Alcohol Use Disorder (AUD)

Overview

Main Concepts:

Notable Features:

High Yield:

Other:

Definition


Excessive drinking is generally considered:

  • >= 4 drinks / day for men

  • >= 3 drinks / day for women

Diagnostics


Assessment

All patients should be screened for unhealthy alcohol use. Those identified should receive a brief counseling intervention geared to identify:

  • The patient's level of awareness of the problem

  • The degree of motivation to change

Once a patient is able to recognize the problems of alcohol use, the patient will likely be more receptive to a trial of decreasing, or abstaining, from alcohol.

[See: Motivational Interviewing]

Look for red flags such as:

  • Evidence of liver toxicity (e.g. elevated LFTs)

  • Worsening hypertension

  • Possible negative social or familial consequences, like effects on family and marriage

Management

Patients with moderate-to-severe AUD should be offered pharmacotherapy in addition to psychosocial interventions. Medications that target the reinforcing effects of alcohol by modulating opioid and glutamate function, have been shown to:

  • Decrease cravings

  • Reduce alcohol consumption

  • Help maintain abstinence

First-line drugs include the glutamate modulator acamprosate and the mu-opioid receptor antagonist naltrexone. Acamprosate modulates activity at the metabotropic glutamate receptor 5, and is mostly excreted unchanged by the kidneys (safe for use in patients with liver disease, but requires dose adjustment in patients with renal failure). Naltrexone is associated with hepatotoxicity and is contraindicated in patients with liver disease and those taking prescription opioids.

A second-line drug, disulfiram (Antabuse), an aldehyde dehydrogenase inhibitor, generates an unpleasant physiologic reaction when alcohol is consumed, and is considered when naltrexone or acomprosate are ineffective or contraindicated. It otherwise should be used for highly motivated or supervised patients with AUD, as patients may otherwise skip a dose when alcohol is desired.

Alcohol Withdrawal

A benzodiazepine, like chlordiazepoxide, is indicated for the treatment of moderate-to-severe alcohol withdrawal. They are not used to treat AUD itself, and have a high risk of abuse.

Management of Methanol or Ethylene Glycol Poisoning

Administer fomepizole, an alcohol dehydrogenase inhibitor, as an antidote for methanol or ethylene glycol poisoning.