Alcohol Use Disorder


Article Author:
Sara Nehring


Article Editor:
Andrew Freeman


Editors In Chief:
Anthony Silva


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
11/22/2018 1:07:29 PM

Introduction

Alcohol misuse has been linked to numerous social, economic, and health problems. Estimates vary but have suggested that up to 40% of patients have experienced complications of alcohol misuse.  In the United States, 138.3 million people age 12 and older, surveyed, report that they actively use alcohol, according to the 2015 National Survey on Drug Use and Health.  Of those, 48.2% report that they had binge drinking episode(s) within 30 days before taking the survey.  Of those who reported binge drinking, 26% reported heavy alcohol use, defined as binge drinking five or more days in the previous 30 days, which accounts for 12.5% of total alcohol users. This means that 5.9%, or 15.7 million people in the United States aged 12 and older, meet criteria for an alcohol use disorder (see image for criteria). More than 85,000 deaths per year can be attributed to alcohol.[1][2][3]

Etiology

Although the pathogenesis of alcohol use disorder is not strictly known, several factors are thought to contribute to its development. These include environmental influences, such as home environments, peer interactions, genetic factors, the level of cognitive functioning, and certain existing personality disorders. Some of the genes suspected include GABRG2 and GABRA2, COMT Val 158Met, DRD2 Taq1A, and KIAA0040.  Personality disorders associated with the development of an alcohol use disorder include disinhibition and impulsivity-type disorders, as well as depressive and socialization-related disorders.[4]

Epidemiology

According to the 2015 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Administration, an estimated 20.8 million Americans age 12 and older had a substance use disorder, of which 15.7 million were alcohol use disorders.  Of those, 2.7 million had an illicit drug use disorder as well.  This number makes alcohol the leading substance abused in the United States.  Of the people with alcohol use disorder and illicit drug disorder, 623,000 of these were adolescents ages 12 to 17 (2.5% of all adolescents). Almost four million (3.8 million) individuals ages 18-25 (10.9% of young adults) and 11.3 million individuals 26 years or older (5.4%) had both an alcohol use disorder and illicit drug disorder. However, this number has been steadily declining since 2002. Almost half of the people with any substance abuse problem, including alcohol, also had a co-existing mental illness.[5][6][7]

Pathophysiology

Multiple theories have been suggested as to why some people develop alcohol use disorders. Some of the more evidence-supported theories include positive-effect regulation, negative-effect regulation, pharmacological vulnerability, and deviance proneness. Positive-effect regulation results in drinking for positive rewards (such as feelings of euphoria). Negative-effect regulation is seen when one drinks to cope with feelings of a negative nature, such as depression, anxiety, or feelings of worthlessness. Pharmacological vulnerability makes a note of an individual's varied response to both acute and chronic effects of alcohol intake and the individual differences in the body's ability to metabolize the alcohol. Deviance proneness speaks more to an individual's tendency towards deviant behavior established during their childhood, often due to a deficiency in socialization at an early age.

Toxicokinetics

The metabolism of alcohol is affected by many factors. Females tend to eliminate alcohol faster than men, although their first-pass metabolism is slower due to lower antidiuretic hormone (ADH) levels, resulting in higher blood alcohol concentration initially. Fetal livers also eliminate alcohol more slowly due to CYP2E1 and ADH not being fully expressed.  Native Americans eliminate alcohol more quickly as well, due to the expression of beta-3 Class 1 ADH isoforms as opposed to subjects only expressing the beta-1 isoform. Alcohol metabolism is also lower in a fasting state, as when one is fed.  This is due to the lower ADH levels seen in the fasting state. There is also an impact on alcohol elimination seen with a time of day; the highest elimination is seen at the end of the daily dark period. Heavy drinking also increases the rate of elimination, although this does eventually slow, once the advanced liver disease is present. Medications that act as ADH inhibitors will slow the alcohol elimination rate. H2 receptor blockers will also inhibit ADH, thereby reducing the first-pass metabolism in the stomach and increasing blood alcohol levels.

History and Physical

History gathering will often reveal reported episodes of binge drinking of four or five or more drinks at a time. Use of CAGE questionnaire will reveal a score of 2 or greater (CAGE means (1) have you ever felt you should Cut down on your drinking, (2) have you ever been Annoyed by people criticizing your drinking, (3) have you ever felt Guilty about your alcohol use, or (4) have you ever needed an Eye-opener to steady your nerves or get rid of a hangover). The patient may also report frequent falls, blackout spells, unsteadiness, or visual disturbances. They may report seizures if they went a few days without drinking, or tremors, confusion, emotional disturbances, and frequent job changes. They may also report social issues, such as job termination, separation/divorce, estrangement from family, of loss of their home. They may also report sleep disturbances.

The patient may have hypertension (HTN) or insomnia initially. In later stages, the patient may complain of nausea/vomiting, hematemesis, abdominal distension, epigastric pain, weight loss, jaundice, or other symptoms or signs suggestive of liver dysfunction. They may be asymptomatic early on.

On exam, they may exhibit signs of cerebellar dysfunction, such as ataxia or difficulty with fine motor skills. They may exhibit slurred speech, tachycardia, memory impairment, nystagmus, disinhibited behavior, or hypotension. They may present with tremors, confusion/mental status changes, asterixis, ruddy palms, jaundice, ascites, or other signs of advanced liver disease. There may also be spider angiomata, hepatomegaly/splenomegaly (early; liver becomes cirrhotic and shrunken in advanced disease). They may develop bleeding disorders, anemia, gastritis/ulcers, or pancreatitis as complications of the alcohol use. Labs will reveal anemia, thrombocytopenia, coagulopathy, hyponatremia, hyperammonemia, elevated ammonia levels, or decreased B12/folate levels as the advanced liver disease develops.

Evaluation

Evaluation should include questions about alcohol use, specifically how often and how much. A CAGE questionnaire as described above should be used, as well as the screening questions for alcohol use disorder that are displayed in the image below. The practitioner should elicit a family history regarding alcohol and other substance use disorders, as well as a family and personal history of any psychiatric disorders. The patient should be screened for any medical or behavioral complications of alcohol abuse, such as macrocytic anemia, elevated liver enzymes, coagulopathies, pancreatitis, frequent falls, job loss, relationship issues, or aberrant behaviors such as risky sexual behavior or impulsiveness.[8][9]

Treatment / Management

Some treatment foci that have demonstrated promise include evidence-based motivational interviewing. This particular approach helps the patients explore the reasons behind their ambivalence with respect to changing their behavior or alcohol cessation to change their substance abuse-related behaviors with a personalized assessment of risks and needs. Other therapies include cognitive behavior therapy, 24-hour residential facilities that aim to treat medical as well as psychiatric complications or comorbidities associated with the alcohol use and process of cessation. There are also multiple programs, such as Alcoholics Anonymous or other 12-step programs that focus on group support/mentors that can provide a source of assistance with the maintenance of abstinence. Many patients have lapses during their lifetime and will require initiation of differing intensities of therapy throughout their lifetime.[10][11]

Differential Diagnosis

  • Bipolar disorder
  • Panic disorder
  • Anxiety disorder

Pearls and Other Issues

Complications of alcohol use disorders can be far-reaching and can impact a patient's socioeconomic status, mental health, interpersonal relationships, employment, and physical well-being.

Early intervention and repeated non-malignant discussions between the patient and provider are important.

The patient's successes should be noted and resources for continued efforts offered at each visit.

Discussion regarding barriers to the patient seeking cessation or assistance should occur to find new ways to approach the alcohol use disorder (AUD) in the hope of improving successful cessation of the behaviors.

 

Enhancing Healthcare Team Outcomes

Alcohol abuse disorder is very common in the US. Unfortunately, most people never come to medical attention until they have a medical problem or get involved with the legal system. The repercussions of alcoholism go way beyond just addiction; the disorder can create havoc in the lives of the family, friends and lead to difficulties in interpersonal and professional relationships. Alcoholics never seek help on their own. All healthcare workers have a responsibility to watch out for alcoholics and make appropriate referrals. The prognosis for most alcoholics is guarded; with less than 20-30% discontinuing drinking. Unfortunately, in many instances some of the organ damage is often irreversible. The key is to educate the patient and the family about the destruction that alcohol can cause. Referral to alcoholics anonymous is recommended, but data indicate that compliance is often low. [1][8](Level V)


  • Image 5611 Not availableImage 5611 Not available
    Contributed by Sara M Nehring
Attributed To: Contributed by Sara M Nehring

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Alcohol Use Disorder - Questions

Take a quiz of the questions on this article.

Take Quiz
Which nutritional substrate is most likely depleted first in an individual with severe alcohol use disorder?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What type of hallucinations do patients with severe alcohol use disorder tend to develop initially?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the first treatment for a patient with alcohol use disorder with depression?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
According to the National Institute on Alcohol Abuse and Alcoholism, how many drinks per week will place an adult male at "at-risk"?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
According to the NIAAA (National Institute on Alcohol Abuse and Alcoholism), which is considered a "standard" drink?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which statement is true regarding alcohol use among adults in the United States?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which statement regarding education and alcohol/drug users is TRUE?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the first step to take with a coworker who has alcohol on his breath?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most effective treatment for patients suffering from alcohol use disorder?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
One smells alcohol on a co-worker who is slurring his speech. He is also providing direct patient care. Which of the following is the recommended response?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements reflects insight into one's alcohol use disorder?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What type of non-medication treatment for alcohol use disorder has the best long term success?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What special concern is there during a surgical procedure on a patient with known alcohol use disorder who is not acutely intoxicated?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following vitamins is necessary for patients with alcohol use disorder?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which metabolic change is commonly seen in patients with alcohol use disorder?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the true statement about alcohol use disorder among older patients.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the best method of screening for alcohol use disorder?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What should the focus of occupational therapy involvement in the treatment of patients with substance use disorder?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the prevalence of alcohol use disorder in the United States?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements shows denial in a patient suffering from alcohol use disorder?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 67-year-old male presents with a vague history of not feeling well, anxiety, and restlessness. He has had several admissions over the past few months for falls, hypoglycemia, and abdominal discomfort. He simply is unable to provide any type of medical history, and his medical chart is not yet available. On a physical exam, you note that he has tachypnea, marked gynecomastia, and spider angiomas. What is the initial working diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 54-year-old male presents complaining of "the shakes." He reports a history of chronic alcohol use of 1 pint of vodka daily. He also has a history of HIV and prior intravenous drug use but has completely abstained for the last 5 years. He has a poor appetite due to nausea in the last 2 days with his last alcohol intake 12 hours ago. His point of care glucose is 235 mg/dL. His vital signs are temperature 37.9 C, heart rate 110 beats/min and irregular to palpation, blood pressure 155/90 mmHg, respirations 22, and pulse oximetry 99% on room air. Which of the following is least likely to be a concomitant diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Alcohol Use Disorder - References

References

Patigny P,Zdanowicz N,Lepiece B, How should psychiatrists and general physician communicate to increase patients' perception of continuity of care after their hospitalization for alcohol withdrawal? Psychiatria Danubina. 2018 Nov     [PubMed]
Marel C,Sunderland M,Mills KL,Slade T,Teesson M,Chapman C, Conditional probabilities of substance use disorders and associated risk factors: Progression from first use to use disorder on alcohol, cannabis, stimulants, sedatives and opioids. Drug and alcohol dependence. 2018 Nov 3     [PubMed]
Jerlhag E, Gut-brain axis and addictive disorders: A review with focus on alcohol and drugs of abuse. Pharmacology     [PubMed]
Pavón FJ,Serrano A,Stouffer DG,Polis I,Roberto M,Cravatt BF,Martin-Fardon R,Rodríguez de Fonseca F,Parsons LH, Ethanol-induced alterations in endocannabinoids and relevant neurotransmitters in the nucleus accumbens of fatty acid amide hydrolase knockout mice. Addiction biology. 2018 Nov 13     [PubMed]
Witkiewitz K,Kranzler HR,Hallgren KA,O'Malley SS,Falk DE,Litten RZ,Hasin DS,Mann KF,Anton RF, Drinking Risk Level Reductions Associated with Improvements in Physical Health and Quality of Life Among Individuals with Alcohol Use Disorder. Alcoholism, clinical and experimental research. 2018 Nov 5     [PubMed]
Degenhardt L,Bharat C,Bruno R,Glantz MD,Sampson NA,Aguilar-Gaxiola S,Alonso J,Andrade LH,Bunting B,Caldas-de-Almeida JM,Cia AH,Gureje O,Karam EG,Khalaf M,McGrath J,Moskalewicz J,Lee S,Mneimneh Z,Navarro-Mateu F,Sasu CC,Scott K,Torres Y,Poznyak V,Chatterji S,Kessler RC, Concordance between the diagnostic guidelines for alcohol and cannabis use disorders in the draft ICD-11 and other classification systems: Analysis of data from the WHO's World Mental Health Surveys. Addiction (Abingdon, England). 2018 Oct 29     [PubMed]
Mannes ZL,Hearn LE,Zhou Z,Janelle JW,Cook RL,Ennis N, The association between symptoms of generalized anxiety disorder and appointment adherence, overnight hospitalization, and emergency department/urgent care visits among adults living with HIV enrolled in care. Journal of behavioral medicine. 2018 Nov 1     [PubMed]
Curry SJ,Krist AH,Owens DK,Barry MJ,Caughey AB,Davidson KW,Doubeni CA,Epling JW Jr,Kemper AR,Kubik M,Landefeld CS,Mangione CM,Silverstein M,Simon MA,Tseng CW,Wong JB, Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Nov 13     [PubMed]
Hellberg SN,Russell TI,Robinson MJF, Cued for risk: Evidence for an incentive sensitization framework to explain the interplay between stress and anxiety, substance abuse, and reward uncertainty in disordered gambling behavior. Cognitive, affective     [PubMed]
Kranzler HR,Soyka M, Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review. JAMA. 2018 Aug 28     [PubMed]
Godderis L,Boonen E,Cabrera Martimbianco AL,Delvaux E,Ivanov ID,Lambrechts MC,Latorraca COC,Leppink N,Pega F,Prüss-Ustün AM,Riera R,Ujita Y,Pachito DV, WHO/ILO work-related burden of disease and injury: Protocol for systematic reviews of exposure to long working hours and of the effect of exposure to long working hours on alcohol consumption and alcohol use disorders. Environment international. 2018 Nov     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Certified Nursing Assistant. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Certified Nursing Assistant, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Certified Nursing Assistant, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Certified Nursing Assistant. When it is time for the Certified Nursing Assistant board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Certified Nursing Assistant.