Alcohol use disorder involves a pattern of alcohol use that typically includes craving and manifestations of tolerance and/or withdrawal along with adverse psychosocial consequences. Alcoholism and alcohol abuse are common but less rigorously defined terms applied to people with problems related to alcohol.
Alcohol use disorder is quite common. It is estimated to be present in 13.9% of adults in the US in any 12-month period. Prevalence is highest among young adults and decreases with age. Among people age 18 to 29 years, the estimated 12-month prevalence of alcohol use disorder is 26.7% (1), and that of severe alcohol use disorder is 7.1%, whereas for people ≥ 65 years, 12-month prevalence of alcohol use disorder is only 2.3%.
At-risk drinking is defined solely by quantity and frequency of drinking:
> 14 drinks/week or 4 drinks per occasion for men
> 7 drinks/week or 3 drinks per occasion for women
Compared with lesser amounts, these amounts are associated with increased risk of a wide variety of medical and psychosocial complications.
(See also Alcohol Toxicity and Withdrawal.)
General reference
1. Grant BF, Goldstein RB, Saha T, et al: Epidemiology of DSM-5 alcohol use disorder results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry 72(8):757–766, 2015. doi: 10.1001/jamapsychiatry.2015.0584
Etiology of Alcohol Use Disorder
The maladaptive pattern of drinking that constitutes alcohol abuse may begin with a desire to reach a state of feeling high. Some drinkers who find the feeling rewarding then focus on repeatedly reaching that state. Many who abuse alcohol chronically have certain personality traits: feelings of isolation, loneliness, shyness, depression, dependency, and hostile and self-destructive impulsivity.
Societal factors—attitudes transmitted through the culture or child rearing—affect patterns of drinking and consequent behavior. Alcohol use disorder can occur in anyone, regardless of their age, sex, background, ethnicity, or social situation. Thus, clinicians should screen for alcohol problems in all patients.
Genetic factors
As much as 45 to 65% of risk variance is thought to be due to genetic factors. The incidence of alcohol use disorder is higher in biologic children of people with alcohol problems than in adoptive children in a given family (and also higher than in the general population). There is evidence of genetic or biochemical predisposition, including data that suggest some people who develop alcohol use disorder are less easily intoxicated (ie, they have a higher threshold for central nervous system effects).
Symptoms and Signs of Alcohol Use Disorder
Serious social consequences in patients with alcohol use disorder usually occur. Frequent intoxication is obvious and destructive; it interferes with the ability to socialize and work. Injuries are common. Eventually, failed relationships and job loss due to absenteeism may result.
People may be arrested because of alcohol-related behavior or be apprehended for driving while intoxicated, often losing driving privileges for repeated offenses. In the US, all states define driving with a blood alcohol content (BAC) at or above 80 mg/dL (0.08%, [17.4 mmol/L]) as a crime, but specific state laws and penalties vary.
Diagnosis of Alcohol Use Disorder
Usually a clinical diagnosis
Screening
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition–Text Revision (DSM-5-TR) considers alcohol use disorder to be present if patients have clinically significant impairment or distress as manifested by the presence of ≥ 2 of the following over a 12-month period:
Taking alcohol in larger amounts or for a longer time than intended
Persistently desiring or unsuccessfully attempting to decrease alcohol use
Spending a great deal of time obtaining, using, or recovering from alcohol
Craving alcohol
Failing repeatedly to meet obligations at work, home, or school because of alcohol
Continuing to use alcohol despite having recurrent social or interpersonal problems because of alcohol
Giving up important social, work, or recreational activities because of alcohol
Using alcohol in physically hazardous situations
Continuing to use alcohol despite having a physical disorder (eg, liver disease) or mental disorder (eg, depression) caused or worsened by alcohol
Having tolerance to alcohol
Having alcohol withdrawal symptoms or drinking alcohol because of withdrawal
Screening
Some alcohol-related problems are diagnosed when people seek medical treatment for their drinking or for obvious alcohol-related illness (eg, delirium tremens, cirrhosis). However, many of these people remain unrecognized for a long time. Female patients with alcohol use disorder are, in general, more likely to drink alone and are less likely to manifest some of the social signs. Therefore, many governmental and professional organizations recommend alcohol screening during routine health care visits.
A scaled approach (see table Levels of Screening for Alcohol Problems) can help identify patients who require more detailed questioning. Several validated detailed questionnaires are available, including the AUDIT (Alcohol Use Disorders Identification Test) and the CAGE questionnaire.
Levels of Screening for Alcohol Problems
Screening Level | Criteria for Use | Screening Technique |
|---|---|---|
1 | If only one question is possible | On any single occasion during the past 3 months, have you had > 5 drinks* containing alcohol? |
2 | For all patients who report drinking alcohol if time allows or For patients who respond “yes” to a level 1 screening question |
|
3 | If level 2 screening identifies risk of alcohol-related problems (ie, for men, > 14 drinks/week or 4 drinks/day; for women, > 7 drinks/week or 3 drinks/day) or If the clinician suspects that patients are minimizing their alcohol use | The 10-question Alcohol Use Disorders Identification Test (AUDIT) |
*A drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of distilled spirits. Adapted from Fleming MF: Screening and brief intervention in primary care settings. Alcohol Res Health 28(2): 57–62, 2004. | ||
Treatment of and Rehabilitation for Alcohol Use Disorder
Rehabilitation programs
Outpatient counseling
Self-help groups
All patients should be counseled to decrease their alcohol use to below at-risk levels.
For patients identified as at-risk drinkers, treatment may begin with a brief discussion of the medical and social consequences and a recommendation to reduce or cease drinking, with follow-up regarding compliance (see table Brief Interventions for Alcohol Problems).
Brief Interventions for Alcohol Problems
Intervention Level | Criteria for Use | Brief Intervention Technique |
|---|---|---|
1 | If screening results determine that intervention is necessary but time is limited | Simply stating concern that the patient’s drinking exceeds recommended limits and could lead to alcohol-related problems; recommending that the patient minimize or stop drinking |
2 | If referral to a specialist is not necessary; if abstinence is not necessarily the goal | Project Limited, structured physician/nurse intervention: 2 brief face-to-face sessions scheduled 1 month apart, with a follow-up telephone call 2 weeks after each session |
3 | If the patient has symptoms of alcohol abuse or dependence; if abstinence is the primary goal | Motivational enhancement; referral to a specialist |
For patients with more serious problems, particularly after less intensive measures have been unsuccessful, a rehabilitation program is often the best approach. Rehabilitation programs combine psychotherapy, including one-on-one and group therapy, with medical supervision. For most patients, outpatient rehabilitation is sufficient; how long patients remain enrolled in programs varies, typically weeks to months, but longer if needed.
Inpatient rehabilitation programs are reserved for patients with more severe alcohol dependence and those with significant and comorbid medical, psychoactive, and substance abuse problems. Treatment duration is usually briefer (typically days to weeks) than that of outpatient programs and may be dictated in part by patients’ insurance.
Psychotherapy involves techniques that enhance motivation and teach patients to avoid circumstances that precipitate drinking. Social support of abstinence, including the support of family and friends, is important.
Maintenance
Maintaining sobriety is difficult. Patients should be warned that after a few weeks, when they have recovered from their last bout, they are likely to find an excuse to drink. They should also be told that although they may be able to practice controlled drinking for a few days or, rarely, a few weeks, they will most likely lose control eventually.
In addition to the counseling provided in outpatient and inpatient alcohol treatment programs, self-help groups and certain drugs may help prevent relapse in some patients.
Alcoholics Anonymous (AA) is the most common self-help group. Patients must find an AA group they feel comfortable in. AA provides patients with nondrinking friends who are always available and a nondrinking environment in which to socialize. Patients also hear others discuss every rationalization they have ever used for their own drinking. The help they give other patients with alcohol use disorder may provide them with the self-regard and confidence formerly found only in alcohol. Many patients with alcohol use disorder are reluctant to go to AA and find individual counseling or group or family treatment more acceptable. Alternative organizations, such as LifeRing Secular Recovery (Secular Organizations for Sobriety), exist for patients seeking another approach.
Drug therapy should be used with counseling rather than as the sole treatment. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides a guide for clinicians on medical management and pharmacotherapy for alcohol dependence—as does the American Psychiatric Association—along with a number of other publications and resources for both health care practitioners and patients.
acute hepatitis or liver failure and in those who are opioid dependent.
an opioid antagonist, and are under study for their ability to decrease alcohol craving.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Al-Anon Family Groups: Support services for adults who abuse alcohol, adults who grew up with an alcoholic, and teens affected by someone else's problematic use of alcohol.
Alcoholics Anonymous: International fellowship of people with a drinking problem that pioneered the 12-step approach to help its members overcome their addiction to alcohol and help others to do the same.
American Psychiatric Association's Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder: Guidelines designed to improve the quality of care and treatment outcomes for patients with alcohol use disorder.
LifeRing Secular Recovery: Support for people with drug and alcohol use problems by facilitating sharing of practical experiences and sobriety support as an alternative to traditional 12-step programs.
National Institutes for Alcohol Abuse and Recovery: Recommendations for screening and brief intervention for alcohol use disorders in the primary care setting.
Findtreatment.gov: Listing of licensed US providers of treatment for substance use disorders.
