Substance use: opioids, cocaine, alcohol withdrawal
Stem
A 34-year-old man, 90 kg, needs open reduction and internal fixation of a tibial plateau fracture after a motorcycle crash last night. He takes buprenorphine-naloxone 8 mg twice daily for opioid use disorder and has been in recovery for two years. He also drinks most of a liter of vodka daily; his last drink was 10 hours ago. He is tremulous, heart rate 108, blood pressure 156/94.
Question
How will you manage his anesthesia and pain control, given his substance use?
Ideal answer
HeadlineTwo problems in parallel: I continue his buprenorphine and build pain control around it, and I treat the alcohol withdrawal that has already started.
- Buprenorphine continued, not tapered, because stopping it risks relapse, and it should not be routinely discontinued;1 I coordinate with him and his prescriber.
- Analgesia built around it: a nerve block catheter if the surgeon agrees, scheduled acetaminophen and an NSAID, a ketamine infusion, and full-agonist opioids titrated for breakthrough with continuous monitoring.
- Thiamine before any glucose, symptom-triggered benzodiazepines by CIWA-Ar, magnesium and potassium replaced, because withdrawal begins as early as 6 hours and his tremor and tachycardia mean it is here.2
- Surgery proceeds, because the fracture is urgent, expecting higher anesthetic requirements; I ask about cocaine and other drugs, because intoxication changes my drug choices.
- A monitored bed afterward, because delirium tremens can begin around 48 hours.2
Breaking down the answer
- Keep buprenorphine going — it can even be started in untreated patients with opioid use disorder and acute pain.1 Stopping it trades a manageable pain problem for relapse and overdose risk; high-affinity full agonists are added and titrated, not withheld.
- Withdrawal on a clock — minor symptoms from 6 hours, hallucinosis after 12 hours, seizures that can come early and recur, delirium tremens from 48 hours, lasting up to 5 days.2 Timing tells me when he is at risk.
- Why thiamine first — Wernicke encephalopathy, which glucose without thiamine can precipitate.2
- Screen for cocaine — elective surgery does not proceed during acute intoxication; an asymptomatic patient with only a positive urine screen has had outcomes similar to controls.3 Urine can stay positive for up to 20 days, which limits its value.4
- Judgment shown — the examiner wants the urgent fracture done, not cancelled, with each substance addressed.
Follow-up question
On the second postoperative evening, he is agitated, picking at the air, sweating, and pulling at his nerve catheter. Heart rate is 132, blood pressure 178/102, temperature 38.4 °C. What do you do?
Follow-up answer
HeadlineDelirium tremens until the mimics are excluded at the bedside; I call for help and tell the team and the ICU.
More than two days after his last drink he is squarely in its window, but I rule out hypoxemia, hypoglycemia, sepsis, compartment syndrome, uncontrolled pain and opioid withdrawal.2 I protect his airway and catheter, give intravenous benzodiazepines in escalating doses until he is calm, add phenobarbital if he is resistant, and use dexmedetomidine up to 0.7 mcg/kg/h only as an adjunct, never alone.2 Thiamine, fluids and electrolytes, and the ICU. Untreated, delirium tremens carries mortality up to 37%; early treatment brings that under 5%.2 I reassess every 15 minutes for sedation, airway and temperature.
Pitfalls that cost points
- Withholding opioids from a patient with opioid use disorder who is in pain.
- Giving dextrose before thiamine.
- Treating cocaine-induced hypertension with a pure beta-blocker.
Rapid-fire
Q: How do you treat cocaine-induced hypertension? A: Benzodiazepines first, then phentolamine, or nitroglycerin or nitroprusside, avoiding beta-blockade because of unopposed alpha stimulation.3
Q: Which vasopressor works better after cocaine? A: A direct-acting agent such as phenylephrine, because catecholamine depletion blunts ephedrine.3 4
Q: Why avoid succinylcholine with acute cocaine? A: Both are metabolized by plasma cholinesterase, so each can prolong the other.3
Q: What forms when cocaine and alcohol are combined? A: Cocaethylene, more potent and longer-acting than cocaine.3
Q: How long should non-emergent surgery wait after cocaine use? A: At least 8 hours is a commonly suggested minimum, longer if he is unstable.4
Numbers to know
| Item | Value |
|---|---|
| Minor alcohol withdrawal | From 6 h2 |
| Delirium tremens onset | From 48 h, lasting up to 5 days2 |
| DT mortality | Up to 37% untreated; under 5% with early treatment2 |
| Dexmedetomidine adjunct | Up to 0.7 mcg/kg/h2 |
| Cocaine half-life | 0.5–1.5 h3 |
| Positive urine screen | Up to 20 days4 |
Links
- Acute pain in the opioid-tolerant patient, PCA and multimodal analgesia, Femoral, adductor canal and popliteal blocks, Dexmedetomidine and ketamine, Perioperative myocardial ischemia and infarction
- Multisociety perioperative buprenorphine guidance (ASRA, 2021)
Sources
- 1.Buprenorphine Management in the Perioperative Period: Multisociety Guidance · ASRA Pain Medicine, 2021 · asra.comSummary page; full text in Reg Anesth Pain Med 2021.
- 2.Delirium Tremens · StatPearls · statpearls.com
- 3.Acute cocaine intoxication · OpenAnesthesia, 2023 · openanesthesia.org
- 4.Anesthetic Management of Patients with Cocaine Intoxication · APSF, 2025 · apsf.org
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.