Guideline sources The following summarized guidelines for the evaluation and management of alcohol use disorder are prepared by our editorial team based on guidelines from the French Society of Alcohology (SFA/AFEF 2022), the American Association for the Surgery of Trauma (AAST 2022), the United States Department of Defense (DoD/VA 2021), the American Association for the Study of Liver Diseases (AASLD 2020), the American Psychiatric Association (APA 2018), the European Association for the Study of the Liver (EASL 2018), the U.S. Preventive Services Task Force (USPSTF 2018), and the American College of Gastroenterology (ACG 2018). 1 2 3 4 5 6 7 8 9 10 11 12 Definition AUD is defined in DSM-5 as a pattern of alcohol consumption leading to problems associated with two or more potential symptoms of tolerance, withdrawal, increased amount of alcohol consumed https://web.pathway.md/diseases/recK68bWnZmuq5dMC 1/8 6/23/23, 2:17 AM Alcohol use disorder Pathway over time, difficulty in controlling drinking, neglect of activities, ineffective efforts to reduce use, craving, failure to fulfil major role obligations, recurrent alcohol use in hazardous situations, time spent drinking or recovering from alcohol, and drinking despite physical/psychological problems in the past year. 9 Epidemiology AUD is caused due to genetic, psychological, and environmental factors. 10 Disease course The neurobiological disturbances due to habitual drinking cause AUD, which increases the risk of damage to the gastrointestinal, cardiovascular, immune, nervous, and other systems. AUD causes increased morbidity and mortality. 11 Prognosis and risk of recurrence AUD is associated with increased mortality from all causes of death (mortality rate ratio, 3.0-5.2). 12 Calculator Calculator AUDIT C for alcohol use CAGE questionnaire for alcohol Guidelines 1. Screening and diagnosis Definition: use the term AUD (defined by DSM-V criteria) in preference to alcoholic, alcohol abuse, alcohol dependence or risky drinker. A Indications for screening: As per AFEF 2022 guidelines, obtain systematic assessment of alcohol consumption in both general practice and specialist consultations. A Show 3 more As per AASLD 2020 guidelines, obtain routine screening for alcohol use using validated questionnaires in all patients receiving care in primary care and gastroenterology/hepatology outpatient clinics, emergency departments, and inpatient admissions. E As per ACG 2018 guidelines, use the AUDs Inventory Test to identify patients with alcohol use and dependence. E As per EASL 2018 guidelines: Screen patients for harmful alcohol consumption by general practitioners and in emergency departments. B https://web.pathway.md/diseases/recK68bWnZmuq5dMC 2/8 6/23/23, 2:17 AM Alcohol use disorder Pathway Use the AUDs Inventory Test or AUDs Inventory Test-Concise to screen patients for AUD and dependence. A As per USPSTF 2018 guidelines: Screen for unhealthy alcohol use in primary care settings in 18 years old adult patients, including pregnant females. B Insufficient evidence to recommend screening for alcohol use in primary care settings in 12-17 years old adolescent patients. I 2. Diagnostic investigations Initial evaluation: As per ACG 2018 guidelines, obtain LFTs and abdominal ultrasound in patients with harmful alcohol use and/or AUDs. E As per APA 2018 guidelines, consider obtaining physiological biomarkers to identify persistently elevated levels of alcohol consumption in the initial evaluation of patients with AUD or in the treatment of patients requiring ongoing monitoring of alcohol use. C Psychiatric evaluation: Assess for current and past use of tobacco and alcohol and any misuse of other substances, including prescribed or OTC medications and supplements, in the initial psychiatric evaluation of patients with suspected AUD. B Obtain quantitative behavioral measurement to detect alcohol misuse and assess its severity in the initial psychiatric evaluation of patients with suspected AUD. B Screening for alcohol-related liver disease: screen for ALD in high-risk populations, such as patients in alcohol rehabilitation clinics, or patients with harmful drinking identified by their general practitioner. B Show 2 more Screening for comorbidities: As per APA 2018 guidelines, evaluate for co-occurring conditions, including substance use disorders, other psychiatric disorders, and other medical disorders that may influence the selection of pharmacotherapy in patients with AUD. B As per EASL 2018 guidelines, screen patients with AUD for concurrent psychiatric disorders and other addictions. A 3. Medical management General principles: ensure a documented comprehensive and person-centered treatment plan including evidence-based nonpharmacological and pharmacological therapies for patients with AUD. B Goals of treatment: https://web.pathway.md/diseases/recK68bWnZmuq5dMC 3/8 6/23/23, 2:17 AM Alcohol use disorder Pathway Consider setting the initial goals of treatment of AUD (such as abstinence from alcohol use, reduction or moderation of alcohol use, other elements of harm reduction) agreed on between the patient and clinician and documented this agreement in the medical records. C Consider including the following discussions in the initial treatment goals and document these in the medical record: patient's legal obligations, such as abstinence from alcohol use, monitoring of abstinence risks to self from continued use of alcohol, such as physical health, occupational functioning, legal involvement risk to others from continued use of alcohol, such as impaired driving. C Naltrexone: do not use naltrexone in patients with AUD using opioids or having an anticipated need for opioids. D Show 3 more Acamprosate: Consider offering acamprosate in patients with moderate-to-severe AUD: having a goal of reducing alcohol consumption or achieving abstinence preferring pharmacotherapy or not responding to nonpharmacological treatments alone not having contraindications to the use of acamprosate. B Show 2 more Disulfiram: Consider offering disulfiram in patients with moderate-to-severe AUD: having a goal of achieving abstinence preferring disulfiram or intolerant to or not responding to naltrexone and acamprosate capable of understanding the risks of alcohol consumption while taking disulfiram not having contraindications to the use of disulfiram. C Anticonvulsants: Consider offering topiramate or gabapentin in patients with moderate-to-severe AUD: having a goal of reducing alcohol consumption or achieving abstinence preferring topiramate or gabapentin or intolerant to or not responding to naltrexone and acamprosate not having contraindications to the use of these medications. C Benzodiazepines: As per AFEF 2022 guidelines, offer benzodiazepines for the treatment of alcohol withdrawal syndrome until symptoms disappear. A As per ACG 2018 guidelines, offer benzodiazepines as the treatment of choice in patients with severe alcohol withdrawal syndrome and ALD. E As per APA 2018 guidelines, do not use benzodiazepines in patients with AUD unless for the treatment of acute alcohol withdrawal or a co-occurring disorder for which a benzodiazepine is indicated. D As per EASL 2018 guidelines, offer benzodiazepines for the treatment of alcohol withdrawal syndrome but not beyond 10-14 days because of the potential for abuse and/or encephalopathy. https://web.pathway.md/diseases/recK68bWnZmuq5dMC 4/8 6/23/23, 2:17 AM Alcohol use disorder Pathway A Antidepressants: do not use antidepressants in patients with AUD unless there is evidence of a co-occurring disorder for which an antidepressant is indicated. D Baclofen: As per AASLD 2020 guidelines, consider offering acamprosate or baclofen for the treatment of AUD in patients with ALD. E As per ACG 2018 guidelines, consider offering baclofen for the prevention of alcohol relapse in patients with ALD. C 4. Inpatient care Prevention of alcohol withdrawal syndrome in ICU: screen patients within 6-24 hours of discontinuation of alcohol consumption. Consider obtaining blood alcohol level as an initial screen, although subjective scoring systems (such as the AUDs Identification Test, the PAWSS) have higher sensitivity and specificity for the prediction of alcohol withdrawal syndrome. E Show 8 more 5. Nonpharmacologic interventions Brief behavioral intervention: As per AFEF 2022 guidelines, offer brief behavioral intervention in patients identified as alcohol misusers. Ensure that all practitioners are able to carry out this brief intervention. A As per AASLD 2020 guidelines, offer brief intervention in patients engaged in hazardous drinking (AUDIT-C 4, AUDIT > 8, binge drinkers). E As per USPSTF 2018 guidelines: Provide brief behavioral counseling interventions to reduce unhealthy alcohol use in persons engaged in risky or hazardous drinking. B Insufficient evidence to recommend brief behavioral counseling interventions for alcohol use in primary care settings in 12-17 years old adolescent patients. I Mindfulness-based therapies: insufficient evidence to recommend for or against mindfulness- based therapies in patients with AUD. I Technology-based interventions: consider implementing structured telephone-based care as an adjunct to usual care in patients with AUD. C Show 2 more 6. Specific circumstances Pregnant and breastfeeding patients: do not offer pharmacological treatment in pregnant and breastfeeding patients with AUD unless for the treatment of acute alcohol withdrawal with https://web.pathway.md/diseases/recK68bWnZmuq5dMC 5/8 6/23/23, 2:17 AM Alcohol use disorder Pathway benzodiazepines or a co-occurring disorder requiring pharmacotherapy. D 7. Patient education General counseling: counsel patients with heavy alcohol use (> 3 drinks per day in males and > 2 drinks per day in females for > 5 years) that they are at an increased risk for liver disease. B 8. Preventative measures Alcohol restriction: As per AFEF 2022 guidelines, consider advising alcohol consumption of 10 standard drinks per week in the general population to avoid overall health risks. C Show 2 more As per AASLD 2020 guidelines, counsel patients without liver disease about safe levels of alcohol use for males ( 2 standard drinks per 24 hours) and females ( 1 standard drink per 24 hours). E 9. Follow-up and surveillance Monitoring of abstinence: consider obtaining hair or urine ethyl glucuronide for accurate monitoring of abstinence in patients with ALD. B 10. Quality improvement Public health measures: As per AFEF 2022 guidelines, disseminate information to the general population on the risks associated with binge drinking, particularly in terms of cardiovascular morbidity and mortality and physical and psychological injuries. A As per EASL 2018 guidelines, address excess alcohol consumption using pricing-based policies and regulation of availability. A Show 3 more Likelihood Ratios Pertinent positives The following findings increase the probability of alcohol use disorder in adults. -1 Finding LR+ Value Presence of AUDIT or AUDIT-C score 8 6.8-12 (8-12) https://web.pathway.md/diseases/recK68bWnZmuq5dMC 6/8 6/23/23, 2:17 AM Alcohol use disorder Pathway Pertinent negatives The following findings decrease the probability of alcohol use disorder in adults. -1 Finding LR- Value Absence of AUDIT or AUDIT-C score 8 0.46-0.62 References 1. Alexandre Louvet, Jean-Baptiste Trabut, Christophe Moreno et al. 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