Alcohol Use Disorder – Diagnosis, Symptoms, and Treatment

What is Alcohol Use Disorder?

Alcohol use disorder is the 3rd leading preventable cause of death in the U.S. The condition likely occurs due to an interplay of genetics, environmental factors, personality traits, and cognition. Features of acute alcohol intoxication include slurred speech (dysarthria), nystagmus, disinhibited behavior, and impaired coordination. Patients with alcohol use disorder may also experience withdrawal, characterized by tremulousness, hallucinations, and seizures. The key features of the diagnosis include problematic alcohol use resulting in clinically significant impairment or distress. The long-term sequelae of alcohol abuse often include cardiomyopathy, dementia, peripheral neuropathy, liver disease, cancer, and death.

What Causes Alcohol Use Disorder?

The exact cause of alcohol use disorder is uncertain. However, there are several factors that appear to be strongly associated with the disease, including genetics, environmental factors, personality traits, and cognition. Environmental influences may include parenting patterns or influences from peers. Personality disorders such as neuroticism and impulsivity are also implicated in the disease. Furthermore, cognitive dysfunction (e.g., impaired memory) is closely associated with alcohol use disorder.

How Common is Alcohol Use Disorder?

Risky drinking and alcohol use disorders are common in the United States and are often initially evaluated in the primary care clinic or emergency department. Alcohol use disorder usually requires referral to a psychiatry specialist, especially if first-line and conservative measures are unsuccessful. One study evaluated alcohol drinking behavior over 30 days in Americans age >12. They found that an estimated 53% of individuals used alcohol at least once, 23% participated in binge drinking, and 6% reported heavy drinking. 3 out of 10 Americans use alcohol in an unhealthy manner, and 28% of adults in the US exceed the threshold for risky drinking. An estimated 4%-40% of hospitalized patients also experience alcohol-related problems. In the United States, excessive alcohol use is considered the 3rd leading preventable cause of death. It leads to approximately 85,000 deaths annually in the US.

Signs and Symptoms

Alcohol use disorder can manifest with states of acute alcohol intoxication or alcohol withdrawal. Feature of acute alcohol intoxication often include:

• Slurred speech (dysarthria)
• Nystagmus
• Disinhibited behavior
• Instability & incoordination
• Low blood pressure and elevated heart rate
• Impaired memory
• Coma

Features of alcohol withdrawal can include:

• Tremulousness
• Agitation
• Hallucinations
• Seizures
• Potentially death

Other potential symptoms and signs of alcohol use disorder are related to its complications such as coexisting injury or trauma, mental health disorders (e.g., depression, anxiety, suicidality), insomnia, hypertension (with long-term use), substance abuse, gastroesophageal reflux, vitamin deficiencies, liver disease, and anemia. Patients with long-term alcohol abuse may also develop peripheral neuropathy, dementia, and alcoholic cardiomyopathy. Other complications include oral, esophageal, and stomach cancer, particularly in individuals who smoke cigarettes.

Diagnosis

The diagnosis of alcohol use disorder is based on criteria set by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The key features of diagnosis include problematic alcohol use resulting in clinically significant impairment or distress. This usually manifests as multiple psychosocial, behavioral, or physiologic features. Your doctor will likely obtain laboratory tests to evaluate alcohol use complications, such as liver dysfunction, electrolyte abnormalities, and anemia. Commonly ordered blood tests include a CMP (comprehensive metabolic panel), CBC (complete blood cell count), thyroid function (TSH, free T4), and coagulation studies (PT/INR, PTT). They will also usually check your cholesterol levels and screen for diabetes.

Alcohol Use Disorder Medication and Treatment

The treatment of alcohol use disorder includes both psychosocial treatment and pharmacologic therapy. Up to 70% of individuals relapse with psychosocial intervention alone. The goal of treatment is to achieve relapse or a reduction in heavy drinking. Medical therapies for alcohol use disorder generally work by altering opioids, glutamate, or serotonin in the brain. The first-line treatment of alcohol use disorder often includes Vivitrol (naltrexone). Depot naltrexone can be considered in non-adherent individuals. Vivitrol (naltrexone) should not be used in individuals with liver disease or those who take opiate analgesics. Patients with acute hepatitis or liver disease generally benefit from treatment with Campral (acamprosate) over other therapies. Baclofen is a reasonable alternative in such patients. Patients that do not respond to the therapies above may benefit from one of the following agents:

• Antabuse (disulfiram)
• Topamax (topiramate) – a neuroleptic
• Neurontin (gabapentin) – a neuroleptic
• Lioresal (baclofen) – a muscle relaxer
• Zofran (ondansetron) – an antiemetic

Antabuse (disulfiram) is generally reserved for highly motivated patients to maintain abstinence. It works by inhibiting the enzyme responsible for alcohol metabolism, which results in unpleasant symptoms such as flushing with alcohol consumption. Selincro (nalmefene) is a newer agent that may also be effective in individuals refractory to the therapies above.

References:

1. Stahre M, Roeber J, Kanny D, et al. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis 2014; 11:E109. - https://www.ncbi.nlm.nih.gov/pubmed/24967831
2. Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med 2005; 352:596. - https://www.ncbi.nlm.nih.gov/pubmed/15703424
3. Fiellin DA, Reid MC, O'Connor PG. New therapies for alcohol problems: application to primary care. Am J Med 2000; 108:227. - https://www.ncbi.nlm.nih.gov/pubmed/10723977