Alcohol use disorder: Difference between revisions

(Created page with "==Background== * Chronic mental illness characterized by inability to limit alcohol ingestion, compulsive drinking, and a negative emotional state when not drinking. * Previo...")
 
 
(26 intermediate revisions by 5 users not shown)
Line 1: Line 1:
==Background==
==Background==
[[File:Number with an alcohol use disorder, OWID.svg|thumb|Epidemiology of alcohol use disorder.]]
* Chronic mental illness characterized by inability to limit alcohol ingestion, compulsive drinking, and a negative emotional state when not drinking.  
* Chronic mental illness characterized by inability to limit alcohol ingestion, compulsive drinking, and a negative emotional state when not drinking.  
* Previously separated into alcohol abuse and alcohol dependence, but as of DSM-5, the diagnoses were combined into alcohol use disorder, and subdivided into mild, moderate, or severe.
* Previously separated into alcohol abuse and alcohol dependence, but as of DSM-5, the diagnoses were combined into alcohol use disorder, and subdivided into mild, moderate, or severe.
* It is estimated that about 6% of adults in the US suffer from alcohol use disorder.  
* It is estimated that about 6% of adults in the US suffer from alcohol use disorder.


==Clinical Features==
==Clinical Features==
* In order to make the diagnosis, patients must have several of the following 11 symptoms:
*Drinking more or for a longer period of time than intended.
# Drinking more or for a longer period of time than intended.
*Feeling incapable of cutting back on the amount of alcohol consumed.
# Feeling incapable of cutting back on the amount of alcohol consumed.
*Becoming sick for an extended period of time as a result of drinking too much.
# Becoming sick for an extended period of time as a result of drinking too much.
*Inability to concentrate due to alcohol cravings.
# Inability to concentrate due to alcohol cravings.
*Inability to care for a family, hold down a job, or perform in school.
# Inability to care for a family, hold down a job, or perform in school.
*Continuing to drink despite problems caused with friends or family.
# Continuing to drink despite problems caused with friends or family.
*Decreased participation in activities which were once important.
# Decreased participation in activities which were once important.
*Finding oneself in dangerous or harmful situations as a direct result of drinking.
# Finding oneself in dangerous or harmful situations as a direct result of drinking.
*Continuing to drink despite adding to another health problem, feeling depressed or anxious or blacking out.
# Continuing to drink despite adding to another health problem, feeling depressed or anxious or blacking out.
*Drinking more as a result of a tolerance to alcohol.
# Drinking more as a result of a tolerance to alcohol.
*Experiencing withdrawal symptoms.
# Experiencing withdrawal symptoms.


* Mild = 2-3 features
;Mild = 2-3 features
* Moderate = 4-5 features
;Moderate = 4-5 features
* Severe = 6 or more features
;Severe = 6 or more features
 
==Differential Diagnosis==
{{Ethanol DDX}}


==Evaluation==
==Evaluation==
* A history alone is sufficient to make the diagnosis of alcohol use disorder, however, if a patient presents to the ER, it is important to evaluate for the presence of acute alcohol intoxication, alcohol withdrawal, and co-ingestion with other drugs or toxic alcohols.
* A history alone is sufficient to make the diagnosis of alcohol use disorder, however, if a patient presents to the ER, it is important to evaluate for the presence of:
**[[Acute alcohol intoxication]],  
**[[Alcohol withdrawal]], and
**Co-ingestion with other drugs or [[toxic alcohols]]
* Check electrolytes, including magnesium and phosphorus<ref> Baj J, Flieger W, Teresiński G, Buszewicz G, Sitarz R, Forma A, Karakuła K, Maciejewski R. Magnesium, Calcium, Potassium, Sodium, Phosphorus, Selenium, Zinc, and Chromium Levels in Alcohol Use Disorder: A Review. J Clin Med. 2020 Jun 18;9(6):1901. doi: 10.3390/jcm9061901. PMID: 32570709; PMCID: PMC7357092. </ref>
**Long-term alcohol intake often has electrolyte abnormalities (including [[hypomagnesemia]] and [[hypokalemia]])
**Low magnesium levels, typically below 0.8 mEq/L, can also cause [[hypocalcemia]] due to suppression of parathyroid hormone secretion and parathyroid hormone resistance


==Management==
==Management==
* If the patient is not acutely intoxicated or at risk for alcohol withdrawal, they should be referred to a social worker or their PCP for resources to quit drinking and can usually be discharged safely.  
{{Vitamin prophylaxis for ETOH}}
* Disulfiram can be prescribed as alcohol avoidance therapy, but this should be done by a PCP or psychiatrist treating the patient's addiction.
 
===Medication Assisted Treatment===
====[[Naltrexone]]====
'''Dosage'''
*[[Naltrexone]] 380 mg IM or 50 mg PO qday #30 tabs, no refills
*Contraindications:
**Any opioid use (including [[Buprenorphine]]):
***Must be off short-acting opioids for 1 week and methadone for 2 weeks
**Planned surgery/anesthesia in next 30 days (okay to use tablets, stop 1 day prior to surgery)
**Acute liver injury with AST or ALT >/= 250 or decompensated cirrhosis (Childs Pugh Class 3)
**[[Pregnancy]]
**Allergy
 
 
'''Evidence'''
*A Cochrane review assessed the efficacy of naltrexone in randomized control trials.<ref>Srisurapanont M, Jarusuraisin N. Opioid antagonists for alcohol dependence. Cochrane Database of Systematic Reviews. 2005;(1). </ref>
**Helps to reduce the number of participants who relapse or return to heavy drinking in a short time frame following treatment (12 weeks).
*Reduces the time in days to first drink when compared to placebo or disulfiram.
*Reduces reported cravings and the total amount of alcohol consumed.
*Should be offered to patients with alcohol use disorder who are interested in reducing alcohol intake.
 
====[[Gabapentin]]====
'''Dosage'''
*[[Gabapentin]] 600 mg PO TID #90 tabs, no refills
**Counsel to decrease to 300 mg PO TID if dizzy, can increase after 1 week
**Renally dosed if CrCl<60
**ACOG approves of use in pregnancy
 
 
'''Evidence'''
*A metanalysis of several randomized control trials demonstrates that use of gabapentin for alcohol use disorder reduces the number of total heavy drinking days. <ref>Kranzler HR, Feinn R, Morris P, Hartwell EE. A meta-analysis of the efficacy of gabapentin for treating alcohol use disorder. Addiction. 2019;114(9):1547-1555.</ref>
*Addition of [[gabapentin]] to [[naltrexone]] further helped to reduce cravings in the first 6 weeks of AUD. <ref>Anton RF, Myrick H, Wright TM, Latham PK, Baros AM, Waid LR, Randall PK. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatry. 2011 Jul;168(7):709-17. doi: 10.1176/appi.ajp.2011.10101436. Epub 2011 Mar 31. PMID: 21454917; PMCID: PMC3204582.</ref>
 
====[[Disulfiram effect|Dilsulfiram]]====
*Can be prescribed as alcohol avoidance therapy. This can be prescribed in the emergency department or referred to PCP/psychiatrist treating the patient's addiction.
 
==Disposition==
*Outpatient
**If the patient is not acutely [[Ethanol toxicity|intoxicated]] or at risk for [[alcohol withdrawal]], they should be referred to a social worker or their PCP for resources to quit drinking and can usually be discharged safely.
 
==See Also==
*[[Ethanol toxicity]]
 
==External Links==
 
 
==References==
<references/>
 
[[Category:Psychiatry]]

Latest revision as of 19:28, 8 November 2023

Background

Epidemiology of alcohol use disorder.
  • Chronic mental illness characterized by inability to limit alcohol ingestion, compulsive drinking, and a negative emotional state when not drinking.
  • Previously separated into alcohol abuse and alcohol dependence, but as of DSM-5, the diagnoses were combined into alcohol use disorder, and subdivided into mild, moderate, or severe.
  • It is estimated that about 6% of adults in the US suffer from alcohol use disorder.

Clinical Features

  • Drinking more or for a longer period of time than intended.
  • Feeling incapable of cutting back on the amount of alcohol consumed.
  • Becoming sick for an extended period of time as a result of drinking too much.
  • Inability to concentrate due to alcohol cravings.
  • Inability to care for a family, hold down a job, or perform in school.
  • Continuing to drink despite problems caused with friends or family.
  • Decreased participation in activities which were once important.
  • Finding oneself in dangerous or harmful situations as a direct result of drinking.
  • Continuing to drink despite adding to another health problem, feeling depressed or anxious or blacking out.
  • Drinking more as a result of a tolerance to alcohol.
  • Experiencing withdrawal symptoms.
Mild = 2-3 features
Moderate = 4-5 features
Severe = 6 or more features

Differential Diagnosis

Ethanol related disease processes

Evaluation

  • A history alone is sufficient to make the diagnosis of alcohol use disorder, however, if a patient presents to the ER, it is important to evaluate for the presence of:
  • Check electrolytes, including magnesium and phosphorus[1]
    • Long-term alcohol intake often has electrolyte abnormalities (including hypomagnesemia and hypokalemia)
    • Low magnesium levels, typically below 0.8 mEq/L, can also cause hypocalcemia due to suppression of parathyroid hormone secretion and parathyroid hormone resistance

Management

Vitamin Prophylaxis for Chronic alcoholics

  • At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
  • Give multivitamin PO; patient at risk for other vitamin deficiencies

Banana bag

The majority of chronic alcoholics do NOT require a banana bag[2][3]

Medication Assisted Treatment

Naltrexone

Dosage

  • Naltrexone 380 mg IM or 50 mg PO qday #30 tabs, no refills
  • Contraindications:
    • Any opioid use (including Buprenorphine):
      • Must be off short-acting opioids for 1 week and methadone for 2 weeks
    • Planned surgery/anesthesia in next 30 days (okay to use tablets, stop 1 day prior to surgery)
    • Acute liver injury with AST or ALT >/= 250 or decompensated cirrhosis (Childs Pugh Class 3)
    • Pregnancy
    • Allergy


Evidence

  • A Cochrane review assessed the efficacy of naltrexone in randomized control trials.[4]
    • Helps to reduce the number of participants who relapse or return to heavy drinking in a short time frame following treatment (12 weeks).
  • Reduces the time in days to first drink when compared to placebo or disulfiram.
  • Reduces reported cravings and the total amount of alcohol consumed.
  • Should be offered to patients with alcohol use disorder who are interested in reducing alcohol intake.

Gabapentin

Dosage

  • Gabapentin 600 mg PO TID #90 tabs, no refills
    • Counsel to decrease to 300 mg PO TID if dizzy, can increase after 1 week
    • Renally dosed if CrCl<60
    • ACOG approves of use in pregnancy


Evidence

  • A metanalysis of several randomized control trials demonstrates that use of gabapentin for alcohol use disorder reduces the number of total heavy drinking days. [5]
  • Addition of gabapentin to naltrexone further helped to reduce cravings in the first 6 weeks of AUD. [6]

Dilsulfiram

  • Can be prescribed as alcohol avoidance therapy. This can be prescribed in the emergency department or referred to PCP/psychiatrist treating the patient's addiction.

Disposition

  • Outpatient
    • If the patient is not acutely intoxicated or at risk for alcohol withdrawal, they should be referred to a social worker or their PCP for resources to quit drinking and can usually be discharged safely.

See Also

External Links

References

  1. ↑ Baj J, Flieger W, Teresiński G, Buszewicz G, Sitarz R, Forma A, Karakuła K, Maciejewski R. Magnesium, Calcium, Potassium, Sodium, Phosphorus, Selenium, Zinc, and Chromium Levels in Alcohol Use Disorder: A Review. J Clin Med. 2020 Jun 18;9(6):1901. doi: 10.3390/jcm9061901. PMID: 32570709; PMCID: PMC7357092.
  2. ↑ Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  3. ↑ Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.
  4. ↑ Srisurapanont M, Jarusuraisin N. Opioid antagonists for alcohol dependence. Cochrane Database of Systematic Reviews. 2005;(1).
  5. ↑ Kranzler HR, Feinn R, Morris P, Hartwell EE. A meta-analysis of the efficacy of gabapentin for treating alcohol use disorder. Addiction. 2019;114(9):1547-1555.
  6. ↑ Anton RF, Myrick H, Wright TM, Latham PK, Baros AM, Waid LR, Randall PK. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatry. 2011 Jul;168(7):709-17. doi: 10.1176/appi.ajp.2011.10101436. Epub 2011 Mar 31. PMID: 21454917; PMCID: PMC3204582.
Retrieved from "https://www.wikem.org/w/index.php?title=Alcohol_use_disorder&oldid=371934"