Alcohol use disorder: Clinical sciences

Alcohol use disorder is a medical condition characterized by the inability to control the consumption of alcohol, despite adverse health and social consequences. The cause of alcohol use disorder is multifactorial and includes psychological, biological, social, and environmental factors. Based on criteria defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, or DSM-5, you can categorize alcohol use disorder as mild, moderate, and severe.

Okay, if a patient presents with chief concerns suggesting alcohol use disorder, first perform an ABCDE assessment to determine if the patient is unstable or stable. If unstable, stabilize the airway, breathing, and circulation, which might require endotracheal intubation with mechanical ventilation. Next, obtain IV access and put your patient on continuous vital sign monitoring including blood pressure, heart rate, pulse oximetry, and cardiac telemetry.

Now, here’s a clinical pearl! Patients with alcohol use disorder might present with a few potentially unstable conditions. The first to consider is alcohol intoxication, which can cause significant CNS depression, coma, and even death. Next, always look out for alcohol withdrawal, which typically begins 12 to 48 hours after the last drink and can result in fatal generalized tonic-clonic seizures. Finally, don’t forget about delirium tremens, which is a rare but severe form of alcohol withdrawal typically occurring 48 hours or more after the last drink.

These patients will have fever, agitation, hallucinations, and extreme hypertension, with the potential for cardiovascular collapse. Treatment of acute intoxication is largely supportive with IV fluids and electrolyte replacement, while withdrawal symptoms are best managed with benzodiazepines.

Now that we’ve addressed unstable patients, let’s return to the ABCDE assessment and take a look at stable patients. If the patient is stable, obtain a focused history and physical exam. Additionally, don’t forget to assess for problematic use of alcohol by administering a screening test, such as the CAGE test and AUDIT.

CAGE is a screening test that asks about the patient’s ability to Cut down their alcohol use, Annoyance regarding other people’s concern about their alcohol use, presence of Guilty feelings related to alcohol use, and use of Eye-openers.

On the other hand, AUDIT stands for Alcohol Use Disorders Identification Test. AUDIT is a screening test that asks patients about the volume and frequency of alcohol use; changes in behavior due to drinking; feelings of regret and guilt; injury of self and others due to alcohol use; experience of blackouts; having an eye-opener or drink first thing in the morning; and concern from others about alcohol use.

Here’s a high-yield fact! The standard definition of one drink is 12 grams of alcohol, which is the average alcohol content in a 12-ounce beer, 5 ounces of wine, or 1.5 ounces of distilled spirits.

Your patient or their close contact may report concerns about their alcohol intake, but keep in mind many individuals may conceal or minimize concerns related to alcohol use despite associated sleep disturbances, such as insomnia, or relationship struggles, such as strained friendships or difficulties with co-workers.

Moreover, some patients might have a history of a mood or personality disorder, such as depression or borderline personality disorder, or childhood trauma, like parental abandonment. Finally, family history may reveal alcohol or other substance use disorders. Additionally, the physical exam may reveal hypertension, hepatomegaly, or splenomegaly.

You could also detect signs of chronic liver conditions, such as jaundice, palmar erythema, spider angiomata, or ascites. But keep in mind that your patient’s examination might be completely normal. Next, if your patient has a score of two or more on their CAGE test, or eight or more on the AUDIT test, you should suspect alcohol use disorder!

Now, here’s a clinical pearl! Excessive alcohol consumption can cause a variety of lab abnormalities. For example, liver enzymes AST and ALT are typically elevated in a two-to-one ratio, while CBC may reveal thrombocytopenia and macrocytic anemia. Additionally, you might notice electrolyte abnormalities, such as hypokalemia, hypomagnesemia, and hypocalcemia; and given poor nutritional status, your patient might also have a thiamine and folate deficiency!

Okay, once you suspect alcohol use disorder, next assess the DSM-5 criteria for alcohol use disorder. The DSM-5 lists eleven criteria of alcohol use disorder that fall into four general categories, including impaired control, physical dependence, social problems, and risky use.

First, let’s discuss factors suggesting impaired control, like if your patient is using more alcohol than intended or for a longer duration than intended. Next, they might be spending more time obtaining, consuming, or recovering from alcohol; or they continue to drink despite insight into the problems caused by alcohol, like after legal consequences.