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Alcohol use disorder

Definition
AUD, according to DSM-V-TR, is characterized by a pattern of alcohol consumption that results in problems associated with ≥ 2 potential symptoms of tolerance, withdrawal, increased amount of alcohol consumed over time, difficulty in controlling drinking, neglect of activities, ineffective efforts to reduce use, craving, failure to fulfill major role obligations, recurrent alcohol use in hazardous situations, time spent drinking or recovering from alcohol, and drinking despite physical/psychological problems in the past year.
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Pathophysiology
AUD is caused due to genetic, psychological, and environmental factors.
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Disease course
The neurobiological disturbances due to habitual drinking cause AUD, which increases the risk of damage to the gastrointestinal, cardiovascular, immune, nervous, and other systems. AUD causes increased morbidity and mortality.
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Prognosis and risk of recurrence
AUD is associated with increased mortality from all causes of death (mortality rate ratio, 3.0-5.2).
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Key sources
The following summarized guidelines for the evaluation and management of alcohol use disorder are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2024; 2018), the American Academy of Family Physicians (AAFP 2024), the Canadian Research Initiative in Substance Misuse (CRISM 2023), the World Health Organization (WHO 2023), the American Association for the Surgery of Trauma (AAST 2022), the French Society of Alcohology (SFA/AFEF 2022), the United States Department of Defense (DoD/VA 2021), the American Association for the Study of Liver Diseases (AASLD 2020), the American Psychiatric Association (APA 2018), the European Association for the Study of the Liver (EASL 2018), and the U.S. Preventive Services Task Force (USPSTF 2018).
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Guidelines

1.Screening and diagnosis

Definition: use the term AUD (defined by DSM-V criteria) in preference to alcoholic, alcohol abuse, alcohol dependence or risky drinker.
A
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  • Indications for screening

  • Choice of screening tool

2.Diagnostic investigations

Psychiatric evaluation
As per CRISM 2023 guidelines:
Conduct a diagnostic interview for AUD using the DSM-V-TR criteria and further assessment to inform a treatment plan, if indicated, in all adult and young patients screening positive for high-risk alcohol use.
B
Use clinical parameters, such as past seizures or delirium tremens, and the PAWSS to assess the risk of severe alcohol withdrawal complications and determine an appropriate withdrawal management pathway.
B

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  • Alcohol biomarkers

  • Evaluation for liver disease

3.Medical management

General principles: as per AAFP 2024 guidelines, offer pharmacotherapy in patients with AUD.
A

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  • Goals of treatment

  • Naltrexone

  • Acamprosate

  • Disulfiram

  • Anticonvulsants

  • Benzodiazepines

  • Antipsychotics and antidepressants

  • Baclofen

  • Clonidine

4.Inpatient care

Prevention of alcohol withdrawal syndrome in the hospital: assess for alcohol withdrawal symptoms in all patients with AUD at hospital admission and manage with benzodiazepines or phenobarbital.
B

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  • Prevention of alcohol withdrawal syndrome in the ICU

5.Nonpharmacologic interventions

General principles: consider offering structured and standardized psychosocial interventions in patients with AUD.
C
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  • Brief behavioral intervention

  • Mindfulness-based therapies

  • Technology-based interventions

6.Specific circumstances

Pregnant and breastfeeding patients: do not offer pharmacological treatment in pregnant and breastfeeding patients with AUD unless for the treatment of acute alcohol withdrawal with benzodiazepines or a co-occurring disorder requiring pharmacotherapy.
D

7.Patient education

General counseling: counsel patients with heavy alcohol use (> 3 drinks per day in males and > 2 drinks per day in females for > 5 years) that they are at an increased risk for liver disease.
B

8.Preventative measures

Alcohol restriction: as per AFEF 2022 guidelines, consider advising alcohol consumption of ≤ 10 standard drinks per week in the general population to avoid overall health risks.
C
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9.Follow-up and surveillance

Maintenance of abstinence: as per CRISM 2023 guidelines, offer ongoing AUD care in all patients completing withdrawal management.
B

10.Quality improvement

Public health measures: as per ACG 2024 guidelines, implement public policy interventions to reduce the burden of AUD and alcohol-associated liver complications, as well as alcohol-related morbidity and mortality.
E