What is the recommended clinical approach for managing substance‑use disorder in medical or surgical inpatients, including screening, withdrawal management, evidence‑based pharmacotherapy, psychosocial support, and discharge planning?

Clinical Management of Substance Use Disorders in Medical-Surgical Inpatients

Medical-surgical inpatients with substance use disorders should receive immediate withdrawal management with benzodiazepines (for alcohol) or supportive care (for stimulants), initiation of evidence-based pharmacotherapy before discharge (naltrexone or acamprosate for alcohol, buprenorphine for opioids), mandatory thiamine supplementation, screening for psychiatric comorbidities, and structured linkage to outpatient addiction services. 1, 2

Immediate Assessment and Screening

• Screen all medical-surgical inpatients for substance use disorders using validated tools (AUDIT-3, AUDIT-C, or ASSIST), as emergency departments identify less than 50% of alcohol-related problems without systematic screening. 3, 4

• Conduct addiction-specific history focusing on: substance type and quantity, last use timing (critical for withdrawal risk), prior withdrawal complications (seizures, delirium tremens), concurrent psychiatric disorders, and social support structure. 5

• Assess withdrawal risk immediately using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale: scores >8 require pharmacological intervention, scores ≥15 indicate severe withdrawal requiring aggressive treatment. 1

Acute Withdrawal Management

Alcohol Withdrawal

• Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal syndrome, with long-acting agents (chlordiazepoxide, diazepam) preferred for most patients due to superior protection against seizures and delirium tremens. 3, 1

• Switch to intermediate-acting benzodiazepines (lorazepam, oxazepam) in patients with advanced age, hepatic dysfunction, or severe medical comorbidities to prevent drug accumulation. 1

• Use symptom-triggered dosing rather than fixed-dose schedules to prevent drug accumulation while ensuring adequate symptom control. 1

• Antipsychotics should never be used as stand-alone medications for alcohol withdrawal; use only as adjunct to benzodiazepines in severe withdrawal delirium unresponsive to adequate benzodiazepine doses. 3

• Do not use anticonvulsants following an alcohol withdrawal seizure for prevention of further withdrawal seizures. 3

• Limit benzodiazepine prescriptions to 7-14 days maximum as extension increases dependence risk, particularly in patients with alcohol use disorder who are at higher risk of benzodiazepine abuse. 1

Opioid Withdrawal

• Initiate buprenorphine during hospitalization for opioid-dependent patients, as office-based pharmacotherapy with buprenorphine is safe and effective (Level A evidence). 3

• Ensure adequate opioid-free period (7-10 days) before starting naltrexone to avoid precipitated withdrawal. 6, 2

Stimulant Withdrawal (Cocaine, Amphetamines)

• Provide supportive environment without specific medication for cannabis, cocaine, or amphetamine withdrawal. 3

• Manage symptoms with symptomatic medications (e.g., for agitation, sleep disturbance) during the withdrawal period. 3

• Monitor closely for depression or psychosis during withdrawal, which occurs less commonly but requires specialist consultation. 3

Mandatory Thiamine Supplementation

• Administer thiamine to ALL patients with alcohol use disorder to prevent Wernicke's encephalopathy, a potentially fatal but preventable neurological complication. 1, 2

• Dosing protocol: 100-300 mg/day orally for prevention in all patients; 100-500 mg/day parenterally for high-risk patients (malnourished, severe withdrawal) or suspected Wernicke's encephalopathy. 1, 2

• Critical sequencing: Give thiamine BEFORE any IV glucose-containing fluids to prevent acute thiamine deficiency. 6, 2

Evidence-Based Pharmacotherapy Initiation

Alcohol Use Disorder

• Initiate naltrexone 50 mg daily as first-line pharmacotherapy after acute withdrawal resolves, as it reduces return to any drinking by 5% and binge-drinking risk by 10%. 1, 6

• Alternative: Acamprosate 666 mg three times daily for patients with liver disease, as it has no hepatotoxicity and undergoes renal excretion only; most effective for maintaining abstinence in already-detoxified patients. 1, 6, 2

• For cirrhotic patients: Use baclofen 30-60 mg/day as naltrexone and disulfiram are contraindicated due to hepatotoxicity risk. 1, 6

• Treatment duration: Acamprosate typically 3-6 months; naltrexone continued as long as beneficial. 6, 2

Opioid Use Disorder

• Buprenorphine is safe and effective for office-based pharmacotherapy of opioid dependence (Level A evidence from Cochrane review and multiple RCTs). 3

• Naltrexone can be used in motivated populations (e.g., healthcare professionals) who cannot or do not wish to take continuous opioid agonist therapy, but has limited success in other groups. 3

Cocaine and Combined Use

• No pharmacologic treatment for cocaine dependence can be recommended for primary care or inpatient settings; behavioral therapies remain the evidence-based standard. 6

• For combined alcohol and cocaine use: Initiate disulfiram 250 mg/day as it may address both substances, and consider adding naltrexone 100 mg/day. 6

Psychiatric Comorbidity Management

• Screen ALL patients with substance use disorders for mental health disorders (anxiety, depression, bipolar disorder, PTSD, personality disorders), as these are highly prevalent and affect outcomes (Level A evidence). 3

• Distinguish primary from substance-induced disorders: Primary disorders predate substance misuse and persist during abstinence; these can be treated with standard psychological and pharmacologic therapies. 3

• Screen for intimate partner violence in all patients with substance use disorders, as rates exceed 50% in some settings; treatment of alcohol use disorders appears to decrease both perpetration and victimization. 3

Psychosocial Support Integration

• Combine pharmacotherapy with psychosocial support routinely, as medications alone are insufficient for comprehensive management. 3, 2

• Offer structured psychological interventions including cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), or motivational interviewing; CBT plus pharmacotherapy shows superior outcomes compared to usual care plus pharmacotherapy. 3, 1, 2

• Encourage engagement with mutual help groups (Alcoholics Anonymous, Narcotics Anonymous) as adjunctive support; these are free, available in most communities, and support all stages of recovery. 3, 1, 2

• Involve family members in treatment where appropriate and offer support to family members in their own right. 3

Discharge Planning and Linkage to Care

• Ensure clinical stability for 24-48 hours before discharge, including stable vital signs, no respiratory distress, oxygen saturation ≥95% on room air, and no comorbidities that could compromise cardiopulmonary reserve. 3

• Screen for mental health, substance use disorders, and social care needs before discharge to identify barriers to outpatient follow-up. 3

• Conduct medication reconciliation and patient counseling by inpatient pharmacist before discharge, particularly for patients on corticosteroid tapers, as this decreases rehospitalization. 3

• Schedule initial outpatient follow-up within 48 hours of discharge, with addiction specialist or primary care follow-up within 2-4 weeks. 3

• Provide written prescriptions for: Naltrexone or acamprosate (for alcohol), buprenorphine (for opioids), thiamine supplementation, and any psychiatric medications. 1, 6, 2

• Link to outpatient addiction treatment services using SAMHSA Treatment Locator, Buprenorphine Physician Locator, or American Society of Addiction Medicine Physician Finder. 3

Inpatient Setting Determination

• Admit to inpatient setting if: Risk of severe withdrawal complications, concurrent serious physical or psychiatric disorders, or lack of adequate social support or reliable supervision. 3, 6

• Outpatient management appropriate for: Mild-to-moderate withdrawal, stable medical/psychiatric status, and adequate social support. 1

• Consider addiction consultation service (ACS) for complex cases, as ACS consultation increases new inpatient medication initiation from 0.9% to 33% and discharge prescriptions from 1.9% to 41.4%. 7, 5

Critical Pitfalls to Avoid

• Never delay or withhold thiamine in high-risk patients or those with suspected Wernicke's encephalopathy, as this leads to irreversible neurological damage. 1, 6, 2

• Never give glucose before thiamine in at-risk patients. 6, 2

• Never start naltrexone during active withdrawal or before adequate opioid-free period (7-10 days), as it precipitates withdrawal. 6, 2

• Never use naltrexone or disulfiram in patients with alcoholic liver disease or cirrhosis due to hepatotoxicity risk; use acamprosate or baclofen instead. 1, 6, 2

• Never extend benzodiazepine prescriptions beyond 7-14 days, as this increases dependence risk. 1

• Never prescribe medications without concurrent psychosocial support, as pharmacotherapy alone has limited efficacy. 6, 2

• Never use antipsychotics as stand-alone treatment for alcohol withdrawal. 3

• Never discharge patients without: Confirmed outpatient appointment, written prescriptions for evidence-based medications, and linkage to addiction treatment services. 3, 5