Primary care physicians play an integral role in the identification and management of alcohol use disorder, which has implications for the safety and physical and mental health of patients, their families, and the public. Screening to identify risky drinking behavior is recommended by the US Preventive Services Task Force but is not always performed consistently or correctly in primary care. When alcohol use disorder is identified, collaboration with patients is essential to determine an appropriate treatment approach. Abstinence may not always be the answer. Approximately one-half of patients with alcohol use disorder experience symptoms of alcohol withdrawal syndrome when decreasing alcohol use abruptly or substantially. Physicians must be adept at recognizing and managing signs of alcohol withdrawal. They should be aware of the range of management options and recognize that pharmacotherapy has been underused.
Case 1. KB is a 22-year-old college senior. When you ask about alcohol use, KB states that he drinks three or four beers on weekdays and 10 to 12 beers with shots of hard alcohol on weekends. His grades have slipped, and he jokingly describes himself as a functioning alcoholic. KB’s father and older brother have struggled with alcohol use. KB began drinking as a college freshman to increase his comfort in social situations. He says that he has tried to cut back a couple of times but has resumed drinking within a few days. He recently attempted Sober October and experienced a shaky feeling when not drinking, so he resumed drinking only light beer for the month. Watching his grandfather struggle with health problems, which he thinks may be alcohol-related, has caused him concern about his own long-term health risks, and he feels that he might need help.
Definition
Alcohol use takes place on a continuum and has the potential for substantial short- and long-term harm to mental and physical health.1 Although recommendations vary slightly, moderate alcohol use in the United States tends to be defined as one drink per day for women and two for men, according to the National Institute on Alcohol Abuse and Alcoholism.1–3 It is important to note that there is no recommended or healthy amount of alcohol consumption according to the World Health Organization.4 The definition of a binge drinking episode generally involves four or more drinks for women and five or more drinks for men in a single occasion.3,5 Heavy drinking definitions vary from number of drinks per week (ie, eight or more for women and 15 or more for men) to number of binge drinking episodes in the previous month (ie, five or more episodes).1
The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision, (DSM-5-TR) criteria for substance use disorders are presented in Table 1.5 They remain the same for various substances and broadly reflect difficulties with controlling substance use (eg, risky or increased use) and its effects (eg, impairments in activities or relationships, cravings, tolerance, withdrawal). No single criterion is required or sufficient to diagnose alcohol use disorder (AUD) or other substance use disorders.
Table 1 DSM-5-TR Criteria for Substance Use Disorder
| Criterion | Example |
|---|---|
| Impaired control | |
| 1. Uses greater amounts or for a longer period than planned | Patient plans to have a quick drink after work on Fridays but, each week, has multiple drinks, stays for hours, and misses dinner at home. |
| 2. Attempts to decrease use are unsuccessful | Patient has tried to quit cigarette smoking completely and reduce the number of cigarettes smoked per day but inevitably returns to smoking two packs per day. |
| 3. A lot of time is spent obtaining, using, or recovering from effects of use | Patient was prescribed oxycontin following back surgery 4 years ago. When the dose was tapered, the patient attempted to get more from a different physician, who checked the state registry and declined. The patient then began purchasing oxycontin illegally. |
| 4. Strong desire (craving) to use | Patient with a fear of flying was prescribed lorazepam to assist with air travel for work. The patient then began taking lorazepam in other situations and ultimately began taking it once or more each day. Since running out of the drug, the patient seems to be experiencing rebound anxiety. |
| Social impairment | |
| 5. Repeated use results in failure to manage commitments at home, school, or work | Patient is failing college courses due to skipping class, sometimes because of active opioid use or withdrawal symptoms. |
| 6. Continued use even when it causes relationship difficulties | Patient’s spouse says that the patient’s drinking is ruining the relationship due to angry outbursts when drinking and that the family cannot depend on the patient anymore. The patient thinks the spouse is being unreasonable. |
| 7. Giving up or reducing occupational, social, or recreational activities because of use | Patient will not take a dream trip to Europe because they do not think they can make it through the long flight without smoking a cigarette. |
| Risky use | |
| 8. Repeated use in dangerous situations | Patient was prescribed a benzodiazepine for insomnia and told to not drive or operate heavy machinery while taking it. The patient regularly drives after taking the medication. |
| 9. Continued use, even when a psychological or physical problem is caused or worsened by use | Patient who drinks heavily and has increased liver enzymes is told by their physician to decrease or quit drinking. The patient abstains for 4 days but resumes use after a tough day at work. |
| Pharmacologic | |
| 10. Tolerance or needing more of the substance to get the desired effect | Patient had previously found that two oxycodone tablets produced euphoria. Lately, they notice that they need at least four to feel the same effect. They request an early prescription refill. |
| 11. Withdrawal symptoms | Patient has a single alcoholic drink each morning before work to avoid experiencing headaches and a shaky feeling. |
Note: Criteria for substance use disorder are applicable to alcohol, sedatives, hypnotics, anxiolytics, tobacco, and opioids. At least 2 of 11 criteria met in a 1-year period indicates substance use disorder: 2-3 for mild, 4-5 for moderate, ≥ 6 for severe.
DSM-5-TR = Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision.
Information from reference 5.
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