Psychiatry/Behavioral · PANCE / PANRE

Alcohol Use Disorder (AUD)

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

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.

Try two board-style Alcohol Use Disorder questions

Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.

Question 1PsychiatryMedium
A 62-year-old woman with alcohol-related cirrhosis (Child-Pugh class B) is admitted for management of alcohol withdrawal. She is tremulous, diaphoretic, and tachycardic with a CIWA-Ar score of 18. Labs reveal AST 142 U/L, ALT 78 U/L, total bilirubin 3.1 mg/dL, INR 1.6, and albumin 2.8 g/dL. The team plans to initiate a benzodiazepine for symptom-triggered therapy. Which of the following benzodiazepines is the most appropriate choice?
  • AAlprazolam
  • BDiazepam
  • CChlordiazepoxide
  • DLorazepam
Reveal answer & full explanation
Correct answer: D — Lorazepam
  • AAlprazolam
  • BDiazepam
  • CChlordiazepoxide
  • DLorazepam✓

Why Lorazepam is correct

  • In patients with significant hepatic impairment, benzodiazepines that undergo only phase II hepatic metabolism (glucuronide conjugation) are preferred, because conjugation is relatively preserved in cirrhosis whereas phase I oxidation via CYP450 is impaired.
  • The mnemonic LOT — Lorazepam, Oxazepam, Temazepam — identifies the three benzodiazepines safe in liver disease and the elderly.
  • Lorazepam undergoes glucuronidation only, has no active metabolites, and is preferred for alcohol withdrawal in cirrhosis.

Why the others are wrong

  • B) Diazepam — undergoes extensive CYP-mediated oxidation to long-acting active metabolites (desmethyldiazepam, oxazepam) that accumulate in cirrhosis and cause oversedation and prolonged encephalopathy.
  • C) Chlordiazepoxide — similar problem; long half-life and active oxidative metabolites make it unsafe in advanced liver disease despite being a standard first-line agent in patients with normal hepatic function.
  • A) Alprazolam — short-acting but still requires CYP3A4 oxidation; accumulates in cirrhosis and also has high abuse/dependence potential, making it a poor choice for alcohol withdrawal.

Additional high-yield points

  • In any cirrhotic or elderly patient needing a benzodiazepine, default to lorazepam, oxazepam, or temazepam.
Question 2PsychiatryMedium
A 55-year-old man with severe alcohol use disorder completes medically supervised detoxification during a hospitalization. He is motivated to remain abstinent but reports strong daily cravings for alcohol. He takes no opioid medications and has no history of opioid use disorder. Which of the following medications is most appropriate to reduce his alcohol cravings?
  • ALorazepam
  • BNaltrexone
  • CDisulfiram
  • DSertraline
Reveal answer & full explanation
Correct answer: B — Naltrexone
  • ALorazepam
  • BNaltrexone✓
  • CDisulfiram
  • DSertraline

Why Naltrexone is correct

  • Naltrexone is a mu-opioid receptor antagonist that blunts the rewarding effect of alcohol and directly reduces craving, which is exactly what this patient reports
  • It is a first-line anti-craving agent for alcohol use disorder per current APA and VA/DoD guidance and is a strong fit once detoxification is complete
  • It can be started while a patient is still drinking and does not require prior abstinence, unlike disulfiram
  • A monthly long-acting injectable formulation is available to support adherence; the stem confirms no opioid use, so there is no risk of precipitating opioid withdrawal

Why the others are wrong

  • Lorazepam — A benzodiazepine used for acute alcohol withdrawal (CIWA-guided), not relapse prevention; choosing it confuses the withdrawal phase, which is already complete, with ongoing craving reduction (right-drug-wrong-phase).
  • Disulfiram — Works by aversion (acetaldehyde accumulation causing flushing and nausea if alcohol is ingested) and deters drinking through fear of the reaction; it does not reduce craving as the lead-in specifically requires (buzzword-matching on 'alcohol use disorder').
  • Sertraline — An SSRI that treats comorbid depression or anxiety but has no established effect on craving or drinking outcomes in alcohol use disorder, so it targets the wrong problem for this lead-in (treating the comorbidity instead of the craving).
🔒 Free preview limit reached

Keep reading — start your free trial

You've read your 2 free diagnosis previews. Create your free account to unlock the full Alcohol Use Disorder (AUD) outline — plus all 514 diagnoses, 6,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.

Start your 7-day free trial → Sign in
Free to start · No credit card · Cancel anytime

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)

Practice Psychiatry/Behavioral questions on FirstPassPA

Turn this outline into retention. 6,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.

Answer the 2 free questions above → Get today's free question →

Related Psychiatry/Behavioral diagnoses

Major Depressive Disorder (MDD)Bipolar I DisorderGeneralized Anxiety Disorder (GAD)Panic DisorderObsessive-Compulsive Disorder (OCD)Post-Traumatic Stress Disorder (PTSD)SchizophreniaBorderline Personality Disorder (BPD)Antisocial Personality Disorder (ASPD)Attention-Deficit/Hyperactivity Disorder (ADHD)Autism Spectrum Disorder (ASD)Opioid Use Disorder (OUD)Stimulant Use DisorderAnorexia Nervosa

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.