Written and peer-reviewed by physicians—but use at your own risk. Read our disclaimer.

banner image

amboss

Trusted medical answers—in seconds.

Get access to 1,000+ medical articles with instant search
and clinical tools.

Try free for 5 days

Alcohol-related disorders

Last updated: October 6, 2020

Summary

Alcohol-related disorders, including alcohol intoxication, alcohol use disorder (AUD), and alcohol withdrawal, are a group of conditions associated with disruptive patterns of alcohol use. Alcohol intoxication is the acute onset of behavioral and psychomotor impairment shortly after an episode of drinking. Alcohol use disorder (AUD) is characterized by clinically significant psychosocial and behavioral problems associated with alcohol use. Alcohol withdrawal develops after a sudden cessation or reduction of alcohol use in patients with a history of excessive drinking. The diagnosis of an alcohol-related disorder can be established using the DSM-5 criteria. The most important aspect of management for all alcohol-related disorders is the cessation of alcohol use. Therapeutic management is guided by the severity of the disorder.

See breakdown of ethanol for a review of alcohol metabolism pathways.

Alcohol intoxication

  • Definition: : a temporary condition in which excessive consumption of alcohol alters a person's consciousness, cognition, perception, judgment, affect, and/or behavior
  • Pathophysiology: The majority of alcohol consumed is absorbed by the proximal small intestine. Only a small amount of alcohol gets absorbed by the oral, esophageal, and/or gastric mucosa.
  • Clinical features
Mild intoxication (BAC 0.01–0.1%, < 100 mg/dL) Moderate intoxication (BAC 0.1–0.3%, 100–300 mg/dL Severe intoxication (BAC > 0.3%; > 300 mg/dL)

In the US, the maximum legal limit for driving under the influence of alcohol is a BAC of 0.08%.

Because alcohol has a long absorption time (approx. 40 min), patients with alcohol intoxication may deteriorate over time.

Haloperidol may worsen respiratory depression secondary to alcohol intoxication!

References:[1][2][3][4][5][6][7][8]

Alcohol use disorder

AUD is a chronic condition in which an uncontrolled pattern of alcohol use leads to significant physical, psychological, and social impairment or distress. Symptoms of withdrawal emerge when drinking is discontinued. Not all individuals who drink heavily develop AUD, and not all individuals with AUD have a history of heavy alcohol use.

Epidemiology

References: [9][11][12][13][14][15][16]

Etiology

  • Genetic factors
  • Neurobiological factors
  • Psychosocial factors
    • Family history of AUD [17]
    • Environmental influence: e.g., social pressure to consume alcohol, economic disadvantage (e.g., unemployment), stressful life events

References:[12][18][19][20]

Diagnostics

Diagnosis of AUD begins with a screening test, which is followed by a confirmatory test based on patient history. Commonly used screening tests include AUDIT-C and CAGE tests. Diagnosis is confirmed if the patient history meets the DSM-V criteria for AUD.

Screening

  • AUDIT-C test
    • Three questions based on the Alcohol Use Disorders Identification Test (AUDIT)
    • Evaluation
      • Every response is given a score from 0 to 4 points.
      • The total score can range from 0 to 12.
      • A positive test suggests the presence of an alcohol use disorder.
        • ≥ 4 in men
        • ≥ 3 in women
Question Response Score
How often did you have a drink containing alcohol in the past year? Never 0
≤ Monthly 1
2–4 times a month 2
2–3 times a week 3
≥ 4 times a week 4
How many drinks did you have on a typical day when you were drinking in the past year? 1–2 0
3–4 1
5–6 2
7–9 3
≥ 10 4
How often did you have ≥ 6 drinks on one occasion in the past year? Never 0
< Once per month 1
Monthly 2
Weekly 3
Daily or almost daily 4
  • CAGE test
    • A series of four questions (CAGE) is used to screen for AUD
      1. Cut down drinking: Have you ever felt you should cut down on your drinking?
      2. Annoyed: Have people annoyed you by criticizing your drinking?
      3. Guilty: Have you ever felt guilty about drinking?
      4. Eye-opener: Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to overcome a hangover?
    • Every “yes” response counts as one point.
    • The CAGE test is considered positive for AUD if ≥ 2 questions are answered in the affirmative.

Diagnostic criteria (according to DSM-5)

  • 11 criteria based on the patient's history within the past 12 months
  • A diagnosis of AUD is established once ≥ 2 criteria are met.
    1. Drinking more or over a longer period than intended
    2. Tried to cut down or stop more than once, but couldn't
    3. Spends a lot of time drinking or recovering from aftereffects
    4. Strong desire to drink alcohol
    5. Drinking has a negative impact on everyday function (social, work etc)
    6. Continued drinking despite social or interpersonal problems
    7. Given up interests and activities that were important because of drinking
    8. Drinking in physically hazardous situations more than once
    9. Continued drinking despite physical or psychological problems
    10. Increasing amount of drinks to maintain same effects as before
    11. Features of withdrawal when the effects of alcohol wear off (see alcohol withdrawal below)
  • Severity
    • Mild: presence of 2–3 criteria
    • Moderate: presence of 4–5 criteria
    • Severe: presence of ≥ 6 criteria

Laboratory tests

Don't be the lAST 2 hALT! (AST levels are at least 2 times higher than those of ALT in case of alcoholic hepatitis).

References:[12][18][21][22][23][24]

Treatment

References:[4][6][25][26][27]

Complications

Alcohol withdrawal

Description

  • Caused by a sudden reduction or cessation of alcohol intake after a prolonged period of heavy drinking
  • Onset and duration vary among different syndromes.
  • May be assessed using the CIWA-Ar score
  • Delirium tremens is the most severe form of alcohol withdrawal.

Individuals with chronic alcohol use often develop withdrawal symptoms 48–72 hours after hospitalization because they do not have access to alcohol in the hospital.

Minor withdrawal

Withdrawal seizures

  • Onset: 6–48 hours after last drink
  • Clinical features: : brief, generalized tonic-clonic seizure (usually a single episode)

Alcoholic hallucinosis

Delirium tremens

  • Definition: persistent alteration of consciousness and sympathetic hyperactivity due to alcohol withdrawal
  • Onset
    • Most commonly occurs 48–96 hours after last consumption of alcohol
    • Symptoms commonly manifest during hospitalization, when the patient is no longer able to drink alcohol.
  • Clinical features
  • Duration: 1–5 days

In contrast to patients with alcoholic hallucinosis, patients with delirium tremens have impaired consciousness and abnormal vital signs.

Treatment

Lorazepam, Oxazepam, and Temazepam are preferred in those who drink a LOT because they are not metabolized by the liver and therefore safe in alcoholic liver disease.

In the case of alcohol withdrawal seizures, benzodiazepines are preferred over other anticonvulsants to prevent further seizures.

References:[1][2][3][4][5][6][7][8]

Alcoholic ketoacidosis

In contrast to diabetic ketoacidosis, blood glucose levels are normal or low in alcoholic ketoacidosis.

References:[1][2][3][4][5][6][7][8]

References

  1. Kasicka-Jonderko A, Jonderko K, Bożek M, Kamińska M, Mgłosiek P. Potent inhibitory effect of alcoholic beverages upon gastrointestinal passage of food and gallbladder emptying. J Gastroenterol. 2013; 48 (12): p.1311-1323. doi: 10.1007/s00535-013-0752-y . | Open in Read by QxMD
  2. Olson KN, Smith SW, Kloss JS, Ho JD, Apple FS. Relationship Between Blood Alcohol Concentration and Observable Symptoms of Intoxication in Patients Presenting to an Emergency Department. Alcohol and Alcoholism. 2013; 48 (4): p.386-389. doi: 10.1093/alcalc/agt042 . | Open in Read by QxMD
  3. Okruhlica L, Slezakova S. Clinical signs of alcohol intoxication and importance of blood alcohol concentration testing in alcohol dependence. Bratislava Medical Journal. 2013; 114 (03): p.136-139. doi: 10.4149/bll_2013_030 . | Open in Read by QxMD
  4. Acute Intoxication. http://www.who.int/substance_abuse/terminology/acute_intox/en/. Updated: January 1, 2017. Accessed: May 5, 2017.
  5. Semmens-Wheeler R, Dienes Z, Duka T. Alcohol increases hypnotic susceptibility. Conscious Cogn. 2013; 22 (3): p.1082-1091. doi: 10.1016/j.concog.2013.07.001 . | Open in Read by QxMD
  6. Ansstas G. Alcoholic Ketoacidosis. In: Khardori R, Alcoholic Ketoacidosis. New York, NY: WebMD. http://emedicine.medscape.com/article/116820. Updated: March 7, 2017. Accessed: October 7, 2017.
  7. Hoffman RS, Weinhouse GL. Management of Moderate and Severe Alcohol Withdrawal Syndromes. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes.Last updated: September 27, 2017. Accessed: December 9, 2017.
  8. Vij K. Textbook of Forensic Medicine & Toxicology: Principles & Practice. Elsevier Health Sciences ; 2014
  9. Cowan E, Su M. Ethanol Intoxication in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/ethanol-intoxication-in-adults.Last updated: September 7, 2016. Accessed: December 13, 2017.
  10. Burns MJ. Delirium Tremens (DTs). In: Pinsky MR, Delirium Tremens (DTs). New York, NY: WebMD. https://emedicine.medscape.com/article/166032. Updated: March 7, 2017. Accessed: December 13, 2017.
  11. Stern TA, Freudenreich O, Smith FA, Fricchione GL, Rosenbaum JF. Massachusetts General Hospital Handbook of General Hospital Psychiatry E-Book. Elsevier Health Sciences ; 2017
  12. Noor NM, Basavaraju K, Sharpstone D. Alcoholic ketoacidosis: a case report and review of the literature. Oxford Medical Case Reports. 2016; 2016 (3): p.31-33. doi: 10.1093/omcr/omw006 . | Open in Read by QxMD
  13. Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problem drinking. J Gen Intern Med. 1998; 13 (6): p.379-388. doi: 10.1046/j.1525-1497.1998.00118.x . | Open in Read by QxMD
  14. Thompson W. Alcoholism. In: Welton RS, Alcoholism. New York, NY: WebMD. https://emedicine.medscape.com/article/285913. Updated: September 12, 2017. Accessed: December 11, 2017.
  15. Tetrault JM. Risky Drinking and Alcohol Use Disorder: Epidemiology, Pathogenesis, Clinical Manifestations, Course, Assessment, and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/risky-drinking-and-alcohol-use-disorder-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis.Last updated: September 12, 2017. Accessed: December 11, 2017.
  16. Saitz R. Screening for Unhealthy Use of Alcohol and Other Drugs in Primary Care. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/screening-for-unhealthy-use-of-alcohol-and-other-drugs-in-primary-care.Last updated: October 21, 2016. Accessed: December 13, 2017.
  17. Torruellas C. Diagnosis of alcoholic liver disease. World J Gastroenterol. 2014; 20 (33): p.11684-11699. doi: 10.3748/wjg.v20.i33.11684 . | Open in Read by QxMD
  18. Sher KJ. The Oxford Handbook of Substance Use and Substance Use Disorders, Band 2. Oxford University Press ; 2016
  19. Johnson BA. Pharmacotherapy for Alcohol Use Disorder. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pharmacotherapy-for-alcohol-use-disorder.Last updated: December 3, 2014. Accessed: May 5, 2017.
  20. Gramlich L, Tandon P, Rahman A. Nutritional Status in Patients With Sustained Heavy Alcohol Use. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/nutritional-status-in-patients-with-sustained-heavy-alcohol-use.Last updated: January 26, 2017. Accessed: December 15, 2017.
  21. Association AP. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. American Psychiatric Pub ; 2018
  22. Nam T. Tran, Alexandra Clavarino, Gail M. Williams, Jake M. Najman. Gender Difference in Offspring's Alcohol Use Disorder by 21 Years: A Longitudinal Study of Maternal Influences. Subst Use Misuse. 2017; 53 (5): p.705-715. doi: 10.1080/10826084.2017.1363233 . | Open in Read by QxMD
  23. Holgate J, Bartlett S. Early Life Stress, Nicotinic Acetylcholine Receptors and Alcohol Use Disorders. Brain Sciences. 2015 .
  24. Yang P et al.. The Risk Factors of the Alcohol Use Disorders—Through Review of Its Comorbidities. Frontiers in Neuroscience. 2018 .
  25. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015; 72 (8): p.757-766. doi: 10.1001/jamapsychiatry.2015.0584 . | Open in Read by QxMD
  26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). undefined. 2013 . doi: 10.1176/appi.books.9780890425596 . | Open in Read by QxMD
  27. Global Status Report on Alcohol and Health 2014. http://www.who.int/substance_abuse/publications/global_alcohol_report/en/. Updated: January 1, 2014. Accessed: May 5, 2017.
  28. Brown TE. ADHD Comorbidities. American Psychiatric Pub ; 2009
  29. Ferri FF. Ferri's Clinical Advisor 2017. Elsevier Health Sciences ; 2016
  30. Sinha R. Chronic Stress, Drug Use, and Vulnerability to Addiction. Ann NY Acad Sc. 2008 .
  31. Risks of Alcoholism Among Native Americans. https://americanaddictioncenters.org/alcoholism-treatment/native-americans. Updated: January 2, 2020. Accessed: July 7, 2020.
  32. Herold G. Internal Medicine. Herold G ; 2014
  33. Teeple RC, Caplan JP, Stern TA. Visual hallucinations: differential diagnosis and treatment.. Prim Care Companion J Clin Psychiatry. 2009; 11 (1): p.26-32. doi: 10.4088/pcc.08r00673 . | Open in Read by QxMD