Alcohol Use Disorders

Definition, Screening & Diagnosis - Spotting the Spirits

• Alcohol Use Disorder (AUD): Maladaptive alcohol use causing significant impairment/distress.

  • DSM-5 Criteria (≥2 of 11 criteria in 12 months):
    • Mild: 2-3 criteria
    • Moderate: 4-5 criteria
    • Severe: ≥6 criteria

• Screening Tools:

  Tool	Items	Focus	Key Cut-offs (Positive Screen)
  CAGE	4	Lifetime problem; Dependence cues	≥2 "Yes". 📌 (Cut down, Annoyed, Guilty, Eye-opener)
  AUDIT	10	Current use, Dependence, Problems	Score ≥8 (general); ≥7 (women/elderly)
  AUDIT-C	3	At-risk drinking (heavy/binge)	Score: Men ≥4; Women ≥3

• Biomarkers (indicate heavy/prolonged use):

  • ↑GGT (Gamma-Glutamyl Transferase)
  • ↑MCV (Mean Corpuscular Volume)
  • ↑CDT (Carbohydrate-Deficient Transferrin) - most specific for chronic alcohol consumption.

⭐ AUDIT-C, a 3-item questionnaire, is a highly effective screening tool for heavy drinking and AUD in primary care.

Acute Effects & Withdrawal - The Alcohol Rollercoaster

• Intoxication: Effects correlate with Blood Alcohol Concentration (BAC).
  • 0.08% (Legal limit): Impaired coordination.
  • >0.3%: Stupor, coma.
• Withdrawal: Begins 6-24h post-last drink. CIWA-Ar score for severity: <8-10 mild, 10-18 moderate, >18 severe.
  • Symptoms: Autonomic hyperactivity (↑HR, ↑BP), tremors, anxiety.
  • Severe: Seizures, hallucinations, Delirium Tremens (DTs).
  • 📌 Mnemonic for DT symptoms: "FATAL DT" - Fever, Autonomic hyperactivity, Tremors, Agitation/Altered mental status, Leukocytosis, Delirium Tremens.

⭐ Delirium Tremens (DTs) is a medical emergency characterized by global confusion, sympathetic overdrive, and has a mortality rate of 5-15% if untreated. Onset 48-96 hours post-last drink.

Chronic Complications - Body's Booze Battle

• Liver: Steatosis → alcoholic hepatitis → cirrhosis.
• GI: Gastritis, pancreatitis, Mallory-Weiss tear.
• CV: Alcoholic cardiomyopathy, hypertension.
• Neuro: Wernicke-Korsakoff syndrome, cerebellar degeneration, peripheral neuropathy.
  • 📌 Wernicke's triad ("COAT"): Confusion, Ophthalmoplegia, Ataxia, Thiamine deficiency.
  • Treat Wernicke's: Thiamine 100-500mg IV/IM TID.
• Cancers: Oropharyngeal, esophageal, liver, laryngeal.

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Management Strategies - Treatment Toolkit

• Withdrawal Management: BZD (e.g., Diazepam, Lorazepam) via CIWA-Ar.
• Relapse Prevention Pharmacotherapy:

  Drug	MOA	Key SE	CIs	Dose (Oral)
  Naltrexone	Opioid antag; ↓cravings	Nausea, HA, hepatotox (rare)	Active opioids, liver fail.	50mg/day
  Acamprosate	GABA/glutamate mod; ↓withdrawal	Diarrhea	Sev. renal impair (CrCl <30mL/min)	666mg TID
  Disulfiram	Aldehyde DH inhib; aversive	Metallic taste, neuropathy	Cardiac dis, psychosis, alcohol use, preg.	250-500mg/day
  📌 For Disulfiram reaction: "Don't Ingest Sulfiram Like Alcohol Makes Nasty Vomiting" - Dyspnea, Itching, Sweating, Lightheadedness, Angina, Nausea, Vomiting.

• Psychosocial Support: MI, CBT, AA.

Pharmacotherapy Selection Algorithm:

⭐ Naltrexone is contraindicated in patients receiving opioid analgesics or with acute hepatitis/liver failure, while Acamprosate is preferred in liver disease but needs dose adjustment in renal impairment.

High‑Yield Points - ⚡ Biggest Takeaways

• CAGE questionnaire is a key screening tool for Alcohol Use Disorder (AUD).
• Wernicke-Korsakoff syndrome results from thiamine (B1) deficiency in chronic alcohol use.
• Delirium Tremens (DTs) is a severe, life-threatening alcohol withdrawal, treat with benzodiazepines.
• Naltrexone, acamprosate, and disulfiram are first-line pharmacotherapies for AUD.
• An AST:ALT ratio > 2:1 strongly suggests alcoholic liver disease.
• Fetal Alcohol Syndrome (FAS) causes distinct craniofacial dysmorphism and neurodevelopmental issues.
• Marchiafava-Bignami disease, a rare complication, involves corpus callosum demyelination.