CD

Alcohol Use Disorder

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Alcohol Use Disorder, Alcohol Abuse, Alcohol Dependence, Alcoholism, Problem Drinking, Alcoholism Complications, Vitamin Deficiency in Alcoholism

  • See Also
  1. Chemical Dependency
  2. Alcohol Toxicity
  3. Alcohol Withdrawal
  4. Alcohol Detoxification
  5. Alcohol Detoxification in Ambulatory Setting
  • Epidemiology
  • General
  1. Prevalence
    1. Alcohol Dependence: 8-14% lifetime
    2. Alcohol Use Disorder
      1. Lifetime: 29% lifetime
      2. U.S. in 2024-2026: 28-29 Million in U.S. (10-14% one year)
  2. Typical age of onset: 15 to to 19 years
  3. Familial predisposition in Autosomal Dominant pattern
  4. Alcohol Use Disorder is responsible for 9 million emergency department visits per year in U.S.
  5. Alcohol-related deaths in U.S.: 178,000 per year (500 per day) in 2024
    1. Many regions of the U.S. see 80 deaths per 100,000 related to Alcohol (up from 7 per 100,000 in 1999)
    2. Alcohol related deaths in the U.S. is more than double that of Opioid related deaths/year (87,000 in 2024)
    3. [PubMed]
  1. Alcohol Impaired Driving Survey (n=102,263)
    1. Overall alcohol Impaired Driving in last month: 2.5%
    2. Lowest rate: Women over age 55 years old (0.1%)
  2. Predictors of alcohol Impaired Driving
    1. Men aged 21 to 34 years: 7%
    2. Over 4 Alcoholic drinks on 1 occasion in last month
    3. Greater than two Alcoholic drinks per day
  3. States of highest alcohol Impaired Driving
    1. Alaska
    2. Nevada
    3. Wisconsin
    4. Michigan
    5. North Dakota
  4. References
    1. Liu (1997) JAMA 277:122-5 [PubMed]
  1. Sinclair Lewis
  2. Edgar Allen Poe
  3. Dylan Thomas
  4. F. Scott Fitzgerald
  5. Jim Thorpe
  6. Sir Winston Churchill
  7. Ulysses S. Grant
  8. Ernest Hemingway
  9. Vincent van Gogh
  • Pathophysiology
  1. See Addiction Pathophysiology
  2. Substance Abuse or Alcoholism Definition Criteria
    1. Compulsion-Preoccupation
    2. Use despite adverse consequences
    3. Loss of Control
    4. Denial
  3. Mechanism
    1. Alcohol increases activity at GABA Receptors with secondary CNS depression
      1. Chronic Alcohol use down regulates GABA Receptors and up regulates NMDA receptors
        1. Results in hyperexcitability and sustained Alcohol seeking behavior
      2. Alcohol Withdrawal results in excessive excitation
    2. Limbic System drive state
      1. Alcohol stimulates Dopamine via mesolimbic system
      2. Triggers Alcohol-related pleasure and reward
      3. Dopamine sensitivity decreases, requiring greater Alcohol amounts to trigger same effect
    3. Alcoholics have lower level of endogenous endorphins
      1. Need TIQs externally from Alcohol to feel normal
  4. Other preparation misued for their Alcohol content
    1. Mouthwash
    2. Vanilla extract
    3. Ethanol-based hand sanitizer (especially in health care centers)
      1. Small ingestions of hand sanitizer can cause significant Alcohol Intoxication (>60% Alcohol)
      2. Some users extract the Alcohol content with salt
  1. One ounce Alcohol takes 1 hour, mouth to excretion
  2. Absorption
    1. No Digestion required before absorption
    2. Small amount absorbed in Stomach
    3. Most Alcohol absorbed in Small Intestine (duodenum)
    4. Absorption is affected by ingested food, gastrointestinal transit time
  3. Metabolism
    1. Alcohol converted to acetaldehyde
    2. Acetaldehyde converted in liver to acetic acid
  4. Excretion
    1. Renal excretion: 10%
    2. Hepatic excretion: 90%
  • History
  1. See Alcoholism Screening
    1. AUDIT-C (or full AUDIT tool, or single question screening)
    2. CAGE Questions
    3. NIAAA Quantity and Frequency Questionnaire
  2. See Alcohol Use Disorder Diagnosis
    1. Alcohol Use Disorder integrates Alcohol Abuse and dependence into a single diagnosis
  3. See Substance Abuse Evaluation
  4. See medical complications and comorbid conditions below
  5. Alcohol use history (See Grading Alcohol Use)
    1. Drinks per day
      1. Men: >2 per day (>14/week) suggests Alcohol Dependence
      2. Women: >1 per day (>7/week) suggests Alcohol Dependence
    2. Last drink
    3. Binge drinking
      1. Men: >5 drinks on single occasion in last year suggests Alcohol Dependence
      2. Women: >4 drinks on single occasion in last year suggests Alcohol Dependence
  6. Other Illicit Drug use
    1. Marijuana
    2. Cocaine
    3. Heroin
    4. Amphetamines
    5. Benzodiazepine Abuse
    6. Barbiturate Abuse
    7. Quaalude
    8. Hallucinogen
  7. Prior attempts at cessation
    1. Greatest duration of sobriety
    2. Trials of cold turkey
    3. Rehabilitation Programs
    4. Detox Center Admissions
  8. Overuse Complications
    1. Blackouts
    2. Seizures
    3. Hangovers
  9. Accidents
    1. Motor Vehicle Accidents
    2. Driving while intoxicated (DUI or DWI)
  10. Injuries
    1. Frequent falls or minor Trauma
    2. Burns
    3. Violence
  11. Withdrawal complications
    1. See Alcohol Withdrawal
    2. Hallucinations
    3. Delirium Tremens (DT's)
    4. Grand Mal Seizures (GTCS)
  • Findings
  • Presentations
  1. Be alert for excessive Alcohol use in patients presenting for other conditions
  2. Alcohol Use Disorder is associated with many comorbid conditions that result in frequent primary care
    1. Insomnia
    2. Hypertension
    3. Gastroesophageal Reflux
    4. Other mental health disorders (e.g. Mood Disorders)
  • Evaluation
  1. See Alcoholism Screening
  2. See Substance Abuse Evaluation
  3. See Skin changes suggestive of chemical dependency
  4. See Eye Examination Signs of Chemical Dependency
  5. See Alcohol Use Disorder Diagnosis
  • Labs
  1. See Substance Abuse Evaluation
  2. Metabolic panel
  3. Complete Blood Count with Platelet Count
    1. Non-megaloblastic Macrocytic Anemia (increased MCV)
    2. Iron Deficiency Anemia
    3. Thrombocytopenia
  4. Lipid panel
    1. Low High Density Lipoprotein
    2. High Triglycerides
  5. Liver Function Tests
    1. Alkaline Phosphatase
    2. Alanine Aminotransferase (ALT, SGPT)
    3. Aspartate Aminotransferase (AST, SGOT)
    4. Serum Bilirubin
    5. Prothrombin Time (PT or INR)
    6. Serum Albumin
  6. Comorbid Liver Disease
    1. Viral Hepatitis Screening
    2. Fibrosis Probability Score (FIB-4 Index, for ages 35-65 years)
    3. Liver Fibrosis Screening with Elastography (for FIB-4 Index >1.3)
      1. Transient Elastography (Fibroscan)
      2. 2D Shear wave Elastography
      3. MR Elastography (BMI >35 kg/m2)
  7. Toxicology
    1. Increased Blood Alcohol Level or Breathalyzer
    2. See Biomarkers of Alcohol Use
    3. Toxicology Screening for other drug use
  8. Monitoring (labs correlating with increased use)
    1. Gamma Glutamyl Transferase (GGT)
    2. Carbohydrate-deficient Transferrin
      1. Limited availability
    3. Phosphatidylethanol (PEth)
      1. Detectable for up to 4 weeks after Alcohol use
      2. PEth >= 20 ng/ml is associated with moderate to heavy Alcohol use
      3. Ulwelling (2018) J Forensic Sci 63(6): 1634-40 [PubMed]
      4. Kechagias (2015) Alcohol Alcohol 50(4): 399-406 [PubMed]
      5. Schrock (2017) Drug Alcohol Depend 178:80-6 [PubMed]
  • Associated Conditions
  • Increased Risk with Alcohol Use Disorder
  1. Background
    1. Morbidity and mortality risk increases linearly with heavy drinking days
  2. Psychiatric Illness
    1. Major Depression
    2. Anxiety
      1. Generalized Anxiety Disorder
      2. Panic Attacks
      3. Agoraphobia
      4. Social Phobia
    3. Bipolar Disorder
    4. Suicide
    5. Schizophrenia
    6. Borderline Personality Disorder
    7. Antisocial Personality Disorder
    8. Other Substance Abuse
      1. Tobacco Abuse: >1 pack per day in 70% of Alcoholics
    9. Post-Traumatic Stress Disorder (Veterans)
  3. Medical Conditions
    1. Resistant Hypertension
    2. Atrial Fibrillation
    3. Cardiomyopathy
    4. Myocardial Infarction
    5. Cerebrovascular Accident
    6. Dementia
    7. Adrenal suppression
    8. Gonadal Suppression (e.g. Infertility)
    9. Gouty Arthritis
    10. Osteoporosis
  4. Cancer
    1. Breast Cancer
    2. Colorectal Cancer
    3. Esophageal Cancer
    4. Hepatocellular Carcinoma
    5. Head and neck cancer
  5. Trauma
    1. Motor Vehicle Accidents
    2. Fall Injury
    3. Burn Injury
    4. Hypothermia
  6. Infectious disease risk
    1. Tuberculosis
    2. AIDS
    3. Viral Hepatitis
  • Complications
  • Medical
  1. Korsakoff's Disease
  2. Alcoholic Hepatitis
  3. Cirrhosis
  4. Pancreatitis
  5. Esophageal Varices
  6. Macrocytic Anemia
  7. Peptic Ulcer Disease
  8. Fetal Alcohol Syndrome (children of female Alcoholics)
  9. Alcohol Withdrawal
  1. Vitamin A Deficiency (Retinol Deficiency)
    1. Presents with night blindness
  2. Vitamin C Deficiency (Scurvy)
    1. Presents with Bleeding Gums, Fatigue
  3. Vitamin B1 Deficiency (Thiamine Deficiency, Wernicke's Encephalopathy)
    1. Presents with Ataxia, Confusion, Ophthalmoplegia (lateral Gaze Palsy)
  4. Vitamin B3 Deficiency (Niacin Deficiency, Pellegra)
    1. Presents with Diarrhea, dermatitis and Dementia (3 D's)
  5. Vitamin B6 Deficiency (Pyridoxine deficiency)
    1. Presents with Glossitis, Peripheral Neuropathy
  6. Vitamin B9 Deficiency (Folic Acid Deficiency)
    1. Presents with Macrocytic Anemia (also caused by B12 Deficiency)
  7. Vitamin B12 Deficiency (Cobalamin Deficiency, Pernicious Anemia)
    1. Presents with weakness, Peripheral Neuropathy, Ataxia, Dementia, macroyctic Anemia
  8. Vitamin D Deficiency
    1. Osteopenia and Osteoporosis
  9. Iron Deficiency
    1. Microcytic Anemia
  10. Magnesium Deficiency
    1. See Hypomagnesemia
  11. References
    1. Jhun et al. in Herbert (2016) EM:Rap 16(9): 8-10
  • Management
  1. Alcohol Use Disorder Management
    1. See Alcohol Dependence Management
    2. See Alcohol Withdrawal
    3. See Substance Addiction Aftercare
    4. Counsel Alcohol cessation at each visit
      1. See Chemical Dependency Brief Counseling
    5. Consider first-line agents that can be used to reduce heavy drinking
      1. Naltrexone
      2. GLP1 Agonists (adjunctive, investigational)
  2. Liver disease screening
    1. See Alcoholic Liver Disease
    2. Fibrosis Probability Score (FIB-4 Index, for ages 35-65 years)
    3. Liver Fibrosis Screening with Elastography (for FIB-4 Index >1.3)
  3. Manage comorbidities and Alcohol Associated Risks (see associated conditions above)
    1. Mental health disorders including high Suicide Risk
    2. Cancer (Breast Cancer, Colorectal Cancer, Esophageal Cancer, Hepatocellular Carcinoma, Head and neck cancer)
    3. Cardiovascular disease (Resistant Hypertension, Atrial Fibrillation, Cardiomyopathy, CAD risk)
    4. Osteoporosis Evaluation
    5. Vitamin Deficiency (see above)
    6. Sleep Disorders including Insomnia
    7. Counseling regarding driving under the influence (DUI) and other injury risk
    8. Infectious disease screening (e.g.. Tuberculosis, HIV, STD)
  4. Vaccinations
    1. Pneumococcal Vaccine
    2. Hepatitis A Vaccine
    3. Hepatitis B Vaccine
  5. Prevent Pregnancy
    1. Prevent Fetal Alcohol Syndrome!
    2. Reliable Contraception (e.g. IUD, Progestin Subcutaneous Implant, Tubal Ligation)
  • Prognosis
  • Relapse after CD treatment
  1. Relapse after Treatment in first 3 months: 50%
  2. Relapse after treatment in first 6 months: 80%
  3. Remain sober with Alcoholics Anonymous > 1 year: 76%
  • Resources
  1. See Chemical Dependency Resources
  2. Alcoholics Anonymous
    1. http://www.aa.org/
  3. Al-Anon/Ala-Teen (Family and Friends of Alcoholics)
    1. http://www.al-anon.org/
  4. Information from your Family Doctor: Alcohol Abuse
    1. http://www.familydoctor.org/healthfacts/006
  5. Rethinking Drinking (NIH)
    1. https://www.rethinkingdrinking.niaaa.nih.gov/
  6. Facts About Excessive Drinking (CDC)
    1. https://www.cdc.gov/drink-less-be-your-best/facts-about-excessive-drinking/index.html
  7. Medical Complications: Common Alcohol-Related Concerns
    1. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/medical-complications-common-alcohol-related-concerns
  • References
  1. Beddingfeld (July, 1996) Hospital Physician 27-39
  2. (1994) Am Fam Physician 50(8):1737-40 [PubMed]
  3. Blondell (1996) Postgrad Med 100(1):69-80 [PubMed]
  4. Chang (1995) Am Fam Physician 52(8): 2267-73 [PubMed]
  5. Enoch (2002) Am Fam Physician 65(3):441-8 [PubMed]
  6. Figueredo (1997) Postgrad Med 101(2):165-76 [PubMed]
  7. Gearhart (1991) Am Fam Physician 44(3):907-13 [PubMed]
  8. Imperato (2026) Crit Dec Emerg Med 40(8): 4-14 [PubMed]
  9. Jaffe (2026) Am Fam Physician 114(4): 358-65 [PubMed]
  10. Tobias (1989) Postgrad Med 86(4):67-79 [PubMed]
  11. Winslow (2016) Am Fam Physician 93(6): 457-65 [PubMed]