Alcohol use disorder

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Epidemiology of alcohol use disorder.
  • Chronic mental illness characterized by inability to limit alcohol ingestion, compulsive drinking, and a negative emotional state when not drinking.
  • Previously separated into alcohol abuse and alcohol dependence, but as of DSM-5, the diagnoses were combined into alcohol use disorder, and subdivided into mild, moderate, or severe.
  • It is estimated that about 6% of adults in the US suffer from alcohol use disorder.

Clinical Features

  • Drinking more or for a longer period of time than intended.
  • Feeling incapable of cutting back on the amount of alcohol consumed.
  • Becoming sick for an extended period of time as a result of drinking too much.
  • Inability to concentrate due to alcohol cravings.
  • Inability to care for a family, hold down a job, or perform in school.
  • Continuing to drink despite problems caused with friends or family.
  • Decreased participation in activities which were once important.
  • Finding oneself in dangerous or harmful situations as a direct result of drinking.
  • Continuing to drink despite adding to another health problem, feeling depressed or anxious or blacking out.
  • Drinking more as a result of a tolerance to alcohol.
  • Experiencing withdrawal symptoms.
Mild = 2-3 features
Moderate = 4-5 features
Severe = 6 or more features

Differential Diagnosis

Ethanol related disease processes


  • A history alone is sufficient to make the diagnosis of alcohol use disorder, however, if a patient presents to the ER, it is important to evaluate for the presence of:
  • Check electrolytes, including magnesium and phosphorus[1]
    • Long-term alcohol intake often has electrolyte abnormalities (including hypomagnesemia and hypokalemia)
    • Low magnesium levels, typically below 0.8 mEq/L, can also cause hypocalcemia due to suppression of parathyroid hormone secretion and parathyroid hormone resistance


Vitamin Prophylaxis for Chronic alcoholics

  • At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
  • Give multivitamin PO; patient at risk for other vitamin deficiencies

Banana bag

The majority of chronic alcoholics do NOT require a banana bag[2][3]

Medication Assisted Treatment



  • Naltrexone 380 mg IM or 50 mg PO qday #30 tabs, no refills
  • Contraindications:
    • Any opioid use (including Buprenorphine):
      • Must be off short-acting opioids for 1 week and methadone for 2 weeks
    • Planned surgery/anesthesia in next 30 days (okay to use tablets, stop 1 day prior to surgery)
    • Acute liver injury with AST or ALT >/= 250 or decompensated cirrhosis (Childs Pugh Class 3)
    • Pregnancy
    • Allergy


  • A Cochrane review assessed the efficacy of naltrexone in randomized control trials.[4]
    • Helps to reduce the number of participants who relapse or return to heavy drinking in a short time frame following treatment (12 weeks).
  • Reduces the time in days to first drink when compared to placebo or disulfiram.
  • Reduces reported cravings and the total amount of alcohol consumed.
  • Should be offered to patients with alcohol use disorder who are interested in reducing alcohol intake.



  • Gabapentin 600 mg PO TID #90 tabs, no refills
    • Counsel to decrease to 300 mg PO TID if dizzy, can increase after 1 week
    • Renally dosed if CrCl<60
    • ACOG approves of use in pregnancy


  • A metanalysis of several randomized control trials demonstrates that use of gabapentin for alcohol use disorder reduces the number of total heavy drinking days. [5]
  • Addition of gabapentin to naltrexone further helped to reduce cravings in the first 6 weeks of AUD. [6]


  • Can be prescribed as alcohol avoidance therapy. This can be prescribed in the emergency department or referred to PCP/psychiatrist treating the patient's addiction.


  • Outpatient
    • If the patient is not acutely intoxicated or at risk for alcohol withdrawal, they should be referred to a social worker or their PCP for resources to quit drinking and can usually be discharged safely.

See Also

External Links


  1. Baj J, Flieger W, Teresiński G, Buszewicz G, Sitarz R, Forma A, Karakuła K, Maciejewski R. Magnesium, Calcium, Potassium, Sodium, Phosphorus, Selenium, Zinc, and Chromium Levels in Alcohol Use Disorder: A Review. J Clin Med. 2020 Jun 18;9(6):1901. doi: 10.3390/jcm9061901. PMID: 32570709; PMCID: PMC7357092.
  2. Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  3. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.
  4. Srisurapanont M, Jarusuraisin N. Opioid antagonists for alcohol dependence. Cochrane Database of Systematic Reviews. 2005;(1).
  5. Kranzler HR, Feinn R, Morris P, Hartwell EE. A meta-analysis of the efficacy of gabapentin for treating alcohol use disorder. Addiction. 2019;114(9):1547-1555.
  6. Anton RF, Myrick H, Wright TM, Latham PK, Baros AM, Waid LR, Randall PK. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatry. 2011 Jul;168(7):709-17. doi: 10.1176/appi.ajp.2011.10101436. Epub 2011 Mar 31. PMID: 21454917; PMCID: PMC3204582.