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Alcohol use disorder

What's new

Updated 2024 SAEM (GRACE-4) guidelines for the management of alcohol use disorder in the emergency department.

Background

Overview

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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Guidelines

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 Academy of Family Physicians (AAFP 2024), the American College of Gastroenterology (ACG 2024,2018), the American Society of Addiction Medicine (ASAM/AAAP 2024), the Society for Academic Emergency Medicine (SAEM 2024), the Canadian Research Initiative in Substance ...
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Screening and diagnosis

Definition: as per EASL 2018 guidelines, 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

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

Medical management

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

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  • Goals of treatment

  • Management in the emergency department

  • Naltrexone

  • Acamprosate

  • Disulfiram

  • Anticonvulsants

  • Benzodiazepines

  • Antipsychotics and antidepressants

  • Baclofen

  • Clonidine

Inpatient care

Prevention of alcohol withdrawal syndrome in the hospital: as per AAFP 2024 guidelines, 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

Nonpharmacologic interventions

General principles: as per WHO 2023 guidelines, 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

Specific circumstances

Pregnant patients, screening
As per SOGC 2020 guidelines:
Ask all pregnant patients about their alcohol consumption using a single, nonjudgmental question to determine use. Use the AUDIT-C, the T-ACE, or another evidence-based screening tool if patients consume alcohol. Establish the pattern of alcohol use to screen for binge drinking.
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Ensure a nonjudgmental, supportive approach to encourage disclosure of alcohol use and accessing of services.
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  • Pregnant patients (counseling)

  • Pregnant patients (brief intervention)

  • Pregnant patients (pharmacotherapy)

  • Patients with stimulant use disorder

Patient education

General counseling: as per ACG 2018 guidelines, 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

Preventative measures

Alcohol restriction: as per AFEF/SFA 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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Follow-up and surveillance

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

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