Behavioral Health

Alcohol use disorder: How best to screen and intervene

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The USPSTF recommends the AUDIT, the AUDIT-C, or the single-question NIAAA screen. The CAGE screening tool has low sensitivity at lower levels of alcohol intake.




Ms. E, a 42-year-old woman, visited her new physician for a physical exam. When asked about alcohol intake, she reported that she drank 3 to 4 beers after work and sometimes 5 to 8 beers a day on the weekends. Occasionally, she exceeded those amounts, but she didn’t feel guilty about her drinking. She was often late to work and said her relationship with her boyfriend was strained. A review of systems was positive for fatigue, poor concentration, abdominal pain, and weight gain. Her body mass index was 41, pulse 100 beats/min, blood pressure 125/75 mm Hg, and she was afebrile. Her physical exam was otherwise within normal limits.

How would you proceed with this patient?

Alcohol use disorder (AUD) is a common and often untreated condition that is increasingly prevalent in the United States.1 The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) characterizes AUD as a combination of signs and symptoms typifying alcohol abuse and dependence (discussed in a bit).2

Data from the 2015 National Survey on Drug Use and Health (NSDUH) showed 15.7 million Americans with AUD, affecting 6.2% of the population ages 18 years or older and 2.5% of adolescents ages 12 to 17 years.3

Alcohol use and AUD account for an estimated 3.8% of all global deaths and 4.6% of global disability-adjusted life years.4 AUD adversely affects several systems (TABLE 15), and patients with AUD are sicker and more likely to die younger than those without AUD.4 In the United States, prevalence of AUD has increased in recent years among women, older adults, racial minorities, and individuals with a low education level.6

Complications of alcohol use disorder

Screening for AUD is reasonable and straightforward, although diagnosis and treatment of AUD in primary care settings may be challenging due to competing clinical priorities; lack of training, resources, and support; and skepticism about the efficacy of behavioral and pharmacologic treatments.7,8 However, family physicians are in an excellent position to diagnose and help address the complex biopsychosocial needs of patients with AUD, often in collaboration with colleagues and community organizations.

Signs and symptoms of AUD

In clinical practice, at least 2 of the following 11 behaviors or symptoms are required to diagnose AUD2:

  • consuming larger amounts of alcohol over a longer period than intended
  • persistent desire or unsuccessful efforts to cut down or control alcohol use
  • making a significant effort to obtain, use, or recover from alcohol

In moderate-to-severe cases:

  • cravings or urges to use alcohol
  • recurrent failure to fulfill major work, school, or social obligations
  • continued alcohol use despite recurrent social and interpersonal problems
  • giving up social, occupational, and recreational activities due to alcohol
  • using alcohol in physically dangerous situations
  • continued alcohol use despite having physical or psychological problems
  • tolerance to alcohol’s effects
  • withdrawal symptoms.

Continue to: Patients meet criteria for mild AUD severity if...


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