2026-2027 | Live Session | Sedatives-Hypnotics: Board Review | September 2026-Sedatives-Hypnotics: Board Review Case Studies

Sedatives-Hypnotics: Board Review Case Studies

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This document is an addiction medicine board-review presentation on sedative-hypnotic use disorders, using several clinical cases to illustrate diagnosis and management.<br /><br />The first case involves a flight attendant with extreme alprazolam and zolpidem use, probable physiologic dependence, and possible withdrawal seizure. She is judged inappropriate for outpatient detoxification and instead undergoes inpatient medically supervised withdrawal using phenobarbital stabilization followed by a structured taper. Later, her panic symptoms recur in residential treatment, raising the question of whether symptoms reflect withdrawal, an underlying anxiety disorder, or both. Non-benzodiazepine treatments such as mirtazapine, gabapentin, and citalopram improve insomnia, daytime anxiety, and panic without reintroducing sedatives.<br /><br />A second case features a traveling business owner with heavy alcohol use plus unknown quantities of illicit benzodiazepines and a history suggesting withdrawal delirium and seizure risk. Because of tremor, autonomic instability, disorientation, and possible prior withdrawal seizures, she requires higher-acuity inpatient withdrawal management rather than rapid transfer to residential care. Phenobarbital is used for stabilization, with adjunctive gabapentin, and then tapered gradually.<br /><br />A third case describes an injured athlete with severe tramadol and alprazolam use, depression, anxiety, and prior withdrawal seizures. Inpatient treatment prioritizes benzodiazepine withdrawal with a phenobarbital taper, while tramadol withdrawal is managed symptomatically with buprenorphine-naloxone, clonidine, and pain-focused non-opioid adjuncts such as gabapentin and topical agents. The case also highlights relapse risk, family dynamics, and the need for careful discharge coordination.<br /><br />The final case is a pregnant patient with opioid and benzodiazepine use disorders, complex PTSD, and multiple prior withdrawal seizures. The plan is to continue buprenorphine, support smoking cessation, maintain effective psychiatric treatment, and attempt a slow outpatient diazepam-based benzodiazepine taper with close follow-up and safety planning rather than inpatient detoxification.

Keywords

sedative-hypnotic use disorder

benzodiazepine dependence

phenobarbital taper

withdrawal seizures

inpatient detoxification

alprazolam misuse

zolpidem abuse

gabapentin

buprenorphine-naloxone

pregnancy and addiction