Substance-Related and Addictive Disorders
23 cases on alcohol, opioid, stimulant, tobacco, and cannabis use disorder pharmacotherapy, withdrawal management, and harm reduction — choose a case below to open its full multi-voice debate.
A man newly diagnosed with compensated cirrhosis wants to start medication for alcohol use disorder today. The two first-line options split cleanly along organ clearance — but the drug that’s cleanest for his liver isn’t the one with the stronger trial result.
A patient specifically requests disulfiram and can explain exactly why she wants it. What she can’t yet offer is anyone to confirm she takes it during the hours she’s actually at risk — and the drug’s own founding trial says that gap matters.
A patient on stable long-term opioid therapy for chronic pain has already tried and lost access to both standard AUD medications. Baclofen’s French trial record is genuinely split — and his own regimen raises a risk neither trial was designed to test.
Two patients in alcohol withdrawal share the same syndrome and nearly the same CIWA score. Only one of them has a liver that can safely clear the usual first-choice drug.
A patient in alcohol withdrawal has already crossed the threshold most definitions use for benzodiazepine-refractory disease. The question is whether to keep giving more of the same drug or add one that works by a different mechanism.
A woman in stable opioid-use-disorder remission wants to try gabapentin for persistent drinking. She’s also the one who brought up, unprompted, that she once misused that exact drug combined with an opioid.
Two patients need medication for opioid use disorder. Neither choice is generically “better” — one man’s housing instability makes daily observed dosing the fix, while one woman’s inflexible job makes that same structure the obstacle.
A patient has twice left treatment intake rather than wait through the withdrawal severity a standard buprenorphine induction requires. A newer, less-studied low-dose protocol is built for exactly this problem — but it is genuinely less proven.
Two patients have both just completed detoxification. One’s history and support system make her a strong antagonist candidate; the other’s own account of four failed attempts points firmly the other way.
A pregnant patient stable on methadone for three years develops new withdrawal symptoms as her pregnancy advances — and fears the correct fix will hurt her baby, based on a belief the evidence doesn’t actually support.
A patient stable on buprenorphine for over a year discloses, unprompted, a single use nine days ago. The question isn’t whether to punish it — it’s what an honest response to real risk looks like without discarding fourteen months of real progress.
A rural family physician can now legally prescribe buprenorphine for an established patient without ever holding a DATA-waiver. Whether she should start today turns out to be a different, harder question than whether she’s allowed to.
A patient with eleven years of impeccable adherence hears her clinic’s new universal naloxone policy as a personal accusation. The policy may be sound population-level medicine and still land badly in a specific relationship.
A worried mother buys naloxone off the shelf, no questions asked, exactly as the 2023 OTC approval intended — then walks up to the counter anyway because she has no idea how to use it.
A man’s unusually severe wound and unusually long, hard-to-rouse highs both point the same direction — a non-opioid sedative now widespread in the fentanyl supply that naloxone was never built to reverse.
A patient with a firm career deadline explicitly declines methadone or buprenorphine and wants full detoxification instead. Respecting that choice still means being honest with her about what it actually risks.
A patient has made real progress in behavioral treatment for methamphetamine use disorder and then plateaued. No medication holds FDA approval for this disorder — but one off-label combination has real randomized trial evidence behind it.
A motivated patient wants a direct recommendation, not a menu — and is nervous about a varenicline safety warning that was formally removed years ago after the very trial that answers her question.
A middle school teacher who confiscates vapes from his own students daily wonders whether he should use one himself to finally quit smoking — after two evidence-based options already failed him.
A patient plateaus on counseling and asks about a medication he read about online. The honest answer is that the drug’s best evidence comes from a population he no longer belongs to.
A veteran’s cannabis genuinely controls pain nothing else has. It has also, over the past year, become something his daughter no longer recognizes — and something he now meets structured criteria for a disorder around.
After eleven years on alprazolam prescribed for a real, understandable reason, a patient agrees to taper — and finds there’s no single agreed way to actually do it.
A patient making real progress in behavioral treatment for gambling disorder plateaus on one specific symptom: an intense urge he describes as feeling just like the alcohol cravings his late father once described to him.