• •"Standard drink": One standard drink is defined as 14 g of absolute ethanol that includes 12 oz of beer, 5 ounces of wine, or 1.5 oz of 80-proof spirits.¹
• •"Moderate drinking": Moderate drinking has been defined as two standard drinks per day for men and one drink per day for women and persons older than 65 yr.²
• •"At-risk drinking": For men, at-risk drinking or harmful alcohol use is defined as more than 14 drinks/wk or more than four drinks/day. For women, at-risk drinking is defined as three or more drinks per day or seven or more drinks per wk.
• •"Binge drinking": Binge drinking is defined as drinking enough within about 2 h to bring alcohol blood concentration up to 0.08 g/dl or higher. Typically, five or more standard drinks for men or four or more standard drinks for women.²
• •"Alcohol use disorder (AUD)": Alcohol use disorder is a problematic pattern of alcohol use characterized by craving, use despite consequences, loss of control over intake, and physiologic dependence. It leads to clinically significant impairment or distress, and it is defined by the DSM-5-TR through specific diagnostic criteria and can be classified as mild, moderate, or severe.³
• •"Alcohol withdrawal": The American Psychiatric Association³ defines diagnostic criteria for alcohol withdrawal as follows:
  1. 1.Cessation of (or reduction in) alcohol use that has been heavy and prolonged
  2. 2.Two (or more) of the following, developing within several hours to a few days of cessation or reduction of alcohol use:
     1. a.Autonomic hyperactivity (e.g., sweating or pulse rate >100 beats/min)
     2. b.Increased hand tremor
     3. c.Insomnia
     4. d.Nausea and vomiting
     5. e.Transient visual, tactile, or auditory hallucinations or illusions
     6. f.Psychomotor agitation
     7. g.Anxiety
     8. h.Generalized tonic-clonic seizures
  3. 3.The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
  4. 4.The symptoms are not attributable to a general medical condition and are not better accounted for by another mental disorder.

Alcohol dependence

Alcohol abuse

Alcohol withdrawal syndrome

Alcoholism

AUD

• •Recurring minor trauma or falls
• •GI bleeding from gastritis and/or varices
• •Pancreatitis (acute and chronic)
• •Liver disease
• •Odor of alcohol on breath
• •Signs of alcohol withdrawal
• •Peripheral neuropathy
• •Recent memory loss

Social and genetic factors play key roles.

• •The United States Preventive Services Task Force (USPSTF)¹² recommends that clinicians screen adults 18 yr and older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Several screening tests (CAGE [Table 1], TWEAK, Single Alcohol Screening Question [SASQ], and Alcohol Use Disorders Identification Test-Concise [AUDIT-C; Table 2]) are available.
• •The four-item CAGE (feeling need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an Eye-opener in the morning) is a popular screening test in primary care. A positive response should lead to further questioning. The sensitivity of the CAGE ranges from 43% to 94%, and its specificity ranges from 70% to 97% in the primary care setting.¹³
• •The five-item TWEAK scale (Tolerance, Worry, Eye-openers, Amnesia, [K] cut down) and the TACE questionnaire (Tolerance, Annoyance, Cut down, Eye-opener) are designed to screen pregnant women for alcohol misuse. They detect lower levels of alcohol consumption that may pose risks during pregnancy.
• •A single-question screening about alcohol consumption in a day ("When was the last time you had more than X drinks in a day?" [where X is five for men and four for women]) with the threshold set at "in the past 30 days" is 82% sensitive and 79% for unhealthy alcohol use, and 88% sensitive and 67% specific for detection of AUD.¹⁴ This single question can also indicate frequency of binge drinking behavior, which would warrant further exploration.
• •The three-question AUDIT-C is a shorter form of the 10-item AUDIT, and the questions center on the quantity and frequency of alcohol use. It asks how often someone has a drink containing alcohol, how many standard drinks containing alcohol one consumes on a typical day when one is drinking, and how often one has six or more drinks on one occasion. Scoring ranges from 0 to 4 on each question with a total score range of 0 to 12. A total score of 3 or higher for women and 4 or higher for men indicates harmful alcohol use and need for further assessment.
• •AUD as defined by the DSM-5-TR³ as a pattern of alcohol use causing significant impairment or distress as manifested by at least two of the following criteria within a 12-mo period: alcohol is often taken in larger amounts than intended; desire or unsuccessful efforts to cut down or control use; large amount of time spent in obtaining, using, or recovering from alcohol; cravings; alcohol use resulting in failure to fulfill major role obligations at work, school, or home; continued use despite persistent social or interpersonal problems caused by alcohol; important social, occupational, or recreational activities are given up or reduced because of use; recurrent alcohol use in situations in which it is physically hazardous; continued use despite knowledge of physiologic or psychologic problem that is likely exacerbated by alcohol; tolerance (increased amounts of use to achieve intoxication or diminished effect with continued use of the same amount of alcohol) or alcohol withdrawal. The presence of two to three symptoms indicates mild AUD; four to five is moderate; and six or greater is severe. Severe or prolonged alcohol use can lead to neurologic sequelae (e.g., memory loss, peripheral neuropathy), liver manifestations (e.g., spider angiomata, palmar erythema, plethoric facies, hepatic and/or spleen enlargement, hypertension, jaundice, ascites, GI bleeding, or esophageal varices), or cardiologic sequelae (cardiomyopathy, atrial fibrillation).¹⁵
• •Laboratory evaluation (see "Laboratory Tests").

Laboratory tests alone do not diagnose alcohol use disorder, though may identify consequences of harmful alcohol use:

• •Increased liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], γ-glutamyltransferase [GGT]; typically, AST:ALT ratio of ≥2:1)
• •Low albumin, hypophosphatemia, hypomagnesemia from malnutrition
• •CBC may reveal low hemoglobin, anemia, pancytopenia, and/or elevated mean corpuscular volume from toxic effect of alcohol on erythrocyte development in nutritional deficiencies
• •Stool for occult blood may be positive as a result of gastritis or variceal bleeding
• •Low folate, vitamin B₁₂, vitamin B₆, vitamin B₁ levels

Computed tomography (CT) or ultrasound of abdomen may reveal fatty liver disease or cirrhosis in advanced stages. Head imaging may be indicated if presentation involves trauma or neurologic signs.

• •Screening, Brief Interventions, and Referral for Treatment (SBIRT) should be implemented in primary care settings.^1,16 Screening scales are discussed above.
• •Evidence-based nonpharmacologic treatment modalities, including cognitive-behavioral therapy (CBT), motivational enhancement therapy, acceptance and mindfulness-based interventions, contingency management approaches, couples and family counseling, and 12-step facilitation therapy, can help patients reduce or stop drinking.¹⁷
• •Acceptance and Commitment Therapy (ACT) is a third-wave CBT therapy that has shown some benefit in alcohol use disorder.¹⁸
• •Some patients also find support groups such as Alcoholics Anonymous (or Secular Alcoholics Anonymous) helpful in achieving and maintaining sobriety.
• •Referral to most intensive substance use care should be considered for individuals with severe alcohol use disorder.
• •Depression, if present, should be treated at same time alcohol is withdrawn.

Alcohol withdrawal syndrome (AWS) occurs when a person stops ingesting alcohol after prolonged consumption. The severity of the syndrome depends on a patient’s pattern and duration of alcohol use and the time from the patient’s last alcohol ingestion. Blood ethanol level decreases by 20 mg/dl/h in a normal person. Alcohol withdrawal can range from minor discomfort requiring minimal medications to multisystem organ failure requiring intensive care treatment. There are four major withdrawal syndromes as discussed below. Table 3 summarizes medications for the treatment of alcohol use disorder. The cornerstone of treatment for alcohol withdrawal syndrome is the use of benzodiazepines, though barbiturates such as phenobarbital are sometimes used, as well as alpha-2 agonists such as clonidine in inpatient settings.

• •Mild/Early Withdrawal:
  1. 1.Time interval: Begin to see symptoms from 6 to 12 h after the last drink.
  2. 2.Manifestation: Tremors, mild agitation or anxiety, insomnia, headache, palpitations/tachycardia, diaphoresis, GI upset; symptoms are relieved by alcohol.
  3. 3.Workup: CBC, electrolytes, glucose, blood urea nitrogen, creatinine, GGT, ALT, AST, serum vitamin B₁₂, and folic acid.
  4. 4.Treatment: Minor withdrawal states can be self-limiting and resolve within 48 h if the patient does not have an excessive alcohol use history, does not have clinical signs of excessive chronic alcohol use (as discussed in laboratory findings above), and does not have risk factors for development of more severe withdrawal states. Patients at risk for more severe withdrawal states should be admitted and managed in an inpatient setting.
  5. 5.Candidates for outpatient detoxification should have a reasonable support system (e.g., reliable contact person) who can monitor progress and lack of any significant comorbid conditions (e.g., suicide risk, seizure disorder, coexisting benzodiazepine dependence, prior unsuccessful outpatient detoxification, pregnancy, cirrhosis) or risk factors for severe withdrawal (history of severe withdrawal symptoms, history of withdrawal seizures or delirium tremens, multiple previous detoxifications, concomitant psychiatric or medical illness, high levels of alcohol consumption [random blood alcohol level >200 mg/dl or history of >15 standard drinks per day], metabolic derangement, early withdrawal signs with elevated blood alcohol level, age >40).
  6. 6.The Clinical Institute Withdrawal Assessment Scale for Alcohol, Revised (CIWA-Ar) scale can be used to measure the severity of alcohol withdrawal. It consists of 10 items: Nausea; tremor; autonomic hyperactivity; anxiety; agitation; tactile, visual, and auditory disturbances; headache; and disorientation. Each item is assigned a score from 0 to 7. For the category of "tremor," 0 indicates that tremor is not present and 7 that tremor is severe, even with arms not extended. The maximum total score is 67. Patients with mild AWS symptoms (CIWA-Ar score <8) can be monitored on an outpatient basis. Benzodiazepines are beneficial for most patients with a CIWA-AR score ≥8 and are strongly recommended in patients with substantial withdrawal symptoms (CIWA-Ar score >12). Patients with CIWA-Ar score of ≥15 should be admitted. Note that some patients will score highly on the CIWA due to subjective symptoms, even when not experiencing withdrawal. Therefore careful interpretation of the score is often required.
  7. 7.Outpatient treatment:
     1. a.The patient and support person(s) should be educated on withdrawal symptoms, time course, medication administration and side effects, and what to do if symptoms worsen. The patient should be assessed daily.
     2. b.Fixed dose regiment is preferred, small quantities are prescribed on each visit.
     3. c.Longer-acting benzodiazepines (e.g., chlordiazepoxide or diazepam) may be preferred due to decreased risk of rebound withdrawal in patients without liver disease (where the preferred agents would be lorazepam, oxazepam).
     4. d.Patients should also be prescribed thiamine and a multivitamin.
  8. 8.Inpatient treatment:
     1. a.In patients with mild to moderate withdrawal and without history of seizures, individualized benzodiazepine administration (rather than a fixed-dose regimen) results in lower benzodiazepine administration and avoids unnecessary sedation. CIWA-Ar monitoring every 4 h with symptom-triggered lorazepam should be administered: for CIWA-Ar scores equal to or greater than 8, patient receives lorazepam 2 to 4 mg.
     2. b.Beta-adrenergic blockers: Beta-blockers are useful for controlling blood pressure and tachyarrhythmias. However, they do not prevent progression to more serious symptoms of withdrawal and, if used, should not be administered alone but in conjunction with benzodiazepines. Beta-blockers should be avoided in patients with contraindications to their use (e.g., bronchospasm, bradycardia, or severe congestive heart failure). Centrally acting alpha-adrenergic agonists such as clonidine ameliorate symptoms in patients with mild to moderate withdrawal but do not reduce delirium or seizures.
     3. c.Vitamin replacement: Thiamine 100 mg intravenous (IV) or intramuscular (IM) for at least 5 days plus oral multivitamins. The IV administration of glucose can precipitate Wernicke encephalopathy in patients with chronic alcohol use with thiamine deficiency; therefore, thiamine administration should precede IV dextrose. In cases where a patient presents with signs of or is judged to be at risk for Wernicke encephalopathy, high doses of parenteral thiamine (up to 500 mg tid for 3-5 days) are recommended.
     4. d.Hydration PO or IV (high-caloric solution): If IV, glucose with Na⁺, K⁺, Mg²⁺, and phosphate replacement as needed.
     5. e.Social rehabilitation: Group therapy such as Alcoholics Anonymous; identification and treatment of social and family problems should be initiated during the patient’s hospital stay.
• •Alcoholic Hallucinosis:
  1. 1.Older term that has fallen out of favor due to overlapping usages and inconsistent definitions.
  2. 2.Time interval: 12 to 24 h after last drink.
  3. 3.Manifestations: Hallucinations usually are auditory, but hallucinations occasionally are visual, tactile, or olfactory; usually there is no clouding of sensorium as in delirium.
  4. 4.Treatment: Most symptoms remit after 48 h, treatment should include treating alcohol withdrawal state.
• •Withdrawal Seizures:
  1. 1.Time interval: Within 12 to 48 h after last drink, though have been described as early as 1 to 2 h
  2. 2.Risk factors: Preexisting seizure disorder, history of head trauma, history of previous alcohol withdrawal seizures
  3. 3.Manifestations: Tonic-clonic generalized convulsions with loss of consciousness; focal signs are usually absent
  4. 4.Workup: Consider further investigation with CT scan of head and electroencephalography if indicated (e.g., presence of focal neurologic deficits, prolonged post-ictal confusion state). In addition, in a febrile patient who is having a seizure or altered mental state, a lumbar puncture is necessary
  5. 5.Treatment: Admission and benzodiazepines for seizure control
     1. a.Diazepam 2.5 mg/min IV or lorazepam 1 to 2 mg IV every 2 h until seizure is controlled (check for respiratory depression or hypotension) may be beneficial for prolonged seizure activity. Withdrawal seizures generally are self-limited. The use of other anticonvulsants for short-term treatment of alcohol withdrawal seizures is not recommended.
     2. b.Thiamine 100 mg IV, followed by IV dextrose, should also be administered. In cases where a patient presents with signs of or is judged to be at risk for Wernicke encephalopathy, high doses of parenteral thiamine (up to 500 mg tid for 3-5 days) are recommended.
     3. c.Electrolyte imbalances (increased Mg²⁺, decreased K⁺, increased or decreased Na⁺, decreased PO₄^3–) that may exacerbate seizures should be corrected.
• •Delirium Tremens (DT):
  1. 1.Time interval: Variable; usually 48 to 72 h after last drink, later onset has also been described
  2. 2.Risk Factors: History of alcohol withdrawal delirium, history of chronic daily alcohol use, age >40, concurrent medical/surgical illnesses, withdrawal symptoms in the context of elevated blood alcohol levels
  3. 3.Manifestations: Tachycardia, hypertension, hyperthermia, disorientation, visual hallucinations (other sensory hallucinations also occur), agitation, paranoid delusions; this is the most serious clinical presentation of alcohol withdrawal (mortality rate is approximately 15% in untreated patients).
  4. 4.Treatment:
     1. a.Admission
     2. b.Vital signs q30min (neurologic signs, if necessary)
     3. c.Use of lateral decubitus or prone position if restraints are necessary
     4. d.NPO: Nasogastric tube for abdominal distention may be necessary but should not be routinely used
     5. e.Laboratory studies: Same as for early alcohol withdrawal
     6. f.Vigorous hydration (4 to 6 L/day): IV with glucose (Na⁺, K⁺, PO₄³–, and Mg²⁺ replacement [if patient has hypophosphatemia or hypomagnesemia])
     7. g.Vitamins: Thiamine 100 mg IV qd. The initial dose of thiamine should precede the administration of IV dextrose; multivitamins (may be added to the hydrating solution). In cases where a patient presents with signs of or is judged to be at risk for Wernicke encephalopathy, high doses of parenteral thiamine (up to 500 mg tid for 3-5 days) are recommended.
     8. h.Sedation: Control of agitation should be achieved with rapid-acting sedative-hypnotic agents in adequate doses to maintain light somnolence for the duration of delirium
        1. 1)Initially: Lorazepam 2 to 5 mg IM/IV repeated prn
        2. 2)Maintenance (individualized dosage): Chlordiazepoxide, 50 to 100 mg PO q4 to 6 h, lorazepam 2 mg PO q4h, or diazepam 5 to 10 mg PO tid; withhold doses or decrease subsequent doses if signs of oversedation are apparent
        3. 3)Midazolam is also effective for managing DTs. Its rapid onset (sedation within 2 to 4 min of IV injection) and short duration of action (approximately 30 min) make it an ideal agent for titration in continuous infusion
     9. i.Treatment of seizures (as previously described)
     10. j.Diagnosis and treatment of concomitant medical, surgical, or psychiatric conditions

• •See Table 3
• •Treatment with agents for reduction of alcohol use should be considered as soon as possible after resolution of alcohol withdrawal syndrome. Initiation during hospital stay may lead to reduction in rehospitalizations within 30 days.¹⁹
• •Pharmacotherapies for alcohol use disorder include:
  1. 1.The long-acting opiate antagonist naltrexone inhibits the rewarding effects of alcohol. The starting dose is 25 mg/day, increased to 50 mg PO qd after 1 wk. An extended-release, once-monthly injection of naltrexone is also available and can be used along with psychosocial support to maintain alcohol abstinence. In patients with opioid dependence, naltrexone can precipitate acute withdrawal syndrome and should not be used at least 7 days from last opioid use. Avoid naltrexone if acute hepatitis, hepatic failure, or ongoing opioid use is present.
  2. 2.Acamprosate is a synthetic compound with a chemical structure similar to the neurotransmitter γ-aminobutyric acid and the amino acid neuromodulator taurine. Its mechanism of action is not completely understood. It is indicated for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation. It should be used only as part of a comprehensive psychosocial treatment program. It does not cause a disulfiram-like reaction as a result of ethanol ingestion. Dose is two 333-mg tablets tid. Treatment should be initiated as soon as possible after the period of alcohol withdrawal, when the patient has achieved abstinence, and should be maintained if the patient relapses. Avoid acamprosate if severe renal impairment is present. Dose adjustments of 333 mg tid for individuals with less severe renal impairment and those weighing <60 kg have been considered.
  3. 3.Disulfiram (Antabuse): Dosage is 250 to 500 mg qd for 1 to 2 wk, then dose range for maintenance is 125 to 500 mg qd. It interferes with the metabolism of alcohol by inhibiting aldehyde dehydrogenase, causing an accumulation of acetaldehyde. It produces unpleasant symptoms (nausea, flushing, elevated blood pressure, headache, weakness) when alcohol is ingested. Forty-eight hours of total abstinence is needed before starting disulfiram to prevent a negative reaction.
  4. 4.Topiramate, baclofen, or gabapentin can be offered as second line drugs; to patients with moderate to severe alcohol use disorder topiramate might be preferable.
  5. 5.Avoid pharmacologic treatments in pregnant or breastfeeding women.
  6. 6.Current promising areas of research include exploring benefits of cyproheptadine-prazosin combination, nalmefene, topiramate, and baclofen on reducing quantity of alcohol consumption.^20,21 Psychedelics may have a role in treatment, although the evidence is weak.²²

See "Referral."

• •To Alcoholics Anonymous or Adult Children of Alcoholics
• •Family members to Al-Anon or Al-A-Teen
• •Many cities have Salvation Army Adult Rehabilitation centers; all patients accepted, regardless of ability to pay

• •Relative indications for inpatient alcohol detoxification are as follows: History of DT or withdrawal seizures, severe withdrawal symptoms, concomitant psychiatric or medical illness, pregnancy, multiple previous detoxifications, recent high levels of alcohol consumption, and lack of reliable support network.
• •Detoxification is not a stand-alone treatment but should serve as a bridge to a formal treatment program for alcohol dependence.
• •Acute management of alcohol withdrawal depends on the pattern of use and last drink.
• •An effective strategy for the primary care physician is to screen patients for harmful alcohol use using scales and follow up the conversation with further exploration of stage of change in a nonjudgmental way.
• •Alcohol-associated liver disease is among the most common liver diseases.

Alcohol Use Disorder (Patient Information)

Drug Use Disorder (Related Key Topic)

Alcoholic Hepatitis (Related Key Topic)

Substance Use Disorder (Related Key Topic)

Wernicke Syndrome (Related Key Topic)