What is the best course of action for a 36-year-old male with opioid use disorder, currently undergoing buprenorphine (Suboxone) treatment, who presents with symptoms of alcohol withdrawal, including tremors, diaphoresis, and discomfort, after stopping alcohol consumption due to suspected pancreatitis, and refuses to go to the emergency department (ED)?

Management of Alcohol Withdrawal in a Patient on Buprenorphine Maintenance Who Refuses ED Evaluation

This patient requires immediate emergency department evaluation for alcohol withdrawal syndrome with suspected pancreatitis, and your documentation of his refusal with witnessed acknowledgment of seizure risk is appropriate risk mitigation, though benzodiazepine treatment should be strongly considered in your office if available. 1

Clinical Documentation Framework

History of Present Illness

Chief Complaint: Follow-up for buprenorphine maintenance therapy; acute alcohol withdrawal symptoms

HPI: 36-year-old male with opioid use disorder on buprenorphine maintenance presents for routine follow-up. Patient reports acute cessation of alcohol use approximately [specify timeframe] ago due to new-onset right upper quadrant abdominal pain concerning for pancreatitis. Since discontinuing alcohol, he has developed classic withdrawal symptoms including:

• Autonomic hyperactivity: Tremors (shakes), diaphoresis (sweats)
• Subjective distress: Reports feeling "uncomfortable"
• Timeline: Symptoms began [X hours] after last alcohol consumption
• Severity assessment needed: CIWA-Ar score should be documented 1

Patient was counseled extensively on the serious risks of managing alcohol withdrawal in the outpatient setting, specifically:

• Risk of progression to severe withdrawal with seizures (typically within 24-48 hours)
• Risk of delirium tremens
• Potential for cardiac complications
• Need for medical monitoring given suspected pancreatitis

Patient adamantly refused ED evaluation despite repeated recommendations. Patient states he has a support person present who will call 911 if his condition deteriorates or if seizure activity occurs. Support person's name and contact information: [document].

Assessment of Withdrawal Severity

Document CIWA-Ar score if possible (scores >8 indicate moderate withdrawal requiring pharmacological treatment; ≥15 indicates severe withdrawal). 1 Key findings to document:

• Vital signs: Blood pressure, heart rate (tachycardia >100 bpm scores points)
• Tremor severity (observable vs. palpable only)
• Diaphoresis extent
• Anxiety level
• Agitation/restlessness
• Nausea or vomiting
• Tactile, auditory, or visual disturbances

Critical Management Decisions

Benzodiazepine Treatment Consideration

Benzodiazepines are the gold standard for alcohol withdrawal syndrome and should be offered if you have prescribing capability. 1 Specifically:

• Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide superior seizure prophylaxis 1
• Short/intermediate-acting benzodiazepines (lorazepam, oxazepam) are safer given his suspected hepatic dysfunction from pancreatitis 1
• Symptom-triggered dosing is preferred over fixed-schedule to prevent drug accumulation 1

Document if benzodiazepines were offered and patient's response. If prescribed, provide only 24-48 hours of medication with mandatory follow-up, given abuse potential in patients with substance use disorder. 1

Buprenorphine Continuation

Continue buprenorphine maintenance without interruption. 1 Document current dose and patient's adherence. Buprenorphine does not treat alcohol withdrawal but maintaining opioid use disorder treatment is critical during this medical crisis. 1

Critical drug interaction warning: Benzodiazepines combined with buprenorphine increase risk of respiratory depression, hypotension, profound sedation, and death. 2 If prescribing benzodiazepines:

• Use minimum effective doses
• Provide explicit warnings about combined CNS depression
• Consider more frequent monitoring or reconsider ED referral 2

Documentation of Refusal and Risk Acknowledgment

Your note should explicitly state:

"Patient was informed that alcohol withdrawal syndrome can progress to life-threatening complications including:

• Generalized tonic-clonic seizures (risk peaks 24-48 hours after cessation)
• Delirium tremens with mortality risk
• Cardiovascular collapse
• Complications from suspected pancreatitis requiring imaging and laboratory evaluation

Patient verbally acknowledged understanding these risks and explicitly refused emergency department evaluation. Support person [name] present during discussion, verbalized understanding of need to call 911 for any concerning symptoms including seizure activity, altered mental status, worsening tremors, fever, or severe confusion. Patient appears to have decision-making capacity at this time."

Safety Planning Documentation

Document the following safety plan:

• Support person: [Name, relationship, contact number] will remain with patient for next 48-72 hours
• 911 criteria: Call immediately for seizure, confusion, hallucinations, fever >101°F, inability to keep down fluids, worsening abdominal pain
• Follow-up: Patient instructed to return to clinic in 24 hours or sooner if symptoms worsen
• Hydration: Encouraged oral fluid intake
• Thiamine supplementation: Consider prescribing thiamine 100mg daily to prevent Wernicke's encephalopathy 1
• Naloxone kit: Ensure patient has take-home naloxone given opioid use disorder 3

Additional Clinical Considerations

Suspected Pancreatitis

Document that definitive evaluation of suspected pancreatitis requires:

• Serum lipase/amylase levels
• Liver function tests
• Abdominal imaging (ultrasound or CT)
• Assessment for complications

Patient's refusal of ED evaluation delays this necessary workup, increasing risk of complications from untreated pancreatitis.

Alcohol Use Disorder Screening

Document alcohol use history using AUDIT questionnaire at next visit when patient is medically stable. 1 Consider medications for alcohol use disorder (naltrexone, acamprosate, disulfiram) once acute withdrawal resolves. 1

Follow-Up Plan

• Mandatory 24-hour follow-up (document specific date/time)
• Reassess CIWA-Ar score
• Vital signs monitoring
• If patient fails to follow up, attempt phone contact and document
• Long-term: Address alcohol use disorder treatment after medical stabilization 1

This documentation protects you medically and legally while respecting patient autonomy, though the clinical situation remains high-risk and ED evaluation remains the standard of care. 1