Alcohol Use Disorder (AUD)



  • Any pattern of alcohol use causing significant physical, mental, or social dysfunction; key features are tolerance, withdrawal, and persistent use despite problems.
  • The severity of AUD exists on a spectrum but is classified as mild, moderate, or severe based on the number of clinical criteria that are met. Manifestation of 2 to 3 of the DSM-5 criteria for substance use disorders is considered mild disease, 4 to 5 is classified as moderate, and ≥6 is severe AUD.
  • DSM-5 criteria for AUD
    • Tolerance or withdrawal
    • Loss of control over the amount of alcohol used
    • Alcohol cravings or unable to cut down or quit using alcohol
    • Alcohol use during hazardous situations or continued alcohol use that leads to hazardous situations
    • A large amount of time is spent using or recovering from alcohol.
    • Continued alcohol use despite known physical or psychological consequences (i.e., hypertension, hyperlipidemia, cirrhosis, depression, anxiety)
    • Continued use of alcohol despite a negative impact on relationships or failure to meet obligations at work or school
    • Social or occupational activities that were once important to the person are abandoned.
  • National Institute on Alcohol Abuse and Alcoholism (NIAAA) criteria for low-risk alcohol use
    • Low-risk alcohol use: NIAAA criteria for low-risk drinking is no more than 14 drinks a week or >4 drinks per occasion. For women, low-risk drinking involves no more than 7 drinks a week or 3 drinks per occasion. Alcohol use that exceeds these levels does not always result in AUD but can still be problematic for an individual.
    • The safest level of use is considered no use because even low-level use is associated with reduction in grey matter and cognitive impairment.
    • Binge drinking: drinking that brings blood alcohol levels to 0.08 g/dL; this is usually 4 drinks for women and 5 drinks for men in 2 hours.
  • Measuring alcohol use
    • A standard drink includes 14 g (0.6 fluid oz) of pure alcohol. This includes:
      • 12 oz of beer that are 5% alcohol
      • 5 oz of wine that are 12% alcohol
      • 1.5 oz of distilled spirits that are 40% alcohol

Geriatric Considerations

  • Multiple drug interactions
  • Signs and symptoms of AUD may be different or attributed to a chronic medical problem or dementia.
  • Accelerated aging from frequent alcohol use together with increased consumption in middle-age and older adults increases risk of cognitive decline and dementia.

Pediatric Considerations

  • Children of alcoholics are at increased risk; 2.5% of adolescents have AUD; 13.4% of youth aged 12 to 20 years report binge drinking in the past month; negative effect on maturation and normal brain development
  • Early-onset drinkers (those who start drinking before age 21 years) are 4 times more likely to develop a problem than those who begin after age 21 years.


Predominant age is 18 to 25 years, but all ages are affected; male > female (3:1)

  • Young drinkers through college age commonly engage in heavy to binge drinking (4 drinks for women and 5 drinks for men in 2 hours) to extreme binge drinking (>15 drinks in one session) on weekends.
  • New data reflects increased drinking in middle-age to older adults and binge drinking, especially in women, increasing risk of cognitive decline and dementia.
  • In the United States, recent increases in AUD come from a dramatic rise in alcohol use in women (84%) as compared to men (35%).


  • 27% of Americans aged ≥18 years reported binge drinking in the past month; 7% reported heavy alcohol use in the past month; 15 million adults (6%) aged >18 years has AUD.
  • Excess drinking cost $249 billion in 2010 in the United States, and kills 88,000 Americans per year: approximately 1 in 10 working-age adults
  • In the United States, harmful alcohol use is the third leading cause of preventable death and has become a major public health crisis.

Etiology and Pathophysiology

  • Multifactorial: genetic, environment, psychosocial
  • Alcohol is a CNS depressant, facilitating γ-aminobutyric acid (GABA) inhibition and blocking N-methyl-D-aspartate receptors.

50–60% of risk is genetic.

Risk Factors

  • Family history; depression; anxiety disorders; bipolar disorder; eating disorders
  • Tobacco and/or other substance abuse
  • Male gender; lower socioeconomic status; unemployment; poor self-esteem
  • Posttraumatic stress disorder; antisocial personality disorder; criminal behavior

General Prevention

  • Counsel patients with family history and risk factors.
  • USPSTF recommended in 2018 to screen adults for alcohol use and provide brief counseling to those with risky drinking habits.
  • Screening and brief intervention (SBI)

Commonly Associated Conditions

  • Cardiomyopathy; atrial fibrillation; hypertension
  • Peptic ulcer disease; cirrhosis; fatty liver; cholelithiasis; hepatitis; pancreatitis
  • Diabetes mellitus; malnutrition; upper GI malignancies
  • Peripheral neuropathy, seizures
  • Abuse and violence
  • Behavioral disorders (depression, bipolar, schizophrenia): >50% of patients have a comorbid substance abuse problem.

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