Alcohol Use Disorder

Background

• Alcohol use disorder is a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis that encompasses a spectrum of unhealthy drinking behaviors.
• Drinking above the recommended limits increases the risk of negative health consequences. Limits are typically defined as:
  • For men, > 14 standard drink units (14 g ethanol) per week or > 4 on a single occasion.
  • For women, > 7 standard drink units (14 g ethanol) per week or > 3 on a single occasion.
  • For pregnant persons or persons < 21 years old, any drinking is considered to increase negative health consequences.
• Alcohol use disorder is the most prevalent substance use disorder with 5% reported prevalence among persons aged ≥ 12 years.
• Genetic and environmental risk factors play a role in the development of alcohol use disorder.
• Alcohol use disorder is associated with psychiatric comorbidities such as depression and anxiety, which can be preexisting or substance-induced.
• Maladaptive drinking behavior in persons with alcohol use disorder is maintained by combination of positive and negative reinforcing effects of alcohol, and long term alcohol exposure causes physiological and functional changes in the brain.

Evaluation

• Screen all patients in primary care or other nonspecialty setting for alcohol use with validated screening tools, which usually assess amount of alcohol consumed and consequences related to drinking (Strong recommendation). Validated screening questionnaires include:
  • Alcohol Use Disorders Identification Test (AUDIT, 10 questions)
  • CAGE (4 questions)
  • Tolerance, Annoyed, Cut-down, Eye-opener (T-ACE, 4 questions)
  • Brief screening assessments such as:
    • Single-item screen ("When was the last time you had more than 5 drinks in one day? [4 drinks, for women]")
    • Alcohol Use Disorders Identification Test - Concise (AUDIT-C, 3 questions)
    • 3-question assessment of quantity, frequency, and maximum drinks
  • screening tools for adolescent substance use from National Institute on Drug Abuse (NIDA), including Screening to Brief Intervention (S2BI) tool and Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD)
• Suspect alcohol use disorder in patients with excessive alcohol use and other clinical warning signs, including tolerance or cravings for alcohol, social or occupational problems related to alcohol use, or signs of alcohol withdrawal.
• Diagnose alcohol use disorder according to diagnostic criteria. Diagnosis typically does not require testing, but consider testing in certain cases such as:
  • Testing for metabolites of alcohol in blood, urine, or hair to verify abstinence or rule out harmful alcohol use.
  • Additional testing if liver disease is suspected, to help confirm diagnosis and exclude other etiologies.
• Diagnosis of alcohol use disorder can be made clinically without additional laboratory testing, but consider testing for physiological biomarkers to identify heavy alcohol consumption as part of initial evaluation, or to verify abstinence in persons who require ongoing monitoring of alcohol use (Weak recommendation).

Management

• In general, management of alcohol use disorder involves a combination of counseling, medication, and social support.
• Offer psychological treatment.
  • Offer or provide brief psychological or behavioral interventions as first-line treatment for patients with positive screening or suspicion of risky drinking and/or alcohol use disorder (Strong recommendation).
    • Brief interventions typically consist of 1-4 brief (5-15 minute) encounters with individualized feedback and recommendations for reducing risky drinking, assessment of patient's readiness to change, negotiation of goals, and arranging follow-up to assess progress.
    • Consider incorporating motivational interviewing into brief interventions.
    • If offered as the only form of treatment, brief interventions may not be effective for reducing drinking in patients with moderate-to-severe alcohol use disorder.
  • Offer counseling, such as cognitive behavioral therapy for changing maladaptive alcohol-related thought processes in order to change subsequent emotions and behaviors (Strong recommendation).
  • Consider encouraging participation in mutual support programs, which may help patients build social network supportive of sobriety.
• Consider pharmacological treatment for patients with moderate-to-severe alcohol use disorder
  • Offer naltrexone (380 mg gluteal intramuscular injection once monthly or 50 mg orally once daily) in patients who want to reduce drinking and who are not taking opioids, or acamprosate (666 mg orally 3 times per day) if naltrexone is contraindicated (Strong recommendation).
  • Consider disulfiram 250 mg orally once daily if naltrexone and acamprosate are ineffective or not well tolerated, and if patient understands the risks of alcohol consumption while taking disulfiram (produces unpleasant reactions if alcohol is consumed) (Weak recommendation).
  • Consider other medications with evidence for efficacy in alcohol use disorder, including:
    • antiseizure medications (options include topiramate and gabapentin); consider if naltrexone and acamprosate are ineffective or not well tolerated (Weak recommendation).
    • nalmefene; consider prescribing in conjunction with continuous psychosocial support for patients with high-risk drinking level 2 weeks after initial assessment and no symptoms of withdrawal.
    • baclofen; consider to help achieve and maintain abstinence.
• Refer to specialist if patient:
  • Continues drinking despite consequences (including medical contraindications).
  • Attempted to reduce drinking but was not successful.
  • Has poor response to primary care management.
  • Has complicated comorbid psychiatric conditions.
• Follow up with patient to mitigate relapse with:
  • Emphasis that abstinence is not required for continuing care.
  • Nonjudgmental monitoring of progress toward goals, medication adherence, specialty aftercare or mutual support groups, alcohol consumption, craving, triggers, and coping strategies .
  • Strategies to address common relapse triggers in patients with current or past alcohol use disorder.