Alcohol Use Disorder (AUD)

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Description

  • Any pattern of alcohol use causing significant physical, mental, or social dysfunction; key features are tolerance, withdrawal, and persistent use despite problems.
  • The severity of alcohol use disorder (AUD) exists on a spectrum but is classified as mild, moderate, or severe based on the number of clinical criteria that are met. Manifestation of 2 to 3 of the DSM-5 criteria for substance use disorders is considered mild disease, 4 to 5 is classified as moderate, and ≥6 is severe AUD.
  • DSM-5 criteria for AUD
    • Impaired control
      • Alcohol cravings
      • Unable to cut down or quit using alcohol
      • A large amount of time is spent using or recovering from alcohol.
      • Drinking larger amounts or over longer time than intended
    • Social dysfunction/physical risk
      • Alcohol use during hazardous situations or continued alcohol use that leads to hazardous situation
      • Continued use of alcohol despite a negative impact on relationships
      • Failure to meet obligations at work or school
      • Social or occupational activities that were once important to the person are abandoned.
      • Continued alcohol use despite known physical or psychological consequences (i.e., hypertension, hyperlipidemia, cirrhosis, depression, anxiety)
      • Physiologic dependence
      • Tolerance or withdrawal
      • Loss of control over the amount of alcohol used
  • National Institute on Alcohol Abuse and Alcoholism (NIAAA) criteria for low-risk alcohol use
    • Low-risk alcohol use: NIAAA criteria for low-risk drinking is no more than 14 drinks a week or no more than 4 drinks per occasion. For women, low-risk drinking involves no more than 7 drinks a week or 3 per occasion. Alcohol use that exceeds these levels does not always result in AUD but can still be problematic for an individual.
    • The safest level of use is considered no use as even low-level use is associated with reduction in gray matter and cognitive impairment.
    • Binge drinking: drinking that brings blood alcohol levels to 0.08 g/dL; this is usually 4 drinks for women and 5 drinks for men in 2 hours.
  • Measuring alcohol use
    • A standard drink includes 14 g (0.6 fluid oz) of pure alcohol. This includes the following:
      • 12 oz of beer, that are 5% alcohol
      • 5 oz of wine, that are 12% alcohol
      • 1.5 oz of distilled spirits that are 40% alcohol

Geriatric Considerations

  • Multiple drug interactions
  • Signs and symptoms of AUD may be different or attributed to a chronic medical problem or dementia.
  • Accelerated aging from frequent alcohol use together with increased consumption in middle-aged and older adults increases risk of cognitive decline and dementia.

Pediatric Considerations

  • Children of alcoholics are at increased risk; 2.5% of adolescents have AUD; 13.4% of youth aged 12 to 20 years report binge drinking in the past month; negative effect on maturation and normal brain development
  • Early-onset drinkers (those who start drinking before age 21 years) are 4 times more likely to develop a problem than those who begin after age 21 years.

Epidemiology

Predominant age 18 to 25 years, but all ages affected; male > female (3:1)

  • Young drinkers through college age commonly engage in heavy to binge drinking (4 drinks for women and 5 drinks for men in 2 hours) to extreme binge-drinking (>15 drinks in one session) on weekends.
  • New data reflects increased drinking in middle-aged to older adults and binge drinking, especially in women, increasing risk of cognitive decline and dementia. Drinking particularly increased during the COVID-19 pandemic.

Prevalence

  • 23% of Americans aged ≥18 years reported binge drinking in the past month; 6% reported heavy alcohol use in the past month; 15 million adults (6%) aged >18 years has AUD.
  • AUD affects ~11% of the US population and contributes to 140,000 deaths annually.
  • In the United States, harmful alcohol use is the third leading cause of preventable death and has become a major public health crisis.
  • <20% of individuals with AUD receive treatment.

Etiology and Pathophysiology

  • Multifactorial: genetic, environment, psychosocial
  • Alcohol is a CNS depressant, facilitating γ-aminobutyric acid (GABA) inhibition and blocking N-methyl-d-aspartate receptors.

Genetics

50–60% of risk is genetic.

Risk Factors

  • Family history; depression; anxiety disorders; bipolar disorder; eating disorders
  • Tobacco and/or other substance abuse
  • Male gender; lower socioeconomic status; unemployment; poor self-esteem
  • Posttraumatic stress disorder; antisocial personality disorder; criminal behavior

General Prevention

  • Counsel patients with family history and risk factors.
  • USPSTF recommends screening adults for alcohol use and providing brief counseling to those with risky drinking habits.
  • Screening and brief intervention (SBI)

Commonly Associated Conditions

  • Cardiomyopathy; atrial fibrillation; hypertension
  • Peptic ulcer disease; cirrhosis; fatty liver; cholelithiasis; hepatitis; pancreatitis
  • Diabetes mellitus; malnutrition; upper GI malignancies
  • Peripheral neuropathy, seizures
  • Abuse and violence
  • Behavioral disorders (depression, bipolar, schizophrenia): >50% of patients have a comorbid substance abuse problem.

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