Skip to content

Alcohol Use Disorder (AUD)

Description:
- Pattern of alcohol use causing significant physical, mental, or social dysfunction.
- Key features: tolerance, withdrawal, persistent use despite problems.
- Severity:
- Mild: 2-3 DSM-5 criteria met
- Moderate: 4-5 criteria
- Severe: ≥6 criteria

DSM-5 Criteria:
- Tolerance or withdrawal
- Loss of control over amount used
- Alcohol cravings or inability to cut down/quit
- Use during hazardous situations
- Large time spent using or recovering
- Continued use despite physical/psychological consequences (e.g., hypertension, depression)
- Continued use despite negative impact on relationships or obligations
- Abandonment of social/occupational activities

Low-Risk Drinking (NIAAA)

  • Men: ≤14 drinks/week or ≤4 drinks/occasion
  • Women: ≤7 drinks/week or ≤3 drinks/occasion
  • Even low-level use associated with grey matter reduction and cognitive impairment
  • Binge drinking: BAC 0.08 g/dL (~4 drinks women, 5 men in 2 hours)

Standard Drink:
- 14 g (0.6 fl oz) pure alcohol
- 12 oz beer (5% alcohol)
- 5 oz wine (12% alcohol)
- 1.5 oz distilled spirits (40% alcohol)

Geriatric Considerations

  • Multiple drug interactions
  • AUD symptoms may mimic chronic disease or dementia
  • Accelerated aging and increased risk of cognitive decline and dementia

Pediatric Considerations

  • Children of alcoholics at increased risk
  • 2.5% adolescents have AUD
  • 13.4% youth (12-20) report binge drinking in past month
  • Early-onset drinkers (<21 years) 4x risk compared to those starting >21 years

Epidemiology

  • Predominant age: 18-25 years; male:female ratio 3:1
  • Heavy/binge drinking common in young adults and increasing in middle-aged/older adults, especially women
  • 27% Americans ≥18 years reported binge drinking past month; 7% heavy use
  • 15 million adults (6%) with AUD in US
  • Alcohol misuse costs $249 billion (2010), causes ~88,000 deaths/year
  • Third leading cause of preventable death in US

Etiology and Pathophysiology

  • Multifactorial: genetic (50-60% risk), environmental, psychosocial
  • Alcohol is a CNS depressant: enhances GABA inhibition, blocks NMDA receptors

Risk Factors

  • Family history, depression, anxiety, bipolar, eating disorders
  • Tobacco/other substance abuse
  • Male gender, low socioeconomic status, unemployment, poor self-esteem
  • PTSD, antisocial personality, criminal behavior

General Prevention

  • Counsel patients with family history or risk factors
  • USPSTF (2018): screen adults for alcohol use, provide brief counseling for risky drinking

Commonly Associated Conditions

  • Cardiomyopathy, atrial fibrillation, hypertension
  • Peptic ulcer disease, cirrhosis, fatty liver, cholelithiasis, hepatitis, pancreatitis
  • Diabetes, malnutrition, upper GI malignancies
  • Peripheral neuropathy, seizures
  • Behavioral disorders (depression, bipolar, schizophrenia) often comorbid (>50% with substance abuse)

Diagnosis

Screening Tools

  • CAGE questionnaire: >2 positive answers = 74-89% sensitive, 79-95% specific; less sensitive in white women, college students, elderly
  • Single-question screen: "How many times in last year have you had X or more drinks in 1 day?" (X=5 men, 4 women); 81.8% sensitive, 79% specific
  • AUDIT: 10-item; >4 score = 70-92% sensitive
  • AUDIT-C: 3-item; >4 men, >3 women = concerning

History

  • Behavioral history, anxiety, depression, insomnia
  • Social dysfunction, relationship issues, domestic violence
  • Trauma, ED visits, motor vehicle accidents related to alcohol

Physical Exam

  • Fever, diaphoresis, agitation
  • Hypertension, cardiomyopathy, tachyarrhythmias
  • Aspiration pneumonia
  • Signs of liver disease, pancreatitis, esophageal varices
  • Myopathy, osteopenia/osteoporosis, bone marrow suppression
  • Neurologic signs: tremor, cognitive deficits, peripheral neuropathy, Wernicke-Korsakoff syndrome (ophthalmoplegia, ataxia, confusion)
  • Dermatologic: burns, bruises, poor hygiene, palmar erythema, spider telangiectasias

Differential Diagnosis

  • Other substance use disorders
  • Depression, dementia, cerebellar ataxia, CVA, essential tremor, seizures
  • Hypoglycemia, diabetic ketoacidosis, viral hepatitis

Diagnostic Tests & Interpretation

  • CBC, liver function tests, electrolytes, BUN/Cr, lipid panel, PT/INR, thiamine, folate
  • Hepatitis A, B, C serology
  • Amylase, lipase if GI symptoms
  • Labs indicative of chronic abuse: AST/ALT ratio >2.0, elevated GGT, carbohydrate-deficient transferrin, uric acid
  • Elevated MCV, prolonged PT, hypertriglyceridemia
  • Decreased serum protein, albumin, thiamine, folate
  • Brain CT/MRI: cortical atrophy, thalamic, basal forebrain lesions
  • Abdominal US: ascites, periportal fibrosis, fatty infiltration, inflammation
  • MELD score calculation
  • Abdominal US every 6 months for hepatocellular carcinoma screening if cirrhosis present

Treatment

General Measures

  • Brief interventions and counseling effective
  • Treat comorbidities cautiously (avoid benzodiazepines if possible)
  • Group/12-step programs (Alcoholics Anonymous) improve insight and acceptance

Medications

First Line (post withdrawal):
- Naltrexone: 50 mg/day PO or 380 mg IM monthly; opiate antagonist; reduces craving and relapse; contraindicated with opioids; caution pregnancy/hepatic failure
- Acamprosate (Campral): 666 mg PO TID; reduces relapse risk; use 1 year if helpful; caution if low CrCl
- Disulfiram: 250-500 mg/day PO; psychological deterrent; severe risks; most effective with supervision; caution with esophageal varices risk

Supplements:
- Thiamine 100 mg/day (IV prior to glucose)
- Folic acid 1 mg/day
- Multivitamins daily

Second Line (off-label):
- Topiramate: 25-300 mg/day PO
- Baclofen: start 5 mg TID, max 60 mg/day
- SSRIs if comorbid depression
- Varenicline may help smokers with AUD

Referral

  • Addiction specialist
  • 12-step or long-term programs
  • Behavioral health professionals

Additional Therapies

  • Cognitive behavioral therapy
  • Motivational interviewing
  • Contingency management

Ongoing Care

  • Weekly follow-up initially; spacing to 4 weeks as stable
  • Daily visits for outpatient detox discouraged for heavy abuse
  • Early outpatient rehab weekly visits

Patient Education

  • Substance Abuse and Mental Health Services Administration (SAMHSA): (800) 662-HELP, https://www.samhsa.gov/find-help
  • Alcoholics Anonymous: https://www.aa.org/
  • Secular Organizations for Sobriety: https://www.sossobriety.org/

Prognosis

  • Chronic relapsing disease; mortality >2x general population
  • Death 10-15 years earlier on average
  • Abstinence improves survival, mental health, family, employment
  • 12-step, cognitive behavioral, motivational therapies effective in first year post treatment

Additional Reading

  • Nadkarni A, Massazza A, Guda R, et al. Common strategies in psychological interventions for AUD: meta-review. Drug Alcohol Rev. 2023;42(1):94-104.
  • NIAAA Clinician's Guide: https://www.niaaa.nih.gov/health-professionals-communities
  • NIAAA Rethinking Drinking: https://www.rethinkingdrinking.niaaa.nih.gov
  • Tucker JA, Chandler SD, Witkiewitz K. Epidemiology of recovery from AUD. Alcohol Res. 2020;40(3):2.

ICD10 Codes

  • F10.10 Alcohol abuse, uncomplicated
  • F10.20 Alcohol dependence, uncomplicated
  • F10.239 Alcohol dependence with withdrawal, unspecified

Clinical Pearls

  • CAGE questionnaire: >2 positive answers = 74-89% sensitive, 79-95% specific; less sensitive for some groups
  • Single-question screen: “How many times in last year had ≥X drinks in one day?” (X=5 men, 4 women); 81.8% sensitive, 79% specific
  • NIAAA "at-risk" drinking: men >14 drinks/week or >4/occasion; women >7/week or >3/occasion