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Opioid use disorder — USMLE Step 3 MCQ

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HardPsychiatry (Outpatient Management)Opioid use disorderUSMLE Step 3

A 52-year-old man in the ICU has severe alcohol withdrawal with hallucinations, diaphoresis, hypertension, and recurrent agitation despite 180 mg of diazepam-equivalent benzodiazepine during the last 3 hours. He is protecting his airway and is not mechanically ventilated. Glucose, magnesium, and potassium have been corrected. Which pharmacologic escalation is most appropriate?

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Correct answer: B — Add protocolized phenobarbital while continuing close respiratory monitoring in ICU

The best answer is “Add protocolized phenobarbital while continuing close respiratory monitoring in ICU”. This is resistant alcohol withdrawal despite very high benzodiazepine exposure. ASAM supports phenobarbital as an adjunct in a closely monitored setting when clinicians are experienced with its narrow therapeutic window and respiratory effects. Dexmedetomidine may control autonomic signs but does not treat the underlying GABA-glutamate imbalance alone. Propofol is generally reserved for resistant withdrawal in patients already requiring mechanical ventilation.

Reference: ASAM Clinical Practice Guideline on Alcohol Withdrawal Management: https://www.asam.org/quality-care/clinical-guidelines/alcohol-withdrawal-management-guideline