Alcohol use disorder

Alcohol use disorder is a problematic pattern of alcohol use leading to significant impairment or distress. Unhealthy alcohol use includes the spectrum of at-risk drinking and alcohol use disorders.

Unhealthy alcohol use is defined by more than 3 drinks per day or 7 per week for women, and more than 4 drinks per day or 14 per week for men. To differentiate between at-risk drinking and alcohol use disorder, the DSM-5-TR criteria should be used.

Unhealthy alcohol use is underdiagnosed and undertreated. Worldwide, alcohol-related mortality is highest among males, adults ages 20-39 years, and people of lower socioeconomic status.

Management should be driven by a process of informed decision-making, considering a patient’s alcohol-related goals, preferences, clinical characteristics, and the evidence behind treatments. These include psychosocial therapies, pharmacologic treatment, or both. Drugs used include naltrexone, acamprosate, disulfiram, gabapentin, and topiramate.

Unhealthy alcohol use includes hazardous use, harmful use, and alcohol use disorder. Hazardous use is defined as alcohol use that puts a patient at risk for harm (commonly, at least two heavy drinking episodes in the previous year), whereas harmful alcohol use is alcohol use that has caused adverse health or psychosocial consequences. Alcohol use disorder is defined as clinically significant impairment or psychosocial stress in the previous 12 months. People with hazardous or harmful alcohol use are at higher risk of developing an alcohol use disorder, but do not have to develop a diagnosable disorder to suffer harm.

Heavy drinking has been defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as more than 3 drinks per day or more than 7 drinks per week for women, and more than 4 drinks per day or more than 14 drinks per week for men.[1]National Institute on Alcohol Abuse and Alcoholism. Drinking levels defined. Feb 2025 [internet publication]. https://www.niaaa.nih.gov/alcohols-effects-health

“Dependence” and “abuse” are old terms that are no longer used since the publication of the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) in 2013. The authors encourage clinicians treating people with alcohol use disorder to use updated terms, because “dependence” can imply that alcohol use disorder cannot exist without withdrawal, and the word “abuse” has been linked to stigma and less patient-centered decisions.[2]Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010 May;21(3):202-7. http://www.ncbi.nlm.nih.gov/pubmed/20005692?tool=bestpractice.com [3]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]. https://www.asam.org/quality-care/clinical-recommendations/asam-clinical-considerations-for-engagement-and-retention-of-non-abstinent-patients-in-treatment ​​ Terms such as “alcoholic,” “alcoholism,” and “addict” are not clinical terms and are associated with stigma and so should not be used. Terms such as "person with alcohol use disorder and addiction" should be used instead.