When should a patient be labeled as having alcohol use disorder?

When to Label as Alcohol Use Disorder

A patient should be labeled as having Alcohol Use Disorder (AUD) when they meet at least 2 of the 11 DSM-V diagnostic criteria within a 12-month period, with severity graded as mild (2-3 criteria), moderate (4-5 criteria), or severe (6 or more criteria). 1

Diagnostic Framework

The DSM-V provides the current gold standard for AUD diagnosis, moving away from the stigmatizing and clinically unhelpful categorical distinction of "alcoholic" versus "non-alcoholic." 1 This dimensional approach recognizes AUD as a spectrum disorder with varying levels of severity rather than an all-or-nothing diagnosis. 2

The 11 DSM-V Diagnostic Criteria

A patient qualifies for AUD diagnosis when experiencing at least 2 of the following within a 12-month period: 1

Loss of Control:

• Alcohol consumed in larger amounts or over longer periods than intended 1, 3
• Persistent desire or unsuccessful efforts to cut down or control use 1, 3
• Great deal of time spent obtaining, using, or recovering from alcohol 1
• Craving or strong desire/urge to use alcohol 1, 3

Social and Functional Impairment:

• Recurrent use resulting in failure to fulfill major role obligations at work, school, or home 1, 2
• Continued use despite persistent or recurrent social/interpersonal problems caused or exacerbated by alcohol 1, 2
• Important social, occupational, or recreational activities given up or reduced because of alcohol use 1, 2
• Recurrent use in physically hazardous situations 1

Physical Dependence:

• Tolerance (need for markedly increased amounts to achieve intoxication or diminished effect with continued use of same amount) 1, 2
• Withdrawal (characteristic withdrawal syndrome or use of alcohol/benzodiazepines to relieve/avoid withdrawal symptoms) 1, 2
• Continued use despite knowledge of persistent physical or psychological problems likely caused or exacerbated by alcohol 1

Severity Classification

The severity grading is critical for treatment planning: 1, 2

• Mild AUD: 2-3 criteria met 1, 2
• Moderate AUD: 4-5 criteria met 1, 2
• Severe AUD: 6 or more criteria met 1, 2

Screening Tools for Identification

AUDIT (Alcohol Use Disorders Identification Test)

The AUDIT remains the gold standard screening tool, developed by WHO with proven high sensitivity and specificity across different clinical settings and countries. 1, 2 This 10-question assessment evaluates consumption patterns, drinking behaviors, and alcohol-related problems. 1, 3

• AUDIT score ≥8 generally indicates hazardous or harmful drinking and warrants full diagnostic evaluation for AUD 4
• AUDIT-C (3-question shortened version) can be used when time is limited while maintaining good sensitivity 3, 2

CAGE Questionnaire

The CAGE provides a brief 4-question tool with 85% sensitivity and 89% specificity: 3, 2

• Cut down: Have you felt you should cut down on drinking?
• Annoyed: Have people annoyed you by criticizing your drinking?
• Guilty: Have you felt guilty about drinking?
• Eye-opener: Have you needed a drink first thing in the morning?

Two or more "yes" responses indicate likely AUD. 2 However, CAGE has lower sensitivity for hazardous drinking in the pre-AUD stage compared to AUDIT. 1

Critical Distinctions

AUD vs. Hazardous Drinking

Hazardous drinking is defined as the stage before AUD and should only be used when AUD criteria are not met. 1 While most patients with AUD are hazardous drinkers, hazardous drinking focuses on quantity and pattern of consumption, whereas AUD diagnosis centers on psychological, social, and physical impairment caused by alcohol use in the past 12 months. 1

Avoiding Stigmatizing Language

The term "alcoholic" should be avoided in clinical practice as it is stigmatizing and not clinically useful. 1, 2 Use "patient with alcohol use disorder" or "person with AUD" instead. 2

Common Pitfalls to Avoid

• Focusing solely on quantity consumed rather than assessing the 11 diagnostic criteria—AUD is diagnosed based on impairment and distress, not just amount of alcohol 1
• Failing to screen routinely—only 1 in 6 US adults report ever being asked about drinking by a health professional, despite AUD affecting up to 14% of US adults annually 5
• Underdiagnosing in primary care—almost 50% of patients have at least one symptom of harmful or hazardous use, yet many go unrecognized 6
• Missing co-occurring psychiatric conditions that frequently complicate AUD diagnosis and treatment 2
• Not distinguishing between low-risk drinking and AUD—a patient with an AUDIT score of 2 has low-risk drinking and does not meet AUD criteria 4

Clinical Implementation

Drinking habits should be routinely assessed in all patients, particularly those with liver disease or other alcohol-related conditions, using validated screening tools. 1 When screening is positive (AUDIT ≥8 or CAGE ≥2), conduct a thorough assessment using the 11 DSM-V criteria to establish diagnosis and severity. 3, 2

Once diagnosed, patients with moderate to severe AUD should be offered first-line pharmacotherapy (naltrexone, acamprosate, or disulfiram) in addition to counseling, though medications remain vastly underutilized with less than 9% of eligible patients receiving them. 5