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PS3.1 | Addiction Psychiatry — PBL Case

CLINICAL SETTING

You are a group of final-year MBBS students attached to the general medicine unit of a district hospital in Tamil Nadu. It is 8:30 AM on a Monday. The ward receives a new patient, Mr Selvam, a 48-year-old male autorickshaw driver, brought by his wife and elder son. He has been in hospital once before — two years ago for a 'liver problem.' His son hands you a discharge summary that reads: 'fatty liver, advised complete alcohol abstinence.' Mr Selvam smells faintly of alcohol. He appears to be holding his hands together deliberately to stop them shaking.

Trigger 1: Presentation and Diagnosis

You take Mr Selvam's history. He reports drinking 180–250 mL of arrack (local distilled liquor, approximately 12–16 standard units) daily for the last 15 years. He drank last night at 10 PM and now, at 8:30 AM (10.5 hours later), feels terrible — tremors of both hands, sweating, and intense anxiety. He says: 'If I don't get a drink by noon, I will not be able to function. I have tried stopping twice — once I shook so badly that my wife called an ambulance.' On physical examination: HR 118 bpm, BP 162/98 mmHg, Temperature 37.6°C, fine-to-coarse tremor of outstretched hands, diaphoresis. Abdomen: hepatomegaly 3 cm below costal margin, mildly tender. GCS 15/15. He is orientated and coherent. His CIWA-Ar score is 14 (moderate withdrawal). Blood tests: serum sodium 132 mEq/L, potassium 3.2 mEq/L, magnesium 0.55 mg/dL, random blood glucose 52 mg/dL.

DISCUSSION POINTS

  • What stage of alcohol withdrawal is Mr Selvam in? Use the withdrawal timeline (6–12 h, 24–48 h, 48–72 h) to justify your answer.
  • Apply ICD-11 criteria: does Mr Selvam have alcohol dependence or harmful use? Cite ALL three required features from the history.
  • His random blood glucose is 52 mg/dL. The intern suggests giving 50 mL of 50% dextrose IV immediately. What must you do FIRST, and why? What clinical syndrome are you preventing?
  • Identify the electrolyte abnormality most relevant to his immediate seizure risk. What is the mechanism by which this electrolyte depletion facilitates seizures in alcohol withdrawal?
  • What does a CAGE score of 4/4 (which his wife reports he would score) indicate, and what are the limitations of CAGE compared to AUDIT?
Click to reveal Trigger 2: Withdrawal Complication on Day 2 (discuss previous trigger first!)

Trigger 2: Withdrawal Complication on Day 2

Mr Selvam is admitted to the general medicine ward. He receives: thiamine 100 mg IV before the dextrose infusion, magnesium sulphate 2 g IV over 20 minutes, intravenous diazepam 10 mg (total 30 mg over 8 hours), normal saline, and oral potassium. By evening of Day 1 his tremors improve and he sleeps. However, at 2 AM on Day 2 (approximately 28 hours after his last drink), the nursing staff call you urgently. Mr Selvam is having a generalised tonic-clonic seizure lasting 90 seconds. Post-ictally he is drowsy but recovers to baseline within 20 minutes. His vitals: HR 132, BP 175/105. No fever. A repeat CIWA-Ar is 18 (severe). By the following afternoon (Day 3, 52 hours post-last-drink) he becomes acutely confused, is seeing 'rats running under the bed,' is pulling at his IV line, and his HR has risen to 136 bpm with BP 190/110 mmHg.

DISCUSSION POINTS

  • The seizure occurred at 28 hours post-cessation. Is this consistent with the expected timeline for alcohol withdrawal seizures? What type of seizure is this?
  • The Day-3 presentation (confusion, visual hallucinations, autonomic hyperactivity) represents the most dangerous complication of alcohol withdrawal. Name it, explain its pathophysiology (GABA/glutamate imbalance), and state its mortality rate if untreated.
  • What is your immediate pharmacological management? Specify the drug class, route, and rationale. At what point would you escalate to ICU care?
  • Distinguish the Day-3 clinical picture from (a) alcoholic hallucinosis and (b) Wernicke encephalopathy. What features differentiate each?
  • Mr Selvam's wife asks: 'Doctor, could this have been prevented?' How do you counsel her about the importance of the medically supervised detoxification he missed after his discharge two years ago?
Click to reveal Trigger 3: Recovery and Relapse Prevention (discuss previous trigger first!)

Trigger 3: Recovery and Relapse Prevention

Mr Selvam recovers fully from delirium tremens after 96 hours of IV benzodiazepine therapy, thiamine replacement, and ICU monitoring. On Day 7 he is alert, oriented, and medically stable. A psychiatrist visits and conducts a motivational interview. Mr Selvam says: 'I now realise I could have died. I want to stop — truly stop. But I am scared. I tried before and I cannot get through the cravings.' His liver function tests show: ALT 96 U/L (normal <40), AST 88 U/L, GGT 210 U/L — indicating significant alcohol-related liver injury. He is a Muslim, and his family has a strong social support network. He will be referred to a de-addiction centre after discharge.

DISCUSSION POINTS

  • Mr Selvam is in the 'contemplation' or 'preparation' stage of Prochaska and DiClemente's Transtheoretical Model. Which stage is this, and how does the motivational interviewing approach differ for a contemplating versus a pre-contemplating patient?
  • Compare the three evidence-based relapse-prevention pharmacotherapies — disulfiram, naltrexone, and acamprosate — on mechanism of action. Given his significant alcohol-related liver disease (elevated transaminases), which agent is most appropriate, and why?
  • Mr Selvam also smokes 10 bidis daily. The de-addiction team plans to address tobacco dependence simultaneously. What first-line pharmacotherapy would you recommend for tobacco cessation, noting his liver disease? Which agent should you avoid and why?
  • Design a brief relapse-prevention plan for Mr Selvam at the time of discharge. Include: (a) the pharmacotherapy chosen with dosing rationale, (b) community or family support element, (c) a specific statement about trigger avoidance, and (d) the follow-up schedule.
  • At the population level, what public health interventions exist in India to address alcohol and tobacco use disorders? Name one national programme for each.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PS3.1] What are the ICD-11 criteria that distinguish alcohol dependence syndrome from harmful use, and how do these categories guide different management pathways?
  2. [PS3.1] What is the predictable timeline of alcohol withdrawal complications (tremors → seizures → delirium tremens), and what immediate pharmacological and nutritional interventions are required at each stage?
  3. [PS3.1] Why must thiamine be administered before intravenous dextrose in malnourished alcohol-dependent patients, and what syndrome does this prevent?
  4. [PS3.1] What are the mechanisms, indications, and contraindications of disulfiram, naltrexone, and acamprosate in alcohol relapse prevention, with specific attention to hepatic safety?
  5. [PS3.1] What is the evidence base for tobacco cessation pharmacotherapy (NRT, bupropion, varenicline), and which agents carry contraindications relevant to patients with comorbid liver disease or seizure disorders?