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alcohol abuse (includes alcohol use disorder, risky alcohol use)

Alcohol use resulting in impairment or distress with multiple psychosocial, behavioral or physiologic features. Etiology: risk factors - long work hours (> 55 hours/week) [1] Epidemiology: - ~10% of adolescents >= 15 years of age meet DSM-5 criteria for alcohol use disorder - prevalence of high-risk drinking >= 4 drinks/day for women, or >= 5 drinks/day for men, at least weekly increased from 10% in 2001-2002 to 13% 2012-2013 [5] - largest increases in high-risk drinking in women (58%), racial/ethnic minorities (41-62%) & seniors [65%) [5] - 17% of U.S. adults report binge drinking in 2015 [7] - binge drinking more common in men than women (22% vs 12%) - more common in person 18-34 (25%) than those > 35 years - whites were most likely to binge drink (19%), followed by American Indians/Alaska Natives (18%) - alcohol use disorder - failure in roles (work problems, absences) - interpersonal problems - difficulty cutting back, tolerance, withdrawal [10] History: - see screening for alcohol abuse Clinical manifestations: - injuries - headaches - nausea - memory impairment - hypertension - recurrent traffic violations - worsening academic performance Laboratory: - see alcoholism - phosphatidylethanol in blood can detect heavy alcohol use Complications: - increased risk for cardiovascular events [4] - initiation of drinking during adolescence alters normal brain development [6] - increased risk for suicide after hospitalization for alcohol-related emergency [8] Management: 1) Public Health Services 5-step brief intervention (5 A's) [3] a) Ask about alcohol use b) Advise to quit c) Assess willingness to attempt to quit d) Assist in attempt & set a quit date e) Arrange for follow-up 2) for patients unwilling to quit, enhance motivation (5 R's) [3] a) non-confrontational strategies (motivational interviewing) b) expore Relevance of alcohol cessation to patient's life c) assist in identifying Risks of alcohol abuse d) assist in identifying Rewards of alcohol cessation e) discuss Roadblocks or barriers to stopping f) Repeat motivational intervention each visit 3) referral to specialty alcohol use disorder program advised 4) psychosocial interventions [3] 5) naltrexone & acamprosate are 1st line agents [3,13] - oral naltrexone 50 mg/day - naltrexone may be used in patients actively drinking - naltrexone contraindicated in liver failure, hepatitis - use IM naltrexone (380 mg Vivatrol IM monthly) for opioid dependence - decreases % of drinking days but does not prevent return to drinking [13] - acamprosate: 2 tablets, 3 times daily - acamprosate contraindicated with renal failure - limited data for use in older adults 6) topiramate reduces % of drinking days, absolute decreas ~ 2 days/month [13] 7) disulfiram may not reduce drinking 8) gabapentin may reduce % of heavy drinking days, but does not improve 5 other outcomes (drinks/day, relapse, days of abstinence, complete abstinence, serum gamma-GGT) [9] 9) hospital discharge may be an opportunity for initiation of treatment for alcohol use disorder [11] Notes: - also see alcoholism & alcohol withdrawal syndrome for more severe alcohol abuse requiring hospitalization

Interactions

disease interactions

Related

alcoholic beverage screening for alcohol abuse

Specific

alcoholism (includes binge drinking) at-risk drinking

General

substance abuse

References

  1. Virtanen M et al. Long working hours and alcohol use: Systematic review and meta-analysis of published studies and unpublished individual participant data. BMJ 2015 Jan 13; 350:g7772 PMID: 25587065 http://www.bmj.com/content/350/bmj.g7772
  2. Clark DB, Martin CS, Chung T et al Screening for Underage Drinking and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Alcohol Use Disorder in Rural Primary Care Practice. J Pediatr 2016 PMID: 27059911 http://www.jpeds.com/article/S0022-3476%2816%2900269-9/pdf
  3. Medical Knowledge Self Assessment Program (MKSAP) 17, 19 American College of Physicians, Philadelphia 2015, 2021 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Whitman IR, Agarwal V, Nah G et al Alcohol Abuse and Cardiac Disease J Am Coll Cardiol. Volume 69, Issue 1, Jan 2017 PMID: 28057245 http://www.onlinejacc.org/content/69/1/13 - Criqui MH, Thomas IC Alcohol Consumption and Cardiac Disease. Where Are We Now? J Am Coll Cardiol. Volume 69, Issue 1, Jan 2017 PMID: 28057246 http://www.onlinejacc.org/content/69/1/25
  5. Grant BF, Chou SP, Saha TD et al Prevalence of 12-Month Alcohol Use, High-Risk Drinking, and DSM-IV Alcohol Use Disorder in the United States, 2001-2002 to 2012-2013. Results From the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. Published online August 9, 2017 PMID: 28793133 http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2647079 - Schuckit MA. Remarkable Increases in Alcohol Use Disorders. JAMA Psychiatry. 2017 Aug 9. PMID: 28793142 http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2647075
  6. Pfefferbaum A, Kwon D, Brumback T et al. Altered brain developmental trajectories in adolescents after initiating drinking. Am J Psych 2017 Oct 31 PMID: 29084454 https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2017.17040469
  7. Kanny D, Naimi TS, Liu Y, et al Annual Total Binge Drinks Consumed by U.S. Adults, 2015. Am J Prev Med. 2018 Apr;54(4):486-496. PMID: 29555021 http://www.ajpmonline.org/article/S0749-3797(17)30753-5/fulltext - Centers for Disease Control & Prevention (CDC) During binges, U.S. adults have 17 billion drinks a year. CDC Press Release. Friday, March 16, 2018 https://www.cdc.gov/media/releases/2018/p0316-binge-drinking.html
  8. Bowden B, John A, Trefan L, Morgan J, Farewell D, Fone D. Risk of suicide following an alcohol-related emergency hospital admission: An electronic cohort study of 2.8 million people. PLoS One 2018 Apr 27; 13:e0194772 PMID: 29702655 Free PMC Article http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194772
  9. Kranzler HR, Feinn R, Morris P, Hartwell EE. A meta-analysis of the efficacy of gabapentin for treating alcohol use disorder. Addiction 2019 May 11 PMID: 31077485 https://onlinelibrary.wiley.com/doi/abs/10.1111/add.14655
  10. NEJM Knowledge+ Psychiatry
  11. Bernstein EY et al. Pharmacologic treatment initiation among Medicare beneficiaries hospitalized with alcohol use disorder. Ann Intern Med 2023 Jun 27; [e-pub]. PMID: 37364264 https://www.acpjournals.org/doi/10.7326/M23-0641 - Mayo-Smith MF, Lawrence D. Treatment of alcohol use disorder in hospitalized patients: Some sobering findings. Ann Intern Med 2023 Jun 27; [e-pub]. PMID: 37364269 https://www.acpjournals.org/doi/10.7326/M23-1419
  12. Reus VI et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry 2018 Jan 1; 175:86. PMID: 29301420 https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2017.1750101 - American Psychiatric Association. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder American Psychiatric Association Publishing; 2018. https://psychiatryonline.org/doi/full/10.5555/appi.books.9781615371969.alcohol00pre
  13. McPheeters M, O'Connor EA, Riley S et al. Pharmacotherapy for alcohol use disorder: A systematic review and meta-analysis. JAMA 2023 Nov 7; 330:1653. PMID: 37934220 PMCID: PMC10630900 (available on 2024-05-07) https://jamanetwork.com/journals/jama/fullarticle/2811435