Alcohol use disorder

Alcohol use disorder (AUD) also called alcohol abuse or alcohol dependence syndrome, is an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences ¹. Alcohol use disorder encompasses the conditions that some people refer to as alcohol abuse, alcohol dependence, alcohol addiction, and the colloquial term, alcoholism. Alcohol use disorder can be mild, moderate, or severe. Severe alcohol use disorder is sometimes called alcoholism or alcohol dependence.

Alcohol use disorder is a medical condition in which you:

• Drink alcohol compulsively
• Can’t control how much you drink
• Feel anxious, irritable, and/or stressed when you are not drinking

An alcohol use disorder can range from mild to severe, depending on your symptoms.

With alcohol use disorder, you are not physically dependent, but you still have a serious problem. The drinking may cause problems at home, work, or school. Alcohol use disorder may cause you to put yourself in dangerous situations, or lead to legal or social problems.

Another common problem is binge drinking. Binge drinking is drinking about five or more drinks in two hours for men. For women, it is about four or more drinks in two hours.

Too much alcohol is dangerous. Heavy drinking can increase your risk of getting certain cancers. Too much alcohol can cause damage to the liver, brain, and other organs. Drinking during pregnancy can harm your baby. Alcohol also increases the risk of death from car crashes, injuries, homicide, and suicide.

Alcoholism or alcohol dependence, is a disease that causes:

• Craving – a strong need to drink
• Loss of control – not being able to stop drinking once you’ve started
• Physical dependence – withdrawal symptoms
• Tolerance – the need to drink more alcohol to feel the same effect

Alcohol use disorder is considered a brain disorder characterized by compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using ². Lasting changes in the brain caused by alcohol misuse perpetuate alcohol use disorder and make individuals vulnerable to relapse. The good news is that no matter how severe the problem may seem, evidence-based treatment with behavioral therapies, mutual-support groups, and/or medications can help people with alcohol use disorder achieve and maintain recovery. According to a National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Administration, 14.1 million adults ages 18 and older (5.6 percent of this age group) had alcohol use disorder in 2019 ³, ⁴. Among youth, an estimated 414,000 adolescents ages 12–17 (1.7 percent of this age group) had alcohol use disorder during this timeframe.

An estimated 16 million people in the United States have alcohol use disorder ². This means that their drinking causes distress and harm. It includes alcoholism and alcohol abuse. Approximately 6.2 percent or 15.1 million adults in the United States ages 18 and older had alcohol use disorder in 2015. This includes 9.8 million men and 5.3 million women. Adolescents can be diagnosed with alcohol use disorder as well, and in 2015, an estimated 623,000 adolescents ages 12–17 had alcohol use disorder ².

To be diagnosed with alcohol use disorder, individuals must meet certain criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), under DSM–5, the current version of the DSM, anyone meeting any two of the 11 criteria during the same 12-month period receives a diagnosis of alcohol use disorder. The severity of alcohol use disorder—mild, moderate, or severe—is based on the number of criteria met.

To assess whether you or loved one may have alcohol use disorder, here are some questions to ask.

Alcohol use disorder is diagnosed when a person answers “yes” to two or more of the questions below.

In the past year, have you:

• Ended up drinking more or for a longer time than you had planned to?
• Wanted to cut down or stop drinking, or tried to, but couldn’t?
• Spent a lot of your time drinking, or recovering from drinking?
• Needed a drink first thing in the morning to steady your nerves or get rid of a hangover?
• Felt a strong need to drink?
• Felt annoyed by criticism of your drinking?
• Had guilty feelings about drinking?
• Found that drinking – or being sick from drinking – often interfered with your family life, job, or school?
• Kept drinking even though it was causing trouble with your family or friends?
• Given up or cut back on activities that you enjoyed just so you could drink?
• Gotten into dangerous situations while drinking or after drinking? Some examples are driving drunk and having unsafe sex.
• Kept drinking even though it was making you feel depressed or anxious? Or when it was adding to another health problem?
• Had to drink more and more to feel the effects of the alcohol?
• Had withdrawal symptoms when the alcohol was wearing off? They include trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, and sweating. In severe cases, you could have a fever, seizures, or hallucinations.

If you have any of these symptoms, your drinking may already be a cause for concern. The more symptoms you have, the more urgent the need for change. A health professional can conduct a formal assessment of your symptoms to see if alcohol use disorder is present.

However severe the problem may seem, most people with alcohol use disorder can benefit from treatment. Unfortunately, less than 10 percent of them receive any treatment.

Ultimately, receiving treatment can improve an individual’s chances of success in overcoming alcohol use disorder.

Talk with your doctor to determine the best course of action for you.

Consider joining Alcoholics Anonymous or another mutual support group (see links below). Recovering people who attend groups regularly do better than those who do not. Groups can vary widely, so shop around for one that’s comfortable. You’ll get more out of it if you become actively involved by having a sponsor and reaching out to other members for assistance.

• Alcoholics Anonymous (https://www.aa.org)
• Moderation Management (https://moderation.org)
• Secular Organizations for Sobriety (https://www.sossobriety.org)
• SMART Recovery (https://www.smartrecovery.org)
• Women for Sobriety (https://womenforsobriety.org)
• Al-Anon Family Groups (https://al-anon.org)
• Adult Children of Alcoholics (https://adultchildren.org)
• National Council on Alcoholism and Drug Dependence (https://recovered.org)
• National Institute on Alcohol Abuse and Alcoholism (https://www.niaaa.nih.gov)
• National Organization on Fetal Alcohol Syndrome (https://fasdunited.org)
• Substance Abuse and Mental Health Services Administration (https://findtreatment.gov)

What is considered 1 drink?

The National Institute on Alcohol Abuse and Alcoholism defines one standard drink as any one of these:

• 12 ounces (355 milliliters) of regular beer (about 5 percent alcohol)
• 8 to 9 ounces (237 to 266 milliliters) of malt liquor (about 7 percent alcohol)
• 5 ounces (148 milliliters) of unfortified wine (about 12 percent alcohol)
• 1.5 ounces (44 milliliters) of 80-proof hard liquor (about 40 percent alcohol)

What is binge drinking?

Binge drinking is drinking so much at once that your blood alcohol concentration (BAC) level is 0.08% or more. For a man, this usually happens after having 5 or more drinks within a few hours. For a woman, it is after about 4 or more drinks within a few hours. Not everyone who binge drinks has an alcohol use disorder, but they are at higher risk for getting one.

What are the dangers of too much alcohol?

Too much alcohol is dangerous. Heavy drinking can increase the risk of certain cancers. It may lead to liver diseases, such as fatty liver disease and cirrhosis. It can also cause damage to the brain and other organs. Drinking during pregnancy can harm your baby. Alcohol also increases the risk of death from car crashes, injuries, homicide, and suicide.

How common is a “dual diagnosis”—such as alcohol use disorder plus anxiety or depression—and how is this treated?

National data indicate that at least one-third of all persons enrolled in addiction treatment programs for alcohol use disorder have a co-occurring mental health disorder—most often anxiety or depression. Likewise, about one out of every four people treated in mental health programs have a co-occurring substance use disorder—most commonly, alcohol use disorder.

The co-occurrence of alcohol and mental health problems is challenging for treatment providers because each issue can complicate the other. It’s important that treatment providers be able to identify and address both issues at the same time. Treatment that focuses on one issue at a time (for example, treating the alcohol use disorder before addressing a patient’s anxiety disorder) is less effective than a comprehensive, integrated approach to dual diagnoses.

What outcome should a person aim for following treatment? Is abstinence from alcohol the only goal, or is it possible to simply cut back on drinking?

For persons with alcohol use disorder, abstaining from drinking (stopping altogether) is generally recommended, and provides the greatest chance of long-term success. Abstaining is especially important when the individual is pregnant or is trying to become pregnant; is taking medications that negatively interact with alcohol; or has a medical or psychiatric disorder that is made worse by drinking. However, decisions about the ultimate goal of alcohol use disorder treatment should be determined in a dialogue between the patient and a credentialed treatment provider.

Some people with an alcohol problem may wish to moderate their drinking, but they ultimately find that it is easier to stop drinking entirely. Others may aim for abstinence but find that, with the skills learned in counseling, they are able to manage occasional drinking without returning to problematic use. If the initial goal is to cut back on drinking, but the person finds that they cannot stay within the recommended daily/weekly drinking limits, then abstinence is strongly advised.

Detox—what is it? Why isn’t it “enough” to help a person stop drinking?

Medical detoxification or “detox”, is the process of getting alcohol or drugs out of a person’s system. When someone who has been drinking heavily for a prolonged period of time suddenly stops drinking, the body can go into a painful or even dangerous process of withdrawal. Symptoms can include nausea, rapid heart rate, seizures, or other problems. Doctors can prescribe medications to address these symptoms and make the process safer and less distressing.

Detox alone is not the same as treatment. While detox helps to stabilize a person with an alcohol problem, it does not teach important skills such as how to identify and address situations that may lead to heavy alcohol use; how to refuse alcohol in social situations; or how to cope with stress in a way that does not involve drinking. All of these are the kinds of skills people learn in treatment that is delivered by health care professionals.

Research shows that people who go through detox without additional treatment are far more likely to relapse. Detox alone is not a fast or effective way to achieve long-term recovery from alcohol use disorder.

I have always heard that treatment happens in residential rehab programs. Isn’t that the best option?

Based on what you might see on TV or in the movies, it would seem like most treatment happens in residential rehab programs. But most people do not use—and do not need—a residential program. Here’s why.

Generally, it is recommended that people with alcohol use disorder seek the least intensive type of care first, and then move to a more intensive level only if they need it. Most people who get treatment for alcohol use disorder start with outpatient counseling, either at a treatment program or in one-on-one sessions with a therapist or doctor. Outpatient treatment gives people the flexibility to continue living at home, and even to continue going to work. It’s also much less expensive than residential or hospital treatment.

Some people will find that outpatient treatment isn’t a good fit for them. This is especially likely for someone who does not have stable or secure housing, or does not have family or friends who are supportive of recovery. Residential programs can help provide stability, support, and a structured daily routine for people who need it. Hospital inpatient programs are best for people who have other health conditions that require medical attention.

In short, residential programs can be very helpful for some people with an alcohol problem but are not necessary for most. It’s important to find options that are the best match for a person’s particular situation.

What if I’m seeking treatment for an adolescent?

Adolescents have many different issues that need to be addressed in different ways, and the treatments themselves are often different. For example, there are no alcohol treatment medications that have been approved for use by adolescents. Counseling for adolescents may use different techniques and often places much greater emphasis on family therapy. And teens need to build different skills and coping strategies than adults. All of these factors make it important to find treatment providers that have special expertise in treating adolescents.

In the meantime, if you need to find treatment for an adolescent, excellent resources are available from The Partnership for Drug-Free Kids (https://drugfree.org/), as well as from the Family Resource Center (http://www.familyresourcectr.org/).

Are treatment records confidential?

Health care providers are required to comply with federal and state laws, as well as their professional code of ethics, regarding patient privacy and the confidentiality of treatment records. There are extra laws in place that specifically protect patients and their records when it comes to addiction treatment. A patient must be asked, and explicitly agree, before their treatment records can be shared with anyone else.

While these laws are well intended, they can sometimes create hurdles that you may not expect. For example, a patient would have to give explicit permission for a treatment program to share their records with the patient’s own primary care doctor. Also, these confidentiality protections may limit how much information a treatment provider can share with a patient’s family members.

What cause alcohol use disorder?

The cause of alcohol use disorder is not well understood; however, several factors are thought to contribute to its development. These include the home environment, peer interactions, genetic factors, level of cognitive functioning, and certain existing personality disorders ⁵.Personality disorders associated with the development of an alcohol use disorder include disinhibition and impulsivity-type disorders, as well as depressive and socialization-related disorders ⁶.

Almost half of the people with any substance abuse problem, including alcohol use disorder, also had a co-existing mental illness ⁷, ⁸. Overall, alcohol use disorder tends to be more common in individuals with less education and low income.

Multiple theories have been suggested as to why some people develop alcohol use disorders. Some of the more evidence-supported theories include positive-effect regulation, negative-effect regulation, pharmacological vulnerability, and deviance proneness. Positive-effect regulation results in drinking for positive rewards (such as feelings of euphoria). Negative-effect regulation is seen when one drinks to cope with feelings of a negative nature, such as depression, anxiety, or feelings of worthlessness. Pharmacological vulnerability makes a note of an individual’s varied response to both acute and chronic effects of alcohol intake and the individual differences in the body’s ability to metabolize the alcohol. Deviance proneness speaks more to an individual’s tendency towards deviant behavior established during childhood, often due to a deficiency in socialization at an early age.

Some of the genes suspected in alcohol use disorder include GABRG2 and GABRA2, COMT Val 158Met, DRD2 Taq1A, and KIAA0040.

Risk factors for developing alcohol use disorder

Alcohol use may begin in the teens, but alcohol use disorder occurs more frequently in the 20s and 30s, though it can start at any age.

• Steady drinking over time. Drinking too much on a regular basis for an extended period or binge drinking on a regular basis can lead to alcohol-related problems or alcohol use disorder.
• Started drinking at an early age. People who begin drinking — especially binge drinking — at an early age are at a higher risk of alcohol use disorder.
• Family history of alcohol abuse. The risk of alcohol use disorder is higher for people who have a parent or other close relative who has problems with alcohol. This may be influenced by genetic factors.
• Depression and other mental health problems. It’s common for people with a mental health disorder such as anxiety, depression, schizophrenia or bipolar disorder to have problems with alcohol or other substances.
• History of trauma. People with a history of emotional or other trauma are at increased risk of alcohol use disorder.
• Having bariatric surgery (weight-loss surgery — involves making changes to your digestive system to help you lose weight). Some research studies indicate that having bariatric surgery may increase the risk of developing alcohol use disorder or of relapsing after recovering from alcohol use disorder.
• Social and cultural factors. Having friends or a close partner who drinks regularly could increase your risk of alcohol use disorder. The glamorous way that drinking is sometimes portrayed in the media also may send the message that it’s OK to drink too much. For young people, the influence of parents, peers and other role models can impact risk.

Alcohol use disorder prevention

Early intervention can prevent alcohol-related problems in teens. If you have a teenager, be alert to signs and symptoms that may indicate a problem with alcohol:

• Loss of interest in activities and hobbies and in personal appearance
• Red eyes, slurred speech, problems with coordination and memory lapses
• Difficulties or changes in relationships with friends, such as joining a new crowd
• Declining grades and problems in school
• Frequent mood changes and defensive behavior

You can help prevent teenage alcohol use:

• Set a good example with your own alcohol use.
• Talk openly with your child, spend quality time together and become actively involved in your child’s life.
• Let your child know what behavior you expect — and what the consequences will be if he or she doesn’t follow the rules.

Alcohol use disorder symptoms

A few mild symptoms — which you might not see as trouble signs — can signal the start of a drinking problem. It helps to know the signs so you can make a change early. If heavy drinking continues, then over time, the number and severity of symptoms can grow and add up to “alcohol use disorder.” Doctors diagnose alcohol use disorder when a patient’s drinking causes distress or harm. See if you recognize any of these symptoms in yourself. And don’t worry — even if you have symptoms, you can take steps to reduce your risks.

Alcohol use disorder can be mild, moderate or severe, based on the number of symptoms you experience.

Alcohol use disorder signs and symptoms may include:

• Being unable to limit the amount of alcohol you drink
• Wanting to cut down on how much you drink or making unsuccessful attempts to do so
• Spending a lot of time drinking, getting alcohol or recovering from alcohol use
• Feeling a strong craving or urge to drink alcohol
• Failing to fulfill major obligations at work, school or home due to repeated alcohol use
• Continuing to drink alcohol even though you know it’s causing physical, social or interpersonal problems
• Giving up or reducing social and work activities and hobbies
• Using alcohol in situations where it’s not safe, such as when driving or swimming
• Developing a tolerance to alcohol so you need more to feel its effect or you have a reduced effect from the same amount
• Experiencing withdrawal symptoms — such as nausea, sweating and shaking — when you don’t drink, or drinking to avoid these symptoms

Alcohol use disorder can include periods of alcohol intoxication and symptoms of withdrawal.

• Alcohol intoxication results as the amount of alcohol in your bloodstream increases. The higher the blood alcohol concentration is, the more impaired you become. Alcohol intoxication causes behavior problems and mental changes. These may include inappropriate behavior, unstable moods, impaired judgment, slurred speech, impaired attention or memory, and poor coordination. You can also have periods called “blackouts,” where you don’t remember events. Very high blood alcohol levels can lead to coma or even death.
• Alcohol withdrawal can occur when alcohol use has been heavy and prolonged and is then stopped or greatly reduced. It can occur within several hours to four or five days later. Signs and symptoms include sweating, rapid heartbeat, hand tremors, problems sleeping, nausea and vomiting, hallucinations, restlessness and agitation, anxiety, and occasionally seizures. Symptoms can be severe enough to impair your ability to function at work or in social situations.

The more symptoms you have, the more serious the problem is. If you think you might have an alcohol use disorder, see your health care provider for an evaluation. Your provider can help make a treatment plan, prescribe medicines, and if needed, give you treatment referrals.

People with alcohol use disorder may also report frequent falls, blackout spells, unsteadiness, or visual disturbances ⁵. They may report seizures if they went a few days without drinking, or tremors, confusion, emotional disturbances, and frequent job changes. They may also report social issues, such as job termination, separation/divorce, estrangement from family, or loss of home. They may also report sleep disturbances.

People with alcohol use disorder may have hypertension (high blood pressure) or insomnia (trouble falling and staying asleep) initially. In later stages, the patient may complain of nausea or vomiting, hematemesis (vomiting blood), bloated abdomen, epigastric pain, weight loss, jaundice, or other symptoms or signs suggestive of liver dysfunction. They may be asymptomatic early on.

People with alcohol use disorder may exhibit signs of cerebellar dysfunction, such as ataxia (impaired balance or coordination) or difficulty with fine motor skills, on exam. They may exhibit slurred speech, tachycardia (fast heart rate), memory impairment, nystagmus (involuntary eye movement which may cause the eye to rapidly move from side to side, up and down or in a circle), disinhibited behavior, or hypotension (low blood pressure). People with alcohol use disorder may present with tremors, confusion/mental status changes, asterixis, reddsih palms, jaundice, ascites, or other signs of advanced liver disease. There may also be spider angiomata, hepatomegaly/splenomegaly (early; liver becomes cirrhotic and shrunken in advanced disease). They may develop bleeding disorders, anemia, gastritis/ulcers, or pancreatitis as complications of alcohol use. Labs will reveal anemia, thrombocytopenia, coagulopathy, hyponatremia, hyperammonemia, elevated ammonia levels, or decreased B12/folate levels as the advanced liver disease develops.

Alcohol use disorder complications

Alcohol depresses your central nervous system. In some people, the initial reaction may be stimulation. But as you continue to drink, you become sedated.

Too much alcohol affects your speech, muscle coordination and vital centers of your brain. A heavy drinking binge may even cause a life-threatening coma or death. This is of particular concern when you’re taking certain medications that also depress the brain’s function.

Alcohol use disorder impact on your safety

Excessive drinking can reduce your judgment skills and lower inhibitions, leading to poor choices and dangerous situations or behaviors, including:

• Motor vehicle accidents and other types of accidental injury, such as drowning
• Relationship problems
• Poor performance at work or school
• Increased likelihood of committing violent crimes or being the victim of a crime
• Legal problems or problems with employment or finances
• Problems with other substance use
• Engaging in risky, unprotected sex, or experiencing sexual abuse or date rape
• Increased risk of attempted or completed suicide

Alcohol use disorder impact on your health

Drinking too much alcohol on a single occasion or over time can cause health problems, including:

• Liver disease. Heavy drinking can cause increased fat in the liver (hepatic steatosis), inflammation of the liver (alcoholic hepatitis), and over time, irreversible destruction and scarring of liver tissue (cirrhosis).
• Digestive problems. Heavy drinking can result in inflammation of the stomach lining (gastritis), as well as stomach and esophageal ulcers. It can also interfere with absorption of B vitamins and other nutrients. Heavy drinking can damage your pancreas or lead to inflammation of the pancreas (pancreatitis).
• Heart problems. Excessive drinking can lead to high blood pressure and increases your risk of an enlarged heart, heart failure or stroke. Even a single binge can cause a serious heart arrhythmia called atrial fibrillation.
• Diabetes complications. Alcohol interferes with the release of glucose from your liver and can increase the risk of low blood sugar (hypoglycemia). This is dangerous if you have diabetes and are already taking insulin to lower your blood sugar level.
• Sexual function and menstruation issues. Excessive drinking can cause erectile dysfunction in men. In women, it can interrupt menstruation.
• Eye problems. Over time, heavy drinking can cause involuntary rapid eye movement (nystagmus) as well as weakness and paralysis of your eye muscles due to a deficiency of vitamin B-1 (thiamin). A thiamin deficiency can also be associated with other brain changes, such as irreversible dementia, if not promptly treated.
• Birth defects. Alcohol use during pregnancy may cause miscarriage. It may also cause fetal alcohol syndrome, resulting in giving birth to a child who has physical and developmental problems that last a lifetime.
• Bone damage. Alcohol may interfere with the production of new bone. This bone loss can lead to thinning bones (osteoporosis) and an increased risk of fractures. Alcohol can also damage bone marrow, which makes blood cells. This can cause a low platelet count, which may result in bruising and bleeding.
• Neurological complications. Excessive drinking can affect your nervous system, causing numbness and pain in your hands and feet, disordered thinking, dementia, and short-term memory loss.
• Weakened immune system. Excessive alcohol use can make it harder for your body to resist disease, increasing your risk of various illnesses, especially pneumonia.
• Increased risk of cancer. Long-term, excessive alcohol use has been linked to a higher risk of many cancers, including mouth, throat, liver, esophagus, colon and breast cancers. Even moderate drinking can increase the risk of breast cancer.
• Medication and alcohol interactions. Some medications interact with alcohol, increasing its toxic effects. Drinking while taking these medications can either increase or decrease their effectiveness, or make them dangerous.

Alcohol use disorder diagnosis

You’re likely to start by seeing your doctor. If your doctor suspects you have a problem with alcohol, he or she may refer you to a mental health professional.

To assess your problem with alcohol, your doctor will likely:

• Ask you several questions related to your drinking habits. The doctor may ask for permission to speak with family members or friends. However, confidentiality laws prevent your doctor from giving out any information about you without your consent.
• Perform a physical exam. Your doctor may do a physical exam and ask questions about your health. There are many physical signs that indicate complications of alcohol use.
• Lab tests and imaging tests. While there are no specific tests to diagnose alcohol use disorder, certain patterns of lab test abnormalities may strongly suggest it. And you may need tests to identify health problems that may be linked to your alcohol use. Damage to your organs may be seen on tests.
• Complete a psychological evaluation. This evaluation includes questions about your symptoms, thoughts, feelings and behavior patterns. You may be asked to complete a questionnaire to help answer these questions.
• Use the DSM-5 criteria. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association, is often used by mental health professionals to diagnose mental health conditions.

DSM-5 alcohol use disorder

DSM-5 Criteria for the Diagnosis of Alcohol Use Disorder ⁹:

• Criterion A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
  1. Alcohol is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
  3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
  4. Craving, or a strong desire or urge to use alcohol.
  5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
  7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
  8. Recurrent alcohol use in situations in which it is physically hazardous.
  9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
  10. Tolerance, as defined by either of the following:
      • a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
      • b. A markedly diminished effect with continued use of the same amount of alcohol.
  11. Withdrawal, as manifested by either of the following:
      • a. The characteristic withdrawal syndrome for alcohol.
      • b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Specify if:

• In early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met).
• In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met).

Specify if:

• In a controlled environment: This additional specifier is used if the individual is in an environment where access to alcohol is restricted.

Alcohol use disorder is defined by a cluster of behavioral and physical symptoms, which can include withdrawal, tolerance, and craving. Alcohol withdrawal is characterized by withdrawal symptoms that develop approximately 4-12 hours after the reduction of intake following prolonged, heavy alcohol ingestion. Because withdrawal from alcohol can be unpleasant and intense, individuals may continue to consume alcohol despite adverse consequences, often to avoid or to relieve withdrawal symptoms. Some withdrawal symptoms (e.g., sleep problems) can persist at lower intensities for months and can contribute to relapse. Once a pattern of repetitive and intense use develops, individuals with alcohol use disorder may devote substantial periods of time to obtaining and consuming alcoholic beverages.

Craving for alcohol is indicated by a strong desire to drink that makes it difficult to think of anything else and that often results in the onset of drinking. School and job performance may also suffer either from the aftereffects of drinking or from actual intoxication at school or on the job; child care or household responsibilities may be neglected; and alcohol-related absences may occur from school or work. The individual may use alcohol in physically hazardous circumstances (e.g., driving an automobile, swimming, operating machinery while intoxicated). Finally, individuals with an alcohol use disorder may continue to consume alcohol despite the knowledge that continued consumption poses significant physical (e.g., blackouts, liver disease), psychological (e.g., depression), social, or interpersonal problems (e.g., violent arguments with spouse while intoxicated, child abuse).

Alcohol use disorder treatment

Most people with an alcohol use disorder can benefit from some form of treatment. Medical treatments include medicines and behavioral therapies. For many people, using both types gives them the best results. People who are getting treatment for alcohol use disorder may also find it helpful to go to a support group such as Alcoholics Anonymous (AA). If you have an alcohol use disorder and a mental illness, it is important to get treatment for both.

Treatment for alcohol use disorder may include:

• Detox and withdrawal. Treatment may begin with a program of detoxification or detox — withdrawal that’s medically managed — which generally takes two to seven days. You may need to take sedating medications to prevent withdrawal symptoms. Detox is usually done at an inpatient treatment center or a hospital.
• Learning skills and establishing a treatment plan. This usually involves alcohol treatment specialists. It may include goal setting, behavior change techniques, use of self-help manuals, counseling and follow-up care at a treatment center.
• Psychological counseling. Counseling and therapy for groups and individuals help you better understand your problem with alcohol and support recovery from the psychological aspects of alcohol use. You may benefit from couples or family therapy — family support can be an important part of the recovery process.
• Oral medications. A drug called disulfiram (Antabuse) may help prevent you from drinking, although it won’t cure alcohol use disorder or remove the compulsion to drink. If you drink alcohol, the drug produces a physical reaction that may include flushing, nausea, vomiting and headaches. Naltrexone, a drug that blocks the good feelings alcohol causes, may prevent heavy drinking and reduce the urge to drink. Acamprosate may help you combat alcohol cravings once you stop drinking. Unlike disulfiram, naltrexone and acamprosate don’t make you feel sick after taking a drink.
• Injected medication. Vivitrol, a version of the drug naltrexone, is injected once a month by a health care professional. Although similar medication can be taken in pill form, the injectable version of the drug may be easier for people recovering from alcohol use disorder to use consistently.
• Continuing support. Aftercare programs and support groups help people recovering from alcohol use disorder to stop drinking, manage relapses and cope with necessary lifestyle changes. This may include medical or psychological care or attending a support group.
• Treatment for psychological problems. Alcohol use disorder commonly occurs along with other mental health disorders. If you have depression, anxiety or another mental health condition, you may need talk therapy (psychotherapy), medications or other treatment.
• Medical treatment for health conditions. Many alcohol-related health problems improve significantly once you stop drinking. But some health conditions may warrant continued treatment and follow-up.
• Spiritual practice. People who are involved with some type of regular spiritual practice may find it easier to maintain recovery from alcohol use disorder or other addictions. For many people, gaining greater insight into their spiritual side is a key element in recovery.

Some people may need intensive treatment for alcohol use disorder. They may go to a residential treatment center for rehabilitation (rehab). Residential treatment programs typically include licensed alcohol and drug counselors, social workers, nurses, doctors and others with expertise and experience in treating alcohol use disorder. Treatment there is highly structured. It usually includes several different kinds of behavioral therapies. Most residential treatment programs include individual and group therapy, support groups, educational lectures, family involvement and activity therapy. It may also include medicines for detox (medical treatment for alcohol withdrawal) and/or for treating the alcohol use disorder.

Medications for alcohol use disorder

Three medicines are U.S. Food and Drug Administration (FDA) approved to treat alcohol use disorder (see Table 1 below).

All of these medications are non-addictive, so you don’t have to worry about trading one addiction for another. Your health care provider can help you figure out if one of these medicines is right for you. They are not a cure, but they can help you manage alcohol use disorder. This is just like taking medicines to manage a chronic disease such as asthma or diabetes.

Used in the context of a comprehensive treatment plan, medications for alcohol use disorder can provide an opportunity for behavioral therapies (counseling) to be helpful by reducing craving or helping to maintain abstinence from alcohol. In that way, medications can give people with an alcohol problem some traction in the recovery process.

It’s important to consult a doctor who understands which people are good candidates for alcohol use disorder medications. Some studies suggest that people with a family history of alcohol use disorder may be likely to benefit from naltrexone, for example. But those who have a liver condition or use opioid medications (such as those prescribed for pain) should not take naltrexone. A doctor can assess these and other conditions and match an appropriate medication with the patient.

As with any other medication, patients should communicate with their doctor about how the medication is working, and the doctor may be able to adjust the dose if needed.

Medications for alcohol use disorder can be prescribed not only by specialists in addiction treatment, but also by primary care physicians.

Naltrexone

Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and the craving for alcohol ¹⁰. Naltrexone is an opioid antagonist, reduces alcohol consumption in patients with alcohol use disorder and is more successful in those who are abstinent before starting the medication ¹¹. The opioid receptor system mediates the pleasurable effects of alcohol. Alcohol ingestion stimulates endogenous opioid release and increases dopamine transmission. Naltrexone blocks these effects, reducing euphoria and cravings ¹². Naltrexone comes either as a pill that is taken daily, or as an injection that can be given once per month. Because naltrexone is metabolized by the liver, liver toxicity is possible, although uncommon. Patients with alcohol use disorder may have liver dysfunction; therefore, caution is warranted. Naltrexone can precipitate severe opioid withdrawal in patients who are opioid-dependent, so these agents should not be used together, and opioids should not be used for at least seven days before starting naltrexone ¹¹. Pain management is challenging for patients taking naltrexone; these patients should carry a medical alert card.

Naltrexone is well tolerated and is not habit-forming. Naltrexone can also reduce your craving for alcohol. This can help you cut back on your drinking.

A Cochrane review that included 50 randomized trials and 7,793 patients found that oral naltrexone decreased heavy drinking (number needed to treat (NNT) = 10) and slightly decreased daily drinking (NNT = 25). The number of heavy drinking days and the amount of alcohol consumed also decreased. Injectable naltrexone did not decrease heavy drinking, but the sample size was small ¹³. A subsequent systematic review of 53 randomized trials including 9,140 patients found that oral naltrexone increased abstinence rates (NNT = 20) and decreased heavy drinking (NNT = 12). There was no difference between naltrexone and acamprosate. Injectable naltrexone did not demonstrate benefit ¹⁴. A randomized trial of 627 veterans with alcohol use disorder who received injectable naltrexone or placebo found that 380 mg of naltrexone given intramuscularly decreased heavy drinking days over six months but did not increase abstinence rates ¹⁵. Another meta-analysis found no difference in heavy drinking between acamprosate and naltrexone; however, it favored acamprosate for abstinence and naltrexone for cravings ¹⁶. Studies of combination therapy with acamprosate and naltrexone have produced mixed results. The COMBINE study did not show that combined therapy was more effective than either agent alone ¹⁷. Another study showed that relapse rates were lower with combined therapy compared with placebo or acamprosate alone, but not compared with naltrexone alone ¹⁸. It is unclear if and when combination therapy should be used, although it may be reasonable to consider it if monotherapy fails. Opioid antagonists may also be helpful when used as needed during high-risk situations, such as social events or weekends ¹⁹.

Like any medicine, naltrexone can cause side effects. Nausea is the most common one. Other side effects include:

• Headache
• Diarrhea
• Constipation
• Dizziness
• Nervousness
• Insomnia
• Drowsiness
• Anxiety

If you get any of these side effects, tell your doctor. They may change your treatment or suggest ways you can deal with the side effects.

Call your doctor immediately if you experience any of the following symptoms:

• Blurry vision
• Confusion
• Hallucinations (hearing or seeing things that aren’t there)
• Severe vomiting or diarrhea
• Vomiting up blood
• Excessive fatigue
• Bleeding or bruising
• Loss of appetite
• Pain in the upper right part of your stomach that lasts more than a few days
• Light-colored bowel movements
• Dark urine
• Yellowing of the skin or eyes

Talk to your doctor if you have a history of depression. Naltrexone may cause liver damage when taken in large doses. Tell your doctor if you have had hepatitis or liver disease.

Acamprosate

Acamprosate (Campral®) acts on the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems and is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria ¹⁰. Acamprosate has been shown to help dependent drinkers maintain abstinence for several weeks to months, and it may be more effective in patients with severe dependence. Acamprosate is a pill that is taken three times per day.

Acamprosate appears to be most effective at maintaining abstinence in patients who are not currently drinking alcohol ¹⁶. Acamprosate seems to interact with glutamate at the N-methyl-d-aspartate receptor, although its exact mechanism is unclear ²⁰. Acamprosate is safe in patients with impaired liver function but should be avoided in patients with severe kidney dysfunction. A systematic review of 27 studies including 7,519 patients using acamprosate showed a number needed to treat (NNT) of 12 to prevent a return to any drinking ¹⁴. A Cochrane review of 24 trials including 6,915 patients concluded that acamprosate reduced drinking compared with placebo (NNT = 9) ²¹. One randomized trial found no difference between acamprosate and placebo, although outcomes improved significantly in both groups. This may be because enrolled patients were highly motivated to decrease alcohol use, increasing the likelihood of success with any treatment ²².

Disulfiram

Disulfiram (Antabuse®) interferes with degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and plapitations whenever you drink alcohol ¹⁰. Knowing that drinking will cause these unpleasant effects may help you stay away from alcohol. The utility and effectiveness of disulfiram are considered limited because compliance is generally poor. However, among patients who are highly motivated, disulfiram can be effective, and some patients use it episodically for high-risk situations, such as social occasions where alcohol is present. It can also be administered in a monitored fashion, such as in a clinic or by a spouse, improving its efficacy.

There are limited trials to support the effectiveness of disulfiram. It does not reduce the craving for alcohol, but it causes unpleasant symptoms when alcohol is ingested because it inhibits aldehyde dehydrogenase and alcohol metabolism. Compliance is a major limitation, and disulfiram is more effective when taken under supervision. One trial randomized 243 patients to naltrexone, acamprosate, or disulfiram with supervision over 12 weeks and determined that patients taking disulfiram had fewer heavy drinking days, lower weekly consumption, and a longer period of abstinence compared with the other drugs ²³. However, a 2014 meta-analysis of 22 randomized trials found that in open-label studies, disulfiram was more effective than naltrexone, acamprosate, and no disulfiram, but blinded studies did not demonstrate benefit for disulfiram ²⁴. In a systematic review of two studies including 492 patients, disulfiram did not reduce drinking rates ¹⁴. A review by the Agency for Healthcare Research and Quality on pharmacotherapy for adults with alcohol-use disorders in outpatient settings found insufficient evidence to support disulfiram’s effectiveness ²⁵.

Topiramate

Topiramate is thought to work by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission, although its precise mechanism of action is not known ¹⁰. Although topiramate has not yet received FDA approval for treating alcohol addiction, it is sometimes used off-label for this purpose. Topiramate has been shown in studies to significantly improve multiple drinking outcomes, compared with a placebo.

Off-label medications

• Anticonvulsants. There are several anticonvulsants that may help patients with alcohol use disorder decrease alcohol consumption, but data are limited. A Cochrane review of 25 trials including 2,641 patients showed that those taking an anticonvulsant (i.e., topiramate, gabapentin [Neurontin], valproate, levetiracetam [Keppra], oxcarbazepine [Trileptal], zonisamide [Zonegran], carbamazepine [Tegretol], pregabalin [Lyrica], or tiagabine [Gabitril]) consumed 1.5 fewer drinks per day than those taking placebo. There was no difference in abstinence rates compared with naltrexone, but anticonvulsants were associated with fewer heavy drinking days and a longer time to relapse; many of the studies were of low quality ²⁶. Topiramate appears to decrease alcohol consumption. The Agency for Healthcare Research and Quality review concluded that there is moderate evidence that topiramate decreases number of drinking days, heavy drinking days, and drinks per day based on two randomized trials ²⁷. An open-label study compared topiramate plus psychotherapy with psychotherapy alone in hospitalized patients after alcohol withdrawal treatment. The topiramate group had lower rates of depression and anxiety and a lower relapse rate after four months ²⁸. However, a randomized trial of 106 patients did not show a difference in alcohol consumption between topiramate therapy and placebo ²⁹. Another randomized trial found that topiramate increased abstinence rates in patients with a specific genetic polymorphism ³⁰. Such targeted medication use for specific populations warrants further study. Three randomized trials suggest a possible benefit from gabapentin. A study of 150 patients found higher abstinence rates in those taking gabapentin compared with placebo (NNT = 8), as well as lower rates of heavy drinking, improved mood, fewer cravings, and improved sleep ³¹. A study of 60 males with an average alcohol consumption of 17 drinks per day in the previous 90 days who underwent alcohol withdrawal treatment and were treated with gabapentin or placebo found that those in the gabapentin group had fewer heavy drinking days and drank less during the 30-day trial ³². A small study of 21 patients had similar results and also found that gabapentin was more effective at improving sleep over the first six weeks of therapy. Dosages of gabapentin used in the study varied from 300 mg twice per day to 1,800 mg at bedtime ³³. Longer studies are needed to evaluate gabapentin for alcohol use disorder. Pregabalin is classified as a controlled substance, and there are limited data regarding its use in alcohol use disorder. A randomized trial comparing pregabalin and naltrexone in 71 patients found no difference in drinking outcomes or cravings, but the pregabalin group had less anxiety, hostility, and psychotic symptomatology ³⁴.
• Antidepressants. Antidepressants are not effective in decreasing alcohol use in persons without coexisting mental health disorders ³⁵. Antidepressants can be helpful in some instances, however, because patients with alcohol use disorder often have coexisting mental health disorders. A trial randomized 170 patients with alcohol dependence and depression to 14 weeks of cognitive behavior therapy plus sertraline (Zoloft; 200 mg per day), naltrexone (100 mg per day), both medications, or double placebo. Those taking a combination of sertraline and naltrexone had higher abstinence rates and a longer delay before relapse to heavy drinking compared with those taking placebo or either agent alone. Neither agent alone was superior to placebo ³⁶. A study of patients with alcohol use disorder and major depression found that 20 to 40 mg per day of fluoxetine (Prozac) reduced drinking, drinking days, and heavy drinking days over 12 weeks ³⁷. There is inconclusive evidence regarding the effectiveness of treating alcohol use disorder with the atypical antipsychotics olanzapine (Zyprexa) and quetiapine (Seroquel).
• Ondansetron. Ondansetron (Zofran) may decrease alcohol consumption in patients with alcohol use disorder. In three studies, ondansetron (4 mcg per kg twice per day) combined with cognitive behavior therapy decreased alcohol consumption and cravings and increased abstinence in young adults with early alcohol use disorder ³⁸. In another trial, a higher dosage of ondansetron (16 mcg per kg twice per day) combined with cognitive behavior therapy decreased depression, anxiety, and hostility ³⁹. This effect may be due to the serotonin-3 antagonist properties of ondansetron. In another randomized trial, men taking ondansetron (8 mg twice per day) had fewer heavy drinking days compared with those taking placebo, although they did not have increased abstinence rates ⁴⁰. The combination of ondansetron (4 mcg per kg twice per day) and naltrexone (25 mg twice per day) may be effective in treating early alcohol use disorder ⁴⁰. The dosages commonly studied (4 to 16 mcg per kg twice per day) are much lower than the current available formulations of 4-mg and 8-mg tablets.

Table 1. Medications for the treatment of Alcohol Use Disorder

Footnotes:

*—Other than hypersensitivity to the drug, which is a possible contraindication for all medications listed.
‡—Good evidence to support use in patients with alcohol use disorder.

§—Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder and other psychiatric disorders.

Abbreviations: FDA = U.S. Food and Drug Administration; MAOI = monoamine oxidase inhibitor.

Behavioral therapies

Another name for behavioral therapies for alcohol use disorder is alcohol counseling. It involves working with a health care professional to identify and help change the behaviors that lead to your heavy drinking.

• Cognitive-behavioral therapy (CBT) helps you identify the feelings and situations that can lead to heavy drinking. It teaches you coping skills, including how to manage stress and how to change the thoughts that cause you to want to drink. You may get CBT one-on-one with a therapist or in small groups.
• Motivational enhancement therapy helps you build and strengthen the motivation to change your drinking behavior. It includes about four sessions over a short period of time. The therapy starts with identifying the pros and cons of seeking treatment. Then you and your therapist work on forming a plan for making changes in your drinking. The next sessions focus on building up your confidence and developing the skills you need to be able to stick to the plan.
• Marital and family counseling includes spouses and other family members. It can help to repair and improve your family relationships. Studies show that strong family support through family therapy may help you to stay away from drinking.
• Brief interventions are short, one-on-one or small-group counseling sessions. It includes one to four sessions. The counselor gives you information about your drinking pattern and potential risks. The counselor works with you to set goals and provide ideas that may help you make a change.

Lifestyle choices

As part of your recovery, you’ll need to focus on changing your habits and making different lifestyle choices. These strategies may help.

• Consider your social situation. Make it clear to your friends and family that you’re not drinking alcohol. Develop a support system of friends and family who can support your recovery. You may need to distance yourself from friends and social situations that impair your recovery.
• Develop healthy habits. For example, good sleep, regular physical activity, managing stress more effectively and eating well all can make it easier for you to recover from alcohol use disorder.
• Do things that don’t involve alcohol. You may find that many of your activities involve drinking. Replace them with hobbies or activities that are not centered around alcohol.

Alternative medicine

Avoid replacing conventional medical treatment or psychotherapy with alternative medicine. But if used in addition to your treatment plan when recovering from alcohol use disorder, these techniques may be helpful:

• Yoga. Yoga’s series of postures and controlled breathing exercises may help you relax and manage stress.
• Meditation. During meditation, you focus your attention and eliminate the stream of jumbled thoughts that may be crowding your mind and causing stress.
• Acupuncture. With acupuncture, hair-thin needles are inserted under the skin. Acupuncture may help reduce anxiety and depression.

Alcohol use disorder prognosis

For most people, treatment for an alcohol use disorder is helpful. But overcoming an alcohol use disorder is an ongoing process, and you may relapse (start drinking again). You should look at relapse as a temporary setback, and keep trying. Many people repeatedly try to cut back or quit drinking, have a setback, then try to quit again. Having a relapse does not mean that you cannot recover. If you do relapse, it is important to return to treatment right away, so you can learn more about your relapse triggers and improve your coping skills. This may help you be more successful the next time.

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