creation date: 2025-11-21 01:28
tags: Pathologies
Alcohol Use Disorder
Background
Definitions
Alcohol use disorder is a diagnosis defined by the DSM-5-TR as a problematic pattern of alcohol use leading to clinically significant impairment or distress. This term encompasses alcohol abuse and alcohol dependance.
Other terminology frequently used include:
- Unhealthy alcohol use: encompasses use that can or has resulted in health consequences but may not meet DSM-5-TR criteria
- Risky use: consumption of an amount that puts an individual at risk
- Males (age <65): >14 drinks per week on average or >4 drinks per day
- Females (all ages) and males (age ≥65): >7 drinks per week on average or >3 drinks per day
- Binge drinking: drinking so much in two hours that blood alcohol concentration reach 0.08 g/dL (approx. 4 drinks for women and 5 for men)
Etiology and Risk Factors
Risk factors for lifetime alcohol use disorder include:
- Male
- Age 18-29
- Indigenous or from white population
- Significant disability
- Other substance use disorder
- Mood disorder (eg. major depression, bipolar disorder)
- Personality disorder (eg. borderline or antisocial personality)
Pathogenesis
The exact pathogenesis is unknown but the development of AUD may be the result of the interplay of the following:
- Genetic vulnerability
- Environmental influences (eg. prenatal exposure, parenting, peer influence)
- Specific personality traits (eg. neuroticism, impulsivity, extroversion)
- Cognitive functioning
A number of pathways have been hypothesized:
- Stress and negative-affect - drinking to relieve negative feelings; associated with stress and trauma in early development
- Pharmacological vulnerability - individual response to alcohol effects
- Deviance proneness - suggests link between social deviance in childhood resulting in deficient socialization
Clinical Presentation
Signs & Symptoms
Alcohol consumption can manifest in a number of ways ranging from asymptomatic to acute intoxication or withdrawal.
Medical manifestations
Common presentations include:
- Sleep disturbances
- Gastrointestinal reflux
- Hypertension
- Incidental abnormal liver enzymes including elevated GGT
Alcohol drinking may also manifest in;
- Trauma or injury
- Anxiety, depression, suicidality
- Comorbid substance use disorders
- Gastrointestinal symptoms
- Cardiac symptoms
- Central or peripheral neurologic symptoms
- Electrolyte disturbances
- Bone marrow suppression (eg. leukopenia, anemia, thrombocytopenia)
- Macrocytosis
- Malignancies of various organ systems
- Social/legal problems
Behavioural manifestations
- Recurrent drinking resulting in failure to fulfill role obligations
- Recurrent drinking in hazardous situations
- Continued drinking despite alcohol-related social problems
- Evidence of tolerance or withdrawal, or use of alcohol to avoid withdrawal
- Drinking in larger amounts or over longer period than intended
- Persistent desire or unsuccessful attempts to stop drinking
- Important activities impacted due to drinking
- Continued drinking despite understanding of problems caused by drinking
- Alcohol craving
AUD can also preset as acute alcohol intoxication or alcohol withdrawal, both of which are discussed separately.
History & Physical Exam
Patients suspected of AUD should be screened. A number of validated tests are available but the following are most frequently used with increasing level of involvement.
Single-item screening
- Do you sometimes drink beer, wine, or other alcoholic beverages?
- How many times in the past year have you had five (four for women) or more drinks in a day?
The test is positive if the response is >0 or if the patient is unsure (implies at least 1).
AUDIT-C
- How often do you have a drink containing alcohol?
- How many drinks containing alcohol do you have on a typical day when you are drinking?
- How often do you have six (four for women) or more drinks on one occasion?
Scoring is for each question ranges from 0-4. A score of ≥7 is suggestive of alcohol use disorder.
AUDIT
This is the most widely validated test consisting of 10 questions. Scores can range from 0-40 with a score ≥8 suggestive of unhealthy alcohol use.
Physical exam should evaluate for sequelae of chronic alcohol use. This consist of:
- Abdominal exam for liver disease, cirrhosis, and gastritis/acid reflux
- Signs of anemia or other bone marrow suppression
- Neuropsychiatric changes including peripheral neuropathy, gait changes
- Cardiovascular exam
Diagnosis
Criteria
The DSM-5-TR defines alcohol use disorder as a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:
- Alcohol is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
- A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
- Craving, or a strong desire or urge to use alcohol.
- Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
- Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
- Recurrent alcohol use in situations in which it is physically hazardous.
- Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
- A markedly diminished effect with continued use of the same amount of alcohol.
- Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for alcohol
- Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
Alcohol use disorder is considered in early remission if criteria was met previously but none are met for at least 3 months, and in sustained remission if none are met for ≥12 months.
Work-up
There is typically no associated workup for alcohol use disorder. However, some laboratory studies may be used to assess the medical impact of alcohol consumption:
- Liver enzymes (AST/ALT of 2 suggests alcohol-induced liver disease)
- CBC (for anemia)
- GGT - indicator of excessive alcohol use
Red Flags / Complications
Liver:
- Alcoholic liver disease
Pancreas: - Acute and chronic pancreatitis
Cardiac: - Alcoholic cardiomyopathy
- Atrial fibrillation (“holiday heart”)
Neurologic: - Wernicke-Korsakoff
- Peripheral neuropathy
- Cerebellar degeneration.
GI: - Gastritis
- Peptic ulcer disease
- Esophageal varices
Hematologic: - Macrocytic anemia
- Thrombocytopenia
Endocrine/metabolic: - Hypoglycemia
- Electrolyte abnormalities
Psychiatric: - Depression
- Anxiety
- Suicidality
Injury risk: - Falls
- MVCs
- Trauma
Fetal: - Fetal Alcohol Spectrum Disorder (FASD)
Management
While abstinence is the primary goal of treatment, reduction may be initial goals especially in patients who are not ready to quit entirely. Establishing treatment goals with the patient is vital for successful management.
Psychosocial Interventions
In patients with mild alcohol use disorder, psychosocial interventions may be sufficient.
Options include:
- Brief motivational counseling
- Participation in a mutual help group
- Community reinforcement and family therapy
Pharmacological
For patients with moderate or severe alcohol use disorder, first-line treatment typically consist of both psychosocial interventions in addition to medication.
Several agents are effective for treatment:
- Naltrexone
- Acamprosate
- Disulfiram
- Topiramate
Nutritional supplementation may include:
- B-vitamins
- Electrolytes prn
- Folic acid