Comprehensive Presentation on Alcohol Use Disorder (AUD)
Alcohol Use Disorder is a chronic relapsing brain disorder characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences, with diagnosis based on specific DSM-5 criteria and treatment requiring both pharmacological and psychosocial interventions. 1
Etiology and Epidemiology
- AUD prevalence has increased by 50% between 2001 and 2013, with greater increases among women, minorities, and those of lower socioeconomic status 1
- Alcohol-associated liver disease comprises a substantial portion of overall cirrhosis burden, with mortality rates increasing particularly among younger patients (25-34 years old) 1
- Approximately 4% of the global disease burden is attributable to alcohol, comparable to tobacco and hypertension 2
- Highest rates of per capita alcohol consumption occur in northern and eastern European countries and Russia 1
- Binge drinking prevalence has increased significantly, with substantial increases in consumption of distilled spirits (+11.5%) and wine (+7.7%) between 2000-2013 1
Pathophysiology
- Chronic alcohol use induces dopaminergic signaling neuroadaptations in ventral tegmental area (VTA) neurons of the mesolimbic reward pathway 3
- Sustained dysfunction of reward circuitry is associated with return to drinking behavior 3
- Repeated ethanol use creates a hypodopaminergic signaling state in the nucleus accumbens, contributing to relapse behavior 3
- Alcohol directly affects multiple neurotransmitter systems including GABA, glutamate, dopamine, and endogenous opioids 4
- Chronic alcohol use leads to neuroadaptations that create both physical and psychological dependence 4
Patient Presentation and Clinical Features
- Patients present with problematic patterns of alcohol use accompanied by clinically significant impairment or distress 1
- Key presenting features include escalating alcohol consumption despite attempts to cut back, negative personal consequences, and alcohol craving 1
- Physical manifestations may include signs of alcohol-associated liver disease, ranging from steatosis to alcoholic hepatitis and cirrhosis 1
- Patients may exhibit withdrawal symptoms when alcohol use is discontinued, including tremors, anxiety, nausea, and in severe cases, seizures or delirium tremens 1
- Social and occupational dysfunction are common, including relationship problems, work performance issues, and financial difficulties 5
Evaluation Tools and Diagnostics
- The AUDIT (Alcohol Use Disorders Identification Test) is recommended as a 10-question assessment with high sensitivity and specificity for detecting hazardous drinking and AUD 5, 1
- The AUDIT-C, a shortened 3-question version focusing on consumption patterns, maintains good sensitivity while requiring less time to administer 5
- The CAGE Questionnaire is a brief 4-question tool with 85% sensitivity and 89% specificity that asks about attempts to Cut down, Annoyance with criticism about drinking, Guilt about drinking, and using alcohol as an Eye-opener 5, 1
- Biomarkers of alcohol use can aid diagnosis, support recovery, and serve as catalysts for discussion with patients 1
- Laboratory tests including liver enzymes (GGT, AST, ALT), carbohydrate-deficient transferrin (CDT), and complete blood count can help identify alcohol-related organ damage 1
Differential Diagnosis
- Other substance use disorders must be distinguished from AUD, as polysubstance abuse is common 6
- Psychiatric disorders with similar presentations include major depressive disorder, bipolar disorder, anxiety disorders, and post-traumatic stress disorder 5
- Medical conditions that may mimic alcohol withdrawal include hypoglycemia, thyrotoxicosis, and certain neurological disorders 5
- Medication side effects or interactions may present similarly to alcohol intoxication or withdrawal 5
- Distinguish AUD from non-problematic alcohol use, which is defined as drinking that doesn't meet diagnostic criteria for AUD 1
Treatment and Management
Pharmacotherapy
- FDA-approved medications for AUD include disulfiram, naltrexone (oral and long-acting injectable), and acamprosate 4
- Acamprosate is indicated for the maintenance of abstinence from alcohol in patients who are abstinent at treatment initiation 6
- The recommended dose of acamprosate is two 333 mg tablets (666 mg total) taken three times daily 6
- Naltrexone reduces the likelihood of return to any drinking by 5% and binge-drinking risk by 10% 4
- Treatment should be initiated as soon as possible after alcohol withdrawal when the patient has achieved abstinence 6
Psychosocial Interventions
- Brief behavioral counseling interventions are recommended for persons engaged in risky or hazardous drinking 1
- Comprehensive management programs should include psychosocial support alongside pharmacotherapy 6
- Early intervention in primary care settings is both feasible and effective 2
- Cognitive-behavioral therapy, motivational enhancement therapy, and twelve-step facilitation are evidence-based approaches 4
- Treatment should address comorbid psychiatric conditions, which are common in patients with AUD 5
Prognosis and Complications
- AUD is a chronic relapsing condition, with relapse rates comparable to other chronic medical conditions 4
- Alcohol is causally related to more than 60 different medical conditions 2
- Complications include alcohol-associated liver diseases (steatosis, alcoholic hepatitis, cirrhosis, hepatocellular carcinoma) 1
- Neurological complications include peripheral neuropathy, Wernicke-Korsakoff syndrome, and cognitive impairment 4
- Cardiovascular complications include cardiomyopathy, hypertension, and arrhythmias 4
Case Study Example
Patient Presentation
A 45-year-old male presents to primary care with complaints of fatigue, abdominal discomfort, and difficulty sleeping. His wife reports he has been drinking "more than usual" over the past year following job loss. Physical examination reveals mild hepatomegaly and spider angiomata. Laboratory tests show elevated GGT, AST>ALT, and macrocytosis.
Assessment
- AUDIT score: 22 (indicating severe AUD)
- Meets 7 DSM-5 criteria for AUD (severe)
- Laboratory and physical findings consistent with early alcoholic liver disease
Management Plan
- Brief intervention during initial visit
- Referral to addiction specialist
- Initiation of naltrexone 50 mg daily
- Weekly counseling sessions
- Regular liver function monitoring
- Involvement in mutual help group (AA)
Follow-up
- Weekly for first month, then biweekly for 3 months
- Monitor for medication adherence, side effects, and drinking status
- Adjust treatment plan based on response
Interactive Elements for Presentation
Pre-test Questions
- What percentage of US adults will experience AUD at some point during their lives?
- Name the four FDA-approved medications for AUD treatment
- What is the recommended screening tool for AUD in primary care settings?
Discussion Questions
- How might stigma affect a patient's willingness to disclose alcohol use?
- What are the challenges in implementing medication-assisted treatment for AUD?
- How would you approach a patient who has relapsed multiple times despite treatment?
Board-Style Questions
A 50-year-old man presents with a 10-year history of daily alcohol consumption (6-8 drinks per day). He reports failed attempts to cut down, morning tremors relieved by drinking, and recent job loss due to alcohol-related absences. Which of the following is the most appropriate initial pharmacotherapy? A. Disulfiram B. Naltrexone C. Acamprosate D. Topiramate E. Benzodiazepines
Which biomarker has the highest specificity for detecting chronic heavy alcohol use? A. Gamma-glutamyl transferase (GGT) B. Aspartate aminotransferase (AST) C. Carbohydrate-deficient transferrin (CDT) D. Mean corpuscular volume (MCV) E. Alanine aminotransferase (ALT)
According to DSM-5 criteria, what is the minimum number of symptoms required for a diagnosis of moderate AUD? A. 2 symptoms B. 3 symptoms C. 4 symptoms D. 5 symptoms E. 6 symptoms