjunct for benzodiazepine-resistant withdrawal. Propofol and mechanical ventilation for refractory cases
2. Nutritional rehabilitation: Thiamine, folate, multivitamin. High-calorie, high-protein diet when tolerating oral intake. Monitor for refeeding syndrome (phosphorus, magnesium, potassium)
3. Medications for alcohol use disorder (initiate before discharge):

• Naltrexone 50 mg daily (first-line) — reduces heavy drinking days and craving. Check LFTs first (contraindicated if AST/ALT >3-5x ULN; reassess when liver enzymes improve). Alternatively, start with 25 mg x3 days, then 50 mg daily
• Alternative: Extended-release naltrexone injection (Vivitrol 380 mg IM monthly) for improved adherence
• Consider adding acamprosate 666 mg three times daily (renally cleared, safe with liver disease) for craving reduction, particularly if naltrexone contraindicated
• Gabapentin 300 mg three times daily (titrate as needed) for residual insomnia, anxiety, and craving (evidence-based adjunct)

1. Psychosocial treatment (arrange before discharge):

• Referral to intensive outpatient program (IOP): 3 hours/day, 3-4 days/week for 8-12 weeks
• Individual counseling: motivational interviewing transitioning to CBT/relapse prevention
• 12-step facilitation: AA meeting attendance (90 meetings in 90 days recommendation)
• Consider residential treatment given unemployment, social instability, and prior failed quit attempts

1. Psychiatric follow-up: Reassess depression after 2-4 weeks of sobriety (alcohol-induced depressive disorder vs. independent major depression). Initiate antidepressant if symptoms persist
2. Discharge planning: Ensure safe living situation, sober support network, outpatient appointment within 1 week, prescription for naltrexone and gabapentin, naloxone kit (in case of polysubstance exposure), smoking cessation resources

Key Learning Points

• Alcohol withdrawal seizures typically occur 12-48 hours after the last drink and are generalized tonic-clonic; they are effectively prevented and treated with benzodiazepines (phenytoin is NOT effective for alcohol withdrawal seizures)
• The "kindling" phenomenon means each successive alcohol withdrawal episode tends to be more severe; patients with prior withdrawal seizures or delirium tremens are at significantly higher risk for complicated withdrawal
• Symptom-triggered benzodiazepine therapy (using CIWA-Ar scores) is superior to fixed-schedule dosing: it results in lower total benzodiazepine doses, shorter treatment duration, and fewer cases of oversedation
• Thiamine must be given BEFORE or concurrently with glucose-containing fluids to prevent precipitation of Wernicke encephalopathy; high-dose IV thiamine (500 mg TID) is recommended for patients at high risk
• FDA-approved medications for alcohol use disorder (naltrexone, acamprosate, disulfiram) are significantly underutilized — fewer than 10% of patients with AUD receive any pharmacotherapy; they should be offered to all patients as part of a comprehensive treatment plan

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