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Opioid use disorder — USMLE Step 3 MCQ

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HardPsychiatry (outpatient management)Opioid use disorderUSMLE Step 3

A 55-year-old with decompensated cirrhosis is admitted 14 hours after his last alcohol use. He has tremor, diaphoresis, visual hallucinations, pulse 112/min, and a withdrawal score requiring medication. He is oriented, has no respiratory depression, and can be reassessed frequently. Which regimen is most appropriate?

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Correct answer: B — Use symptom-triggered lorazepam with close respiratory and mental-status monitoring

The best answer is “Use symptom-triggered lorazepam with close respiratory and mental-status monitoring”. Benzodiazepines remain first-line for clinically important alcohol withdrawal. In substantial liver disease, an agent such as lorazepam that relies less on oxidative hepatic metabolism is preferred, and symptom-triggered dosing is appropriate when trained staff can reassess reliably. Long-acting oxidatively metabolized agents may accumulate; adrenergic blockers and gabapentin do not provide adequate seizure or delirium prevention in this presentation.

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