# Substance Use Disorders Management

> Substance use disorders for FMGE Medicine: chlordiazepoxide withdrawal protocols, thiamine before glucose, maintenance therapy and tobacco cessation.

- Canonical URL: https://prepelephant.com/topics/fmge/medicine/substance-use-disorders-management
- Exam / course: FMGE · Subject: Medicine
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Substance Use Disorders Management", PrepElephant, https://prepelephant.com/topics/fmge/medicine/substance-use-disorders-management

## Direct answer

Withdrawal safety comes first: alcohol withdrawal is managed with a benzodiazepine — chlordiazepoxide titrated by symptom scores (CIWA-Ar), roughly 60-120 mg daily in divided doses tapering over 5-7 days — and thiamine always precedes any glucose-containing infusion to prevent Wernicke's encephalopathy. Maintenance of alcohol dependence uses naltrexone, acamprosate or supervised disulfiram; opioid dependence is treated with buprenorphine-naloxone maintenance (or methadone where available) after withdrawal stabilisation, and opioid overdose with naloxone. Tobacco dependence — India's largest burden — responds to the 5As structure: brief advice, then nicotine replacement, bupropion or varenicline 1 mg twice daily for twelve weeks. Every plan layers relapse-prevention counselling, family involvement, and linkage to de-addiction services under the District Mental Health Programme.

## What you must remember

- **Withdrawal timeline:** 6-24 hours tremor, sweating, anxiety; 12-48 hours seizures; 48-96 hours delirium tremens (confusion, hallucinations, autonomic storm) — untreated mortality is high, and history of past withdrawal seizures predicts future ones.
- **Chlordiazepoxide convention:** 10-25 mg per dose titrated against CIWA-Ar, commonly 60-120 mg total daily in divided doses, tapering over about a week; parenteral lorazepam substitutes when hepatic failure clouds metabolism.
- **Thiamine rule:** 100 mg intramuscularly three times daily for suspected Wernicke's (confusion, ataxia, ophthalmoplegia), always before glucose — carbohydrate loading without thiamine precipitates the lesion; remember Korsakoff amnesia follows untreated Wernicke's.
- **Maintenance pharmacotherapy:** naltrexone 50 mg daily (opioid-free first, hepatotoxicity check) reduces drinking reward; acamprosate 666 mg three times daily for craving; disulfiram 250-500 mg supervised — flushing, vomiting and hypotension on alcohol; contraindicated in cardiac and psychotic disease.
- **Opioid pathway:** buprenorphine-naloxone sublingual maintenance reduces illicit use and mortality; naloxone 0.4-2 mg intravenous reverses overdose; methadone exists in limited centres under NDPS Act regulation.
- **Tobacco cessation menu:** nicotine replacement (patch, gum, lozenge), bupropion 150 mg sustained-release twice daily (seizure contraindication), varenicline titrated to 1 mg twice daily for 12 weeks — the highest abstinence rates among single agents.
- **Screening instruments:** AUDIT for alcohol, CAGE as the brief classic, Fagerström for nicotine dependence; severity guides setting — outpatient detoxification for mild withdrawal, inpatient for seizures, delirium tremens or comorbidity.
- **Indian anchors:** the National Drug Dependence Treatment Centre at AIIMS anchors clinical training and guidelines, District Mental Health Programme clinics deliver de-addiction care, and inhalant abuse among street children is a distinctly Indian pattern to recognise.

## How to work through an admission

A 46-year-old man is admitted two days after his last drink following a pancreatitis admission: he is tremulous, sweating, pulse 118, and by hospital day three he is confused and seeing insects on the wall. This is progression to delirium tremens, and the response is immediate: chlordiazepoxide in higher doses guided by CIWA-Ar (or intravenous lorazepam given his liver disease), parenteral thiamine before any dextrose, fluid and electrolyte correction — hypokalaemia and hypomagnesaemia feed seizures — and a quiet, lit room. Before any glucose-containing fluid runs, thiamine 100 mg three times daily is established; the ophthalmoplegia-confusion-ataxia triage is checked daily, because the cost of missing Wernicke's is a permanent amnesia.

Once the storm passes, detoxification is only the doorway: discharge planning includes relapse-prevention counselling, naltrexone or acamprosate chosen by liver function and craving pattern, family psychoeducation, and linkage to the nearest de-addiction service. Compare the parallel path of a young man with heroin dependence: buprenorphine-naloxone maintenance with counselling, plus naloxone education for the family — and the tobacco-using father of both, offered varenicline with a quit date. Three dependencies, three pharmacologies, one common structure — withdrawal safety first, maintenance second, relapse prevention always.

## How the FMGE frames it

The sequence questions dominate: which vitamin before glucose (thiamine), which drug class for withdrawal seizures and delirium tremens (benzodiazepines), and which agent is dangerous with alcohol (disulfiram's flushing reaction, metronidazole). Wernicke's triad versus Korsakoff amnesia is a perennial, and the CIWA-Ar-guided dosing concept appears as "symptom-triggered therapy". Opioid questions test naloxone pharmacology (short half-life, repeat dosing) and buprenorphine's ceiling effect and precipitated withdrawal if started too early. Tobacco stems ask to pick varenicline or nicotine replacement for a scheduled quit attempt, with bupropion's seizure contraindication as the safety distractor. The Indian programme layer supplies community-medicine crossovers — NDDTC at AIIMS, District Mental Health Programme de-addiction clinics, and the inhalant-abuse pattern among street children — while the NDPS Act explains why opioid agonist treatment is centre-restricted.

## Frequently asked questions

### What is the drug of choice for alcohol withdrawal and delirium tremens?

A benzodiazepine — chlordiazepoxide orally titrated by CIWA-Ar (intravenous lorazepam in liver failure or delirium tremens).

### Why is thiamine given before glucose in alcohol dependence?

Carbohydrate infusion consumes the remaining thiamine and can precipitate Wernicke's encephalopathy, so thiamine precedes any dextrose-containing fluid.

### Which drugs maintain abstinence from alcohol?

Naltrexone (reduces reward), acamprosate (reduces craving) and supervised disulfiram (aversion) — each with counselling.

### How is opioid dependence treated long-term?

Buprenorphine-naloxone maintenance (methadone in select centres) with psychosocial support, plus naloxone for overdose reversal.

### Which smoking-cessation drug has the highest efficacy and how is it dosed?

Varenicline, titrated over a week to 1 mg twice daily for about twelve weeks, with nausea and vivid dreams as its common adverse effects.