Psychiatry/Behavioral · PANCE / PANRE

Alcohol Use Disorder (AUD)

Problematic alcohol use causing impairment or distress, meeting >=2 of 11 DSM-5-TR criteria in 12 months.

Also known as: AUD, alcoholism, alcohol dependence, alcohol abuse

Overview

A pattern of alcohol use leading to clinically significant impairment or distress, defined by >=2 of 11 DSM-5-TR criteria within a 12-month period. Severity: mild (2-3), moderate (4-5), severe (>=6).

Epidemiology

Past-year prevalence ~10-14% of US adults; lifetime ~30%. Male-to-female ratio narrowing; high rates in young adults and those with psychiatric comorbidity.

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Risk factors

Family history (heritability ~50%)
Early-onset drinking (<14 years)
Comorbid psychiatric illness — mood, anxiety, PTSD, ASPD, ADHD
Trauma history
Male sex, certain occupations, social environment
Other SUDs

Pathophysiology

Chronic alcohol use produces neuroadaptation: upregulated glutamatergic (NMDA) and downregulated GABAergic tone, accounting for tolerance and withdrawal phenomena. Mesolimbic dopaminergic reinforcement drives compulsive use.

Clinical presentation

Symptoms

DSM-5-TR criteria: larger amounts/longer than intended; persistent desire/unsuccessful attempts to cut down; great time spent obtaining/using/recovering; craving; failure to fulfill role obligations; continued use despite social/interpersonal problems; reduction in activities; use in physically hazardous situations; continued use despite physical/psychological problems; tolerance; withdrawal
Withdrawal — CIWA-Ar tracks severity: tremor, anxiety, autonomic hyperactivity, nausea, headache, hallucinations, seizures, delirium tremens

Signs / physical exam

Hepatomegaly, spider angiomata, palmar erythema, caput medusae in chronic users
Macrocytosis, elevated GGT, AST:ALT >2:1
Withdrawal: tachycardia, hypertension, tremor, diaphoresis, agitation

Differential diagnosis

Mood/anxiety disorder — May drive self-medication; reassess after sustained abstinence
PTSD — Frequent comorbidity; address trauma in treatment plan
Withdrawal mimics: hyperthyroidism, sepsis, sympathomimetic intoxication — Vital signs, TSH, infectious workup
Delirium from other causes — Especially in hospitalized; consider Wernicke encephalopathy

Diagnostic workup

Diagnostic criteria

DSM-5-TR: A problematic pattern of alcohol use leading to clinically significant impairment or distress, with >=2 of 11 criteria in 12 months. Severity: 2-3 mild, 4-5 moderate, >=6 severe. USPSTF recommends screening all adults with AUDIT-C or single-item screen.

Labs

CBC (macrocytosis), CMP (LFTs, electrolytes, glucose, Mg, phosphate), GGT, lipase if indicated
PT/INR (synthetic liver function)
Urine drug screen, breath alcohol
Hepatitis B/C, HIV; consider thiamine, folate
AUDIT-C screen >=4 (men) or >=3 (women) prompts full AUDIT and diagnostic interview

Imaging

Abdominal ultrasound or FibroScan for cirrhosis evaluation
CT head for trauma/altered mental status

Diagnostic algorithm

flowchart TD
  A[Last drink] --> B[6-12 h: Tremor, anxiety,<br/>insomnia, GI upset]
  B --> C[12-48 h: Risk of<br/>withdrawal seizures]
  C --> D[12-24 h: Alcoholic<br/>hallucinosis - intact sensorium]
  D --> E[48-96 h: Delirium tremens<br/>autonomic instability, confusion]
  E --> F[Mortality 5% treated<br/>up to 35% untreated]
  C --> G[Treat with symptom-triggered<br/>benzodiazepine + thiamine]

Timeline of alcohol withdrawal syndromes from last drink to delirium tremens.

Treatment

First-line

Behavioral: motivational interviewing, CBT, 12-step facilitation, contingency management, mutual help (AA, SMART Recovery)
Pharmacotherapy — naltrexone (oral 50 mg/day or IM XR 380 mg monthly) reduces heavy drinking and craving
Acamprosate (333 mg three tablets TID) — supports abstinence; safe in liver disease, requires renal dosing
Disulfiram — aversive deterrent; requires motivation and supervision; avoid in CAD, severe liver disease
Withdrawal management: benzodiazepine (lorazepam, diazepam, chlordiazepoxide) symptom-triggered dosing using CIWA-Ar; thiamine BEFORE glucose to prevent Wernicke; folate, multivitamin, magnesium

Second-line / adjunct

Topiramate, gabapentin — emerging evidence for reducing heavy drinking
Treat comorbid psychiatric illness; integrated care superior to sequential
Residential rehabilitation for severe disease
Hospitalization for complicated withdrawal, severe medical illness, or DT risk

Complications

Withdrawal seizures (peak 12-48 h), delirium tremens (48-96 h, mortality ~5% treated, ~35% untreated)
Wernicke encephalopathy (ophthalmoplegia, ataxia, confusion) and Korsakoff syndrome (anterograde amnesia, confabulation)
Cirrhosis, hepatocellular carcinoma, pancreatitis
Cardiomyopathy, hypertension, atrial fibrillation ('holiday heart')
Cancer (oropharyngeal, esophageal, breast, colorectal)
Fetal alcohol spectrum disorders
Trauma, motor vehicle crashes, suicide

PANCE pearls

Give IV thiamine 500 mg TID x 3 days for suspected Wernicke (not 100 mg PO which underdoses) — BEFORE glucose to prevent precipitating encephalopathy.
DT typically begins 48-96 hours after last drink — risk factors include prior DT, prior withdrawal seizures, autonomic hyperactivity, electrolyte derangements.
Naltrexone is contraindicated with opioid use (precipitates withdrawal); confirm opioid-free x 7-10 days before starting.
AUDIT-C is a 3-question rapid screen; positive prompts brief intervention and consideration of pharmacotherapy.
Pharmacotherapy is markedly underutilized — offer to every patient with AUD.

References

USPSTF 2018 — Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: USPSTF Recommendation. JAMA 2018
VA/DoD 2021 — VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders (2021)
NIAAA / SAMHSA — NIAAA Clinician's Guide; SAMHSA TIP 49: Incorporating Alcohol Pharmacotherapies
DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)

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