Description

• 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 symptoms. 2 to 3 of the DSM-5 criteria for substance use disorders (see below) is considered mild disease. 6 or more is classified as severe AUD.
  • Continued use despite related social or interpersonal problems or physical or psychological problems
  • Recurrent use in hazardous situations
  • Failure to fulfill obligations at work, school, or home
  • Cravings, tolerance, withdrawal
  • Using more than intended or for longer periods of time than intended
  • Persistent desire or attempts to cut down/stop
  • Social, occupational, or recreational activities sacrificed for alcohol use
• “Risky drinking” or “unhealthy use” refers to individuals who do not meet formal criteria for AUD or have not been identified as experiencing AUD yet drink at levels that place them at increased risk of negative outcomes.
  • Women: >3 drinks per day, >7 drinks per week
  • Men: >4 drinks per day, >14 drinks per week
• Binge drinking
  • Drinking that brings blood alcohol levels to 0.08 g/dL
  • Usually 4 drinks for women and 5 drinks for men in 2 hours
• National Institute on Alcohol Abuse and Alcoholism criteria for “at-risk” drinking: men: >14 drinks a week or >4 per occasion; women: >7 drinks a week or >3 per occasion
• The 2015–2020 Dietary Guidelines for Americans defines moderate drinking as up to 1 drink per day for women and up to 2 drinks per day for men.

Geriatric Considerations

• Multiple drug interactions
• Signs and symptoms may be different or attributed to 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 (1).

Pediatric Considerations

• Children of alcoholics are at increased risk; 2.5% of adolescents have AUD; 13.4% of youth age 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.

Epidemiology

• Predominant age 18 to 25 years, but all ages 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 (2).
• Global increase in AUD over the past 20 years. The COVID-19 pandemic has been associated with increases in alcohol consumption on a global scale.
• In the United States, recent increases in AUD come from a dramatic rise in AUD in women (84%) as compared to men (35%).
  • Stems from increases in heavy and binge drinking in adolescent girls as well as women
  • Women also tend to experience more alcohol-related health issues than men (3).

Prevalence

• 27% of Americans age ≥18 years reported binge drinking in the past month; 7% reported heavy alcohol use in the past month; 15 million adults (6%) age >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 (4).

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.

Genetics
50–60% of risk is genetic.

Risk Factors

• Family history; depression; anxiety disorders; bipolar disorder; eating disorders
• Tobacco use; 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) (1)

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.