Alcohol Use Disorders
Author / Curator: Christopher Steele, MD MPH MS
*** This page has links for screening, therapy groups, patient education and medical therapy for patients.
(1) Be concise.
(2) Be evidence-based. (Everything should have a reputable citation and resource)(3) Be clinically relevant. (Avoid unnecessary discussion of pathophysiology and epidemiology if it does not help clinical decision-making).
- 1 Learning Objectives
- 2 Top Teaching Points
- 3 Background
- 4 Diagnosis and Screening
- 5 Management
- 6 Trial Summaries
- 7 Ongoing controversies / New updates
- 8 Teaching Resources
- 9 References
- Identify and define unhealthy alcohol consumption, including what is alcohol use disorder.
- Understand the importance of the PCP to be the frontline to identify alcohol use disorders.
- Know the unhealthy side-effects drinking has to the body and be able to communicate that to patients.
- Determine how to effectively screen patients for alcohol use disorders.
- Know how to manage patients with alcohol use disorders, including providing or referring to services such as brief counseling, medical advise, support groups, detoxification, and pharmacotherapy.
Top Teaching Points
- A patient is considered a high-risk drinker based on exceeding a daily or weekly limit of a standard drink. For men, this is more than 2 standard drinks a day or 15 or more standard drinks a week and for a female this is more than 1 standard drink a day or 8 or more standard drinks a week.
- Alcohol use disorder is a term coined in the DSM-V to combine alcohol dependence and abuse. This disorder is sub-classified into mild, moderate and severe and is not based on quantity of alcohol, but more so on the effects it has on a patient's life. 
- The USPSTF recommends screening people for alcohol use disorders during their annual visit (grade B evidence).
- It is estimated that 10-36% of patients coming to primary care providers have an alcohol use disorder.
- Providers should screen with AUDIT-C first, and if a patient is positive, complete the full AUDIT screening tool.
- AUDIT was found to be a superior screening exam compared to CAGE screening tool for patients with heavy drinking (>14 drinks/week) or active alcohol abuse or dependence.
- Brief Interventions are a good first step in helping someone combat alcohol use disorders and has been shown to lower the amount of drinks consumed in a week, less medical visits and lasting effects for at least 2 years.
- There are three medications approved to treat alcohol use disorders. They are acamprosate, disulfiram and naltrexone. 
Alcoholism is a major issues in the United States and alcohol use disorders plague nearly 10-36% of patients seen at a PCP clinic. In 2000, alcohol was estimated to cause 85,000 premature deaths in the United States and is the third preventable cause of death following smoking and obesity.  Approximately 10.5% to 16% of patients are adequately screened for alcohol use disorders during their PCP visits. 
The National Institute of Alcohol Abuse and Alcoholism (NIAAA) defines heavy drinking based on gender and number of drinks over either a day or weeks time. This method is better at determining if a patient is at risk of an AUD and may not be introspective about their disease impact on others. The following table summarizes the criteria to define heavy drinking:
|National Institute on Alcohol Abuse and Alcoholism Definition of Heavy Drinking|
|Drinks in 1 day||Drinks in 1 week|
|Male||5 or more standard drinks||15 or more standard drinks|
|Female||4 or more standard drinks||8 or more standard drinks|
Standard Drink Size
- 1 Beer = 12 oz
- 1 Glass of wine = 5 oz
- 1 Shot of hard alcohol = 1.5 oz
The downfall of the NIAAA definition is it does not measure the impact the drinking has on the patient's life. The DSM-V has combined the diagnoses of alcohol dependence and alcohol abuse into the collective term alcohol use disorder (AUD) which is discussed more below and focuses more on the impact of the drinking on the patient. The following section will go over how a practitioner could screen and diagnose alcohol use disorder below.
Consequences of drinking
The consequences of alcohol use disorders is catastrophic and responsible for numerous deaths, accidents and social life problems in society. Nearly 1 in 3 deaths from suicide and motor vehicles crashes are attributed to alcohol intake.  Unhealthy drinking can lead to conditions such as hepatitis, cirrhosis, insomnia, macrocytic anemia, dementia and peripheral neuropathies related to thiamine deficiencies, worsening gout and cancers such as squamous cell esophageal and pharyngeal carcinomas, liver cancer and colon cancer. Patients may also drink alcohol as a means to treat an undiagnosed illness such as anxiety or serious mental illness such as depression, schizophrenia or bipolar disorder. Likewise, it is not appropriate to diagnose someone with a mental illness if there is concurrent alcohol use disorder since their symptoms may be all explained by alcohol.
Diagnosis and Screening
THE NIAAA definition of heavy drinking can be used as a cue to investigate into a patient's social history further through a screening tool such as the AUDIT-C. Unfortunately, there lacks specific biomarkers to screen for alcohol use disorders and a majority of the diagnosis comes from a patient feeling comfortable to disclose their drinking history. The doctor patient relationship is uncanny in allowing patients to feel comfortable to disclose their alcohol related issues.
The best initial screening test is the AUDIT-C, which is a modified version of the full AUDIT.   AUDIT screening tool was found to be a superior screening exam compared to CAGE screening tool for patients with heavy drinking (>14 drinks/week) or active alcohol abuse or dependence. As a result, the focus will be on AUDIT/AUDIT-C over CAGE.
The audit C asks 3 questions while the full audit asks 10 questions. Essentially, all practitioners should start off with the AUDIT-C and then progress to AUDIT if the earlier is positive.
Calculators for practitioners to screen their patients:
- AUDIT-C: https://www.mdcalc.com/audit-c-alcohol-use
- Positive for men if score is 4 or more, and for women a score of 3 or more.
If patient screens positive for the AUDIT-C, the AUDIT should be completed.
- AUDIT (Full): https://www.uptodate.com/contents/calculator-alcohol-consumption-screening-audit-questionnaire-in-adults-patient-education
Once a patient screens positive, the practitioner should take the next steps and diagnosed AUD.
DSM-V Alcohol Use Disorder (AUD)
The following is the way to make the diagnosis of AUD. 
In the past year, have you:
- Had times when you ended up drinking more, or longer than you intended?
- More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
- Spent a lot of time drinking? Or being sick or getting over the aftereffects?
- Experienced craving — a strong need, or urge, to drink?
- Found that drinking — or being sick from drinking — often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
- Continued to drink even though it was causing trouble with your family or friends?
- Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
- More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?
- Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?
- Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
- Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, sweating or sensed things that were not there?
Subcategorization: Practitioners then summate the total number of yes answers to determine if the AUD is mild, moderate, severe or present.
- Not an AUD - 0 to 1 yes response
- Mild AUD - 2 to 3 yes responses
- Moderate AUD - 4 to 5 yes responses
- Severe AUD - 6 or more yes responses
Brief Intervention and Patient Education
Brief interventions focused on behavioral counseling are the best approach for anyone identified to have high-risk drinking or an alcohol use disorder. Brief interventions are designed to be done by clinicians without formal training in counseling to help motivate patients to change their behaviors.
Brief alcohol interventions has moderate evidence behind reducing harmful alcohol consumption with possibly no real difference in outcomes when compared to longer counseling sessions. A meta-analysis of 19 trials found that brief interventions of about 15 minutes led to 5 less drinks per week, less medical visits over a year period and effects estimated to last nearly 2 years. A 21 study meta-analysis led to similar conclusions but found the benefits were greater for men than women.
There are many approaches towards brief motivation but the FRAMES approach provides a quick mnemonic style for healthcare providers to remember when accomplishing behavioral counseling. 
- Feedback: Let the patient know their drinking is a problem and evidence (e.g. screening or labs) that it has effected their lives.
- Responsibility: Help the patient realize it is their responsibility to cut their drinking down.
- Advice: Offer the advice that they should stop or cut down on their drinking.
- Menu: Provide options to achieve these goals and help them determine which option is best for them.
- Empathy: Demonstrate support on the challenges of stopping drinking and offer your support through the process.
- Self-efficacy: Motivate and empower the patient to go forth with the new change and be their own advocate through the process.
The other important aspect to change is patient education and making sure the patient understands the effects alcohol has on their body and lives. Most people may have a poor understanding of what alcohol can do to the body and may empower patients to make change. The following section summarizes great handouts for brief patient education:
- Patient Education Handouts: https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets
Many patients will engage in support groups to help them stay sober. The most popular option is the 12-step approach with the most famous being Alcoholic's Anonymous (AA). An 8 study meta-analysis of these support groups may help patients accept and keep in treatment programs, however, no studies have ever shown that this is effective to reduce alcohol use disorders in the general population. Despite this, some patients swear by this and it should be offered when available. Some patients may have issues with the religious connotation of AA and may wish to partake in other options such as SMART recovery or online forums. There is some evidence that online support groups are also a great alternative for patients who may not have access to a support group or want to preserve the anonymity. 
- Alcoholic's Anonymous (Find a Group): https://www.aa.org/pages/en_US/find-local-aa
- SMART Recovery (non-religious alternative to AA): https://www.smartrecovery.org/local/#s=1
- Alcohol Help Center (Online forum): http://alcoholhelpcenter.net/
Some people may feel that they are not able to stop drinking alcohol without medical intervention, but may either not meet criteria for inpatient admission or want to be treated in an outpatient setting. Another option to offer patients is non-inpatient admissions for alcohol detoxification.
- Treatment Center Finder: https://findtreatment.samhsa.gov/
|Pharmacotherapy Options for Alcohol Use Disorder |
|Medication||Mechanism of Action||Dosage*||Indications/Other Information|
|Approved by the FDA for Alcohol Use Disorders|
|666 mg three times daily||Contraindicated in renal failure.|
|Disulfiram||Aldehyde dehydrogenase inhibitor||250 mg daily, can titrate to 500 mg daily||Warn patients that it will result in flushing and severe illness when used with alcohol.|
|Naltrexone||Mu receptor antagonist||50 mg daily||Clinician should monitor liver function test (LFT) if prescribed.|
|Thiamine||Plays a role in nerve condution and pyruvate metabolism.||100 mg daily||For all alcoholics to prevent complications from thiamine deficiency.|
|Not Approved by the FDA for Alcohol Use Disorders|
|Gabapentin||GABA analog||900 mg, twice daily||Must lower the dose at chronic kidney disease stage 3a or worse.|
|Fluoxetine||Serotonin re-uptake inhibitor||Initial dose 20 mg can titrate to 80 mg daily||Should be used with patients who also have depression.|
|Ondansetron||Selective serotonin antagonist||Dosed at 4 mcg per kg per day||Only category B drug on the list. Should also watch for a prolonged QTc.|
|Topiramate||Multiple, including GABA agonist||Start with 25 mg daily and increas to a total of 300 mg twice daily||Should monitor both serum bicarbonate and ammonia levels. Only category D medication for pregnancy of those listed.|
*Must be dose-adjusted for people with acute kidney injury (AKI) or chronic kidney diseases.
- Gabapentin for treatment of AUD: 12-week double blinded study with 150 adult males prescribed 0 900 and 1800 mg per day dosing of gabapentin. Overall, they found 4% abstained from alcohol in the placebo group with 11% in the 900 mg dosed group and 17% in the 1800 mg dose without serious adverse events. They concluded that 1800 mg dose of gabapentin was effective at treating the symptoms related to alcohol abstinence such as sleep disturbances and cravings.
- AUDIT: The Alcohol Use Disorders Identification Test (AUDIT) was a WHO initiative developed from six countries that polled ~1900 people. The original question bank asked approximately 150 questions and the final study AUDIT itself was brought down to 10 questions that touched upon domains of alcohol consumption, drinking behaviors and social consequences of alcohol use. The study found that 94% of patients identified to have harmful drinking patterns had a score of 8 or more out of a maximum score of 40.
Ongoing controversies / New updates
- Alcoholic's Anonymous: The following link is an article that summarizes key points that people have for being for or against this organizations: https://www.thefix.com/content/aa-advocate-and-aa-critic-debate-pros-and-cons-12-step-model
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- United States Services Protective Task Force. USPSTF A and B Recommendations. Accessed on 5 March 2018.https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
- Buchsbaum DG, Buchanan RG, Centor RM, Schnoll SH, Lawton MJ. Screening for alcohol abuse using CAGE scores and likelihood ratios. Ann Intern Med. 1991;115:774–7.
- Bradley KA. et al. Screening for problem drinking: Comparison of CAGE and AUDIT. J Gen Intern Med. 1998 Jun; 13(6): 379–389.
- Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis.Arch Intern Med. 2005;165(9):986–995.
- Winslow BT, Hebert M. Medications for alcohol use disorders. Am Fam Physician. 2016 Mar 15;93(6):457-465.
- Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000 [published corrections appear in JAMA. 2005;293(3):293–294,298]. JAMA. 2004;291(10):1238–1245.
- Berger D and Bradley KA. Primary Care Management of Alcohol Misuse. Med Clin North Am. 2015 Sep;99(5):989-1016.
- McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–2645.
- L.R. McKnight-Eily, Y. Liu, R.D. Brewer, et al.Vital signs: communication between health professionals and their patients about alcohol use–44 states and the District of Columbia, 2011. MMWR Morb Mortal Wkly Rep, 63 (1)(2014), pp. 16-22
- J.B.A. MacLeod, D.W. HungerfordAlcohol-related injury visits: do we know the true prevalence in U.S. trauma centres Injury. 42 (9)2011, 922-926
- B.F. Grant, F.S. Stinson, D.A. Dawson, et al.Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry, 2004 61(8):807-816
- Bush K et al. The AUDIT Alcohol Consuption Questions (AUDIT-C): An effective brief screening test for problem drinking. Arch Internal Med. 1998 (3):1789-1795.
- Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grand M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption – II. Addiction. 1993;88:791–804.
- Searight HR. Realistic approaches to counseling in the office setting. Am Fam Physician. 2009 Feb 15;79(4):277-284.
- Kaner EF et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018 Feb 24;2:CD004148.
- Kaner EF, Beyer F, Dickinson HO, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007;(2).
- Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD005032.
- White A et al. Online alcohol interventions: a systemic review. J Med Internet Res. 2010 Dec 19;12(5):e62.
- Berger D, Bradley KA. Primary Care Management of Alcohol Misuse. Med Clin North Am. 2015 Sep;99(5):989-1016.
- "Acamprosate: Summary". IUPHAR/BPS Guide to Pharmacology. International Union of Basic and Clinical Pharmacology. Retrieved 11 March 2017.
Acamprosate is a NMDA glutamate receptor antagonist and a positive allosteric modulator of GABAA receptors.
- Mason BJ et al. Gabapentin Treatment for Alcohol Dependence: A Randomized Controlled Trial. JAMA Intern Med. 2014 Jan 1; 174(1): 70–77.