Alcohol Use Disorder

Clinical picture

• Escalating quantity and frequency with failed cutdown attempts, morning drinking, and blackouts that patients reframe as ordinary social use.
• Tolerance shows as high-dose functioning; withdrawal emerges 6-24 hours after the last drink as tremor, sweating, tachycardia, nausea, and anxiety.
• Craving is cue-driven and situational, intensifying with stress, negative affect, and exposure to drinking environments or social pressure.
• Physical signs include hypertension, elevated GGT and MCV, spider angiomata, palmar erythema, gastritis, peripheral neuropathy, and unexplained trauma.
• Interpersonal fallout precedes medical presentation: absenteeism, DUIs, marital conflict, and role failure often bring the patient in before symptoms do.
• Comorbid insomnia, depressed mood, and anxiety typically improve substantially within 2 to 4 weeks of sustained abstinence.

Criteria snapshot

• Requires at least 2 of 11 problematic use indicators within 12 months, spanning impaired control, social impairment, risky use, and pharmacologic criteria.
• Severity is graded by symptom count: mild 2-3, moderate 4-5, and severe 6 or more, replacing the older abuse and dependence split.
• Craving, a strong desire or urge to drink, was added to the criterion set, while recurrent legal problems were removed from it.
• Tolerance and withdrawal are not counted when alcohol is taken solely under appropriate medical supervision, a rare situation for alcohol.
• Specifiers cover early remission (3 to under 12 months), sustained remission (12 months or more), and being in a controlled environment.

Neurobiology

• Alcohol potentiates GABA-A inhibition and blocks NMDA glutamate receptors; chronic use reverses this balance, driving withdrawal hyperexcitability.
• Mesolimbic dopamine release in the nucleus accumbens, amplified by endogenous opioid signaling at mu receptors, underlies reinforcement and craving.
• Repeated withdrawals kindle progressively severe episodes, raising seizure and delirium tremens risk with each successive detoxification.
• Allostatic shift recruits extended amygdala CRF and dynorphin systems, converting drinking from reward-seeking to negative-reinforcement relief.
• Heritability is roughly 50%, and ADH1B and ALDH2 variants that produce flushing are strongly protective in East Asian populations.
• Chronic use causes thiamine depletion with Wernicke encephalopathy risk, cerebellar atrophy, hepatic steatosis to cirrhosis, and cortical volume loss.

Psychology

• Negative reinforcement dominates late-stage use: drinking relieves withdrawal dysphoria, anxiety, and insomnia rather than producing euphoria.
• Alcohol expectancies for tension reduction and social ease, learned early from family and media, predict initiation and heavier adolescent consumption.
• Alcohol myopia narrows attention to immediate cues, impairing consideration of long-term consequences and inflating disinhibited behavior.
• Shame-based self-concept and stigma drive concealment, delayed help-seeking, and abstinence violation effects after a single lapse.
• Classical conditioning links people, places, and moods to craving, and cue reactivity persists for many months into abstinence.

Differential & comorbidity

• Substance-induced depressive and anxiety disorders resolve within weeks of abstinence, while independent disorders persist and need their own treatment.
• Screen with AUDIT-C or AUDIT, and differentiate from unhealthy drinking without disorder, bipolar disorder, and PTSD-driven self-medication.
• Comorbidity includes mood and anxiety disorders, PTSD, ADHD, tobacco use disorder, and other sedatives; polysubstance use raises overdose risk.
• Suicide risk is elevated roughly two to threefold, and acute intoxication increases impulsive attempts and the lethality of chosen means.
• Assess withdrawal severity with CIWA-Ar; scores above 8 to 10 warrant medication, and prior seizures or delirium tremens indicate inpatient detox.

Pharmacologic treatment

• Naltrexone 50 mg/day oral or 380 mg IM monthly is first-line, reducing heavy drinking days; check LFTs and avoid with any opioid agonist.
• Acamprosate 666 mg TID supports abstinence maintenance and is preferred in hepatic impairment; reduce the dose for CrCl of 30 to 50 mL/min.
• Disulfiram 250 mg/day works only with supervised dosing and high motivation, and the aversive reaction can itself be medically dangerous.
• Off-label topiramate 200-300 mg/day and gabapentin 900-1800 mg/day have supporting trial data, especially with comorbid anxiety or insomnia.
• Withdrawal management uses symptom-triggered lorazepam or chlordiazepoxide plus thiamine 100 mg given before any glucose load.

Psychotherapy

• Motivational interviewing and brief interventions of 1 to 4 sessions reliably reduce consumption in risky drinkers who are not yet dependent.
• CBT with relapse prevention over 12 to 16 sessions targets high-risk situations, coping skills, and abstinence violation cognitions.
• Contingency management yields the largest short-term effect sizes, and the community reinforcement approach restructures competing reinforcers.
• Behavioral couples therapy improves both drinking outcomes and relationship functioning more than individual therapy delivered alone.
• Twelve-step facilitation produces abstinence rates equal to or better than CBT and durably increases mutual-help group engagement.

Adjunct options

• AA and secular alternatives such as SMART Recovery provide free, sustained recovery capital, and active linkage clearly beats passive referral.
• Use ASAM criteria to match level of care, from outpatient counseling through medically managed inpatient withdrawal.
• Monitor with AUDIT, timeline followback, and biomarkers such as phosphatidylethanol, carbohydrate-deficient transferrin, and GGT.
• Treat comorbid insomnia behaviorally with CBT-I rather than sedatives, and correct thiamine, folate, and magnesium deficits.
• Screen for hepatitis C, vaccinate against hepatitis A and B, and coordinate hepatology follow-up for patients with advanced liver disease.

Clinical pearls

• Two or more of 11 criteria in 12 months makes the diagnosis; the count sets severity.
• Give thiamine before any glucose load to avoid precipitating Wernicke encephalopathy.
• Naltrexone works even while the patient is still drinking; abstinence is not required.