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Alcohol use disorder

Last reviewed: 14 Sep 2025
Last updated: 25 Sep 2025

Summary

Definition

History and exam

Key diagnostic factors

  • withdrawal
  • tolerance
  • increased/decreased liver size, jaundice, ascites
Full details

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
Full details

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
Full details

Diagnostic investigations

1st investigations to order

  • diagnostic interview
  • alcohol level (breath and blood)
  • Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar)
Full details

Investigations to consider

  • carbohydrate-deficient transferrin (CDT)
  • gamma glutamyl transpeptidase (gamma-GT), alanine aminotransferase (ALT), aspartate aminotransferase (AST)
  • CBC
  • urinary ethyl glucuronide
  • phosphatidylethanol (PEth)
Full details

Treatment algorithm

ONGOING

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

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

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 Differentials
  • Guidelines

    • 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 Guidelines
  • Patient information

    Alcohol-use disorder

    More Patient information
  • Calculators

    Alcohol Consumption Screening AUDIT Questionnaire

    More Calculators
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