Summary
Definition
History and exam
Key diagnostic factors
- withdrawal
- tolerance
- increased/decreased liver size, jaundice, ascites
Other diagnostic factors
- insomnia
- erectile dysfunction
- nicotine use disorder
- gastrointestinal distress
- muscle cramps, pain, tenderness, altered sensory perception
- hypertension and tachycardia
- impaired nutritional status
- broad-based gait
Risk factors
- family history of alcohol use disorder
- depression, anxiety, and other mental health disorders
- socioeconomic deprivation
- lack of facial flushing on exposure to alcohol
- low responsivity to the effects of alcohol
- history of gastric bypass
Diagnostic investigations
1st investigations to order
- diagnostic interview
- alcohol level (breath and blood)
- Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar)
Investigations to consider
- carbohydrate-deficient transferrin (CDT)
- gamma glutamyl transpeptidase (gamma-GT), alanine aminotransferase (ALT), aspartate aminotransferase (AST)
- CBC
- urinary ethyl glucuronide
- phosphatidylethanol (PEth)
Treatment algorithm
at-risk drinking
alcohol use disorder: nonpregnant adult with no concurrent opioid use or mental health diagnosis
alcohol use disorder: nonpregnant adult with concurrent opioid use
alcohol use disorder: nonpregnant adult with concurrent mental health diagnosis
alcohol use disorder: nonpregnant adolescent
alcohol use disorder: pregnant
Contributors
Authors
Elisabeth Poorman, MD, MPH
Assistant Professor of Medicine
Department of Medicine
University of Illinois Chicago
Chicago
IL
Disclosures
EP declares that she has no conflicting interests.
Marlene Martin, MD
Associate Professor of Clinical Medicine
Director, Addiction Care Team
San Francisco General Hospital
University of California, San Francisco
San Francisco
CA
Disclosures
MM is a board member for the National Harm Reduction Coalition and has done consultancy work for the Society of Hospital Medicine.
Sarah Messmer, MD
Assistant Professor of Clinical Medicine and Pediatrics
University of Illinois Chicago
Chicago
IL
Disclosures
SM declares that she has no conflicting interests.
Acknowledgements
Dr Elisabeth Poorman, Dr Marlene Martin, and Dr Sarah Messmer would like to gratefully acknowledge Dr Colin Drummond, Dr Julie R. Pittman, Dr Philip H. Chung, Dr Robert M. Swift, and Dr Lorenzo Leggio, previous contributors to this topic.
Disclosures
CD, JRP, PHC, and RMS declare that they have no competing interests. LL is an author of a reference cited in this topic.
Peer reviewers
Stephen Holt, MD, MS
Associate Professor of Medicine
Yale School of Medicine
New Haven
CT
Disclosures
SH declares that they have no competing interests.
Bhanu Prakash Kolla, MD, FRCPsych
Professor of Psychiatry
Department of Psychiatry and Psychology
Addiction Psychiatrist and Sleep Physician
Center for Sleep Medicine, Mayo Clinic
Rochester
MN
Disclosures
BPK declares that they have no competing interests.
Paul S. Haber, MD
Royal Prince Alfred Hospital and Discipline of Medicine
University of Sydney
Sydney
Australia
Disclosures
PSH is an author of a reference cited in this topic.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
American Society of Addiction Medicine. Engagement and retention of nonabstinent patients in substance use treatment: clinical consideration for addiction treatment providers. Oct 2024 [internet publication].Full text
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.
World Health Organization. International classification of diseases, 11th revision (ICD-11). Feb 2025 [internet publication].Full text
US Department of Veterans Affairs. VA/DOD clinical practice guidelines: management of substance use disorders. 2021 [internet publication].Full text
Reus VI, Fochtmann LJ, Bukstein O, 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(1):86-90.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Other psychiatric disorders
- Other substance use disorders (especially sedatives)
More DifferentialsGuidelines
- Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR)
- Management of substance use disorders: guidelines from the VA/DoD
More GuidelinesPatient information
Alcohol-use disorder
More Patient informationCalculators
Alcohol Consumption Screening AUDIT Questionnaire
More CalculatorsLog in or subscribe to access all of BMJ Best Practice
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