alcohol use disorder

clinical identity

A chronic, relapsing disorder characterized by compulsive alcohol use, loss of control, and negative emotional states when not using. Management has shifted from “abstinence only” to patient-centered goals (reduction vs. abstinence) using the 2023 CMAJ Guidelines.

screening & diagnosis

• Screening:
  • SASQ (Single Alcohol Screening Question): “How many times in the past year have you had 5 (men) or 4 (women) drinks in a day?” ($>0$ is positive).
  • AUDIT-C: Scored 0–12. $\ge 4$ indicates at-risk drinking.
• Diagnosis (DSM-5-TR):
  • Requires $\ge 2$ of 11 criteria in 12 months (e.g., tolerance, withdrawal, craving, social repercussion, failure to cut down).
  • Severity: Mild (2–3), Moderate (4–5), Severe ($\ge 6$).

management framework

1. Determine Goal: Abstinence vs. Harm Reduction (reduced consumption).
2. Withdrawal Risk: Screen with PAWSS. If high risk, manage withdrawal first.
3. Psychosocial: CBT, family therapy, and culturally safe care (especially for Indigenous populations) are standard of care.
4. Pharmacotherapy: Offer to all patients with moderate-severe AUD.

pharmacotherapy

first-line agents

drug	Naltrexone	Acamprosate
mechanism	$\mu$-opioid antagonist. Blocks endogenous opioids released by alcohol (reduces “buzz”/reward).	Modulates NMDA (glutamate) & GABA systems. Restores excitatory/inhibitory balance.
best for	Reducing heavy drinking days and cravings. Effective even if patient is not fully abstinent.	Maintaining abstinence.
dosing	25 mg PO daily x 3d $\to$ 50 mg PO daily.	666 mg (2 tabs) PO TID.
key contraindications	Current Opioid Use (precipitates withdrawal). Acute Hepatitis/Liver Failure.	Severe Renal Impairment (CrCl $<30$ mL/min).
common se	Nausea (transient), headache, dizziness.	Diarrhea, bloating.
exam pearl	Must be opioid-free for 7–10 days before starting.	”Safe for the liver, bad for the kidneys.”

second-line agents

• Topiramate:
  • Mechanism: GABA enhancement/Glutamate inhibition.
  • Role: Reduces heavy drinking days.
  • Issues: Cognitive slowing (“Dopamax”), paresthesias, metabolic acidosis, weight loss.
• Gabapentin:
  • Role: Useful if concurrent mild withdrawal symptoms or anxiety.
  • Evidence: Weak/Conditional recommendation.

agents to avoid (CMAJ 2023)

• SSRIs: Do NOT prescribe for AUD alone. Evidence shows no benefit and potential worsening of drinking in some subtypes. Only use if concurrent anxiety/depression diagnosis exists.
• Benzodiazepines: Do NOT use for chronic AUD management (high abuse potential, synergism with alcohol). Limit to acute withdrawal.
• Antipsychotics: No benefit for AUD; increased harm.

special considerations

• Liver Disease:
  • Cirrhosis (Child-Pugh A/B): Acamprosate is preferred (no hepatic metabolism). Naltrexone requires caution/monitoring.
  • Acute Alcoholic Hepatitis: Avoid Naltrexone.
• Pregnancy: All agents generally avoided; focus on psychosocial support.
• Disulfiram (Antabuse):
  • Status: No longer first-line (adherence issues).
  • Mechanism: Irreversible inhibition of aldehyde dehydrogenase $\to$ buildup of acetaldehyde $\to$ flushing, vomiting, hypotension upon drinking.
  • Use: Only for highly motivated patients with supervised administration.

related pages: Alcohol Withdrawal, Naltrexone, Acamprosate, Cirrhosis