Alcohol use disorder: Clinical sciences

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Introduction0:00–0:35

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.

Unstable Patient0:35–2:07

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.

Stable Patient2:07–5:16

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.

DSM-5 Criteria5:16–7:02

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.
Next up is physical dependence. For example, the patient might report cravings for alcohol; have unsuccessful attempts to decrease or stop drinking; or even develop withdrawal symptoms, such as tremor or restlessness.
Additionally, over time, your patient could develop tolerance, which means they have to drink more alcohol to reach the desired effect.
Now, social problems are apparent if your patient has reduced or given up important daily activities, like their favorite hobby or even personal hygiene.
Other important social problems include failing to fulfill major obligations, such as work-related or parenting responsibilities; or continuing to consume alcohol despite these social and interpersonal problems.
Finally, risky use refers to alcohol use in physically hazardous situations, like operating a motor vehicle, drinking while another person is under their care, or even drinking on the job.

Assess severity of AUD7:02–7:18

Now, if your patient meets two or more criteria in the last 12 months, you can diagnose alcohol use disorder! Next, assess the severity of your patient’s alcohol use disorder based on the number of criteria that are met.

Mild AUD7:18–8:11

Okay, if your patient meets two or three of the DSM-5 criteria, diagnose mild alcohol use disorder! The first step in management is counseling in the form of a brief intervention, typically during a routine outpatient encounter.
You should use motivational interviewing techniques, like asking open-ended questions, which helps patients develop insight into the effects of their alcohol use.
Patients with mild alcohol use disorder can also benefit from individual or group counseling. Commonly used techniques include cognitive-behavioral therapy, or CBT, with additional support from groups like Alcoholics Anonymous or AA, SMART recovery, among many other options.
Finally, don’t forget to treat associated medical conditions, such as electrolyte disturbances or mood disorders. Next, if your patient meets four to five of the DSM-5 criteria, diagnose moderate alcohol use disorder.

Moderate AUD8:11–10:11

Again, these patients will benefit from counseling, either in an individual or group setting, and they might need treatment programs, either in an inpatient or outpatient setting.
Inpatient alcohol treatment programs provide a medically supervised environment for safe alcohol withdrawal management in patients at risk for severe or complicated withdrawal, as well as education on alcohol use disorder.
On the flip side, outpatient programs are less structured and do not usually include medically supervised withdrawal. Instead, these programs focus on education and group activities with others in recovery.
Next, offer pharmacologic therapy to support a patient’s abstinence and reduce the risk of relapse. The most common medications are naltrexone, acamprosate, and disulfiram.
Naltrexone is an opioid receptor antagonist used as a first-line medication. It reduces the positive effects of alcohol, helps reduce cravings, and is started before attaining abstinence.
Acamprosate, a neuromodulator, is another first-line option that helps balance the dysregulated neuronal activity during alcohol withdrawal in addition to reducing cravings.
If naltrexone and acamprosate are not tolerated or ineffective, you can offer disulfiram as a second-line therapy, which irreversibly inhibits aldehyde dehydrogenase, a hepatic enzyme that metabolizes alcohol.
If alcohol is consumed while on disulfiram, serum acetaldehyde levels increase, causing undesirable symptoms such as facial flushing, tachycardia, nausea, vomiting, hypotension, and headache.
Lastly, don’t forget to treat associated medical conditions! Finally, if your patient meets six or more of the DSM-5 criteria, diagnose severe alcohol use disorder.

Severe AUD10:11–10:31

These patients will benefit from counseling, a treatment program, pharmacologic therapy, and treatment of any associated conditions!
Alright, as a quick recap… If your patient’s CAGE or AUDIT screening test is positive, and they meet two or more of the DSM-5 criteria, diagnose alcohol use disorder and determine the severity of the disease based on the number of criteria met.

Review10:31–11:08

All patients with alcohol use disorder benefit from counseling and treatment of associated conditions. Additionally, if your patient has moderate or severe alcohol use disorder, they should participate in an alcohol treatment program, and may require pharmacologic therapy to support abstinence and reduce