Alcohol use disorder

Background
  • Chronic mental illness characterized by inability to limit alcohol ingestion, compulsive drinking, and a negative emotional state when not drinking.
  • Previously separated into alcohol abuse and alcohol dependence, but as of DSM-5, the diagnoses were combined into alcohol use disorder, and subdivided into mild, moderate, or severe.
  • It is estimated that about 6% of adults in the US suffer from alcohol use disorder.

Clinical Features
  • Drinking more or for a longer period of time than intended.
  • Feeling incapable of cutting back on the amount of alcohol consumed.
  • Becoming sick for an extended period of time as a result of drinking too much.
  • Inability to concentrate due to alcohol cravings.
  • Inability to care for a family, hold down a job, or perform in school.
  • Continuing to drink despite problems caused with friends or family.
  • Decreased participation in activities which were once important.
  • Finding oneself in dangerous or harmful situations as a direct result of drinking.
  • Continuing to drink despite adding to another health problem, feeling depressed or anxious or blacking out.
  • Drinking more as a result of a tolerance to alcohol.
  • Experiencing withdrawal symptoms.
Mild = 2-3 features
Moderate = 4-5 features
Severe = 6 or more features

Differential Diagnosis

Evaluation
  • A history alone is sufficient to make the diagnosis of alcohol use disorder, however, if a patient presents to the ER, it is important to evaluate for the presence of acute alcohol intoxication, alcohol withdrawal, and co-ingestion with other drugs or toxic alcohols.

Management
  • If the patient is not acutely intoxicated or at risk for alcohol withdrawal, they should be referred to a social worker or their PCP for resources to quit drinking and can usually be discharged safely.

Dilsulfiram
  • Disulfiram can be prescribed as alcohol avoidance therapy. This can be prescribed in the emergency department or referred to PCP/psychiatrist treating the patient's addiction.

Evidence:
    • A Cochrane review assessed the efficacy of naltrexone in randomized control trials.[1]
    • Naltrexone helps to reduce the number of participants who relapse or return to heavy drinking in a short time frame following treatment (12 weeks).
    • Naltrexone reduces the time in days to first drink when compared to placebo or disulfiram.
    • Naltrexone reduces reported cravings and the total amount of alcohol consumed.
    • Naltrexone should be offered to patients with alcohol use disorder who are interested in reducing alcohol intake.

Dosage:
    • Naltrexone 380 mg IM or Naltrexone 50 mg PO qday #30 tabs, no refills

Contraindications for use in AUD:

    • Any opioid use (including Buprenorphine):
      • Must be off short-acting opioids for 1 week and methadone for 2 weeks
    • Planned surgery/anesthesia in next 30 days (okay to use tablets, stop 1 day prior to surgery)
    • Acute liver injury with AST or ALT >/= 250 or decompensated cirrhosis (Childs Pugh Class 3)
    • Pregnancy
    • Allergy

Evidence:
    • A metanalysis of several randomized control trials demonstrates that use of gabapentin for alcohol use disorder reduces the number of total heavy drinking days. [2]
    • Furthermore, the addition of gabapentin to naltrexone further helped to reduce cravings in the first 6 weeks of AUD. [3]

Dosage
    • Gabapentin 600 mg PO TID #90 tabs, no refills
      • counsel to decrease to 300 mg PO TID if dizzy, can increase after 1 week
      • renally dosed if CrCl<60
      • ACOG approves of use in pregnancy


Vitamin Prophylaxis for Chronic alcoholics
  • At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
  • Give multivitamin PO; patient at risk for other vitamin deficiencies

Banana bag

The majority of chronic alcoholics do NOT require a banana bag[4][5]

  • Thiamine 100mg IV
  • Folate 1mg IV (cheaper PO)
  • Multivitamin 1 tab IV (cheaper PO)
  • Magnesium sulfate 2mg IV
  • Normal saline as needed for hydration

Disposition
  • Outpatient

See Also



References
  1. Srisurapanont M, Jarusuraisin N. Opioid antagonists for alcohol dependence. Cochrane Database of Systematic Reviews. 2005;(1).
  2. Kranzler HR, Feinn R, Morris P, Hartwell EE. A meta-analysis of the efficacy of gabapentin for treating alcohol use disorder. Addiction. 2019;114(9):1547-1555.
  3. Anton RF, Myrick H, Wright TM, Latham PK, Baros AM, Waid LR, Randall PK. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatry. 2011 Jul;168(7):709-17. doi: 10.1176/appi.ajp.2011.10101436. Epub 2011 Mar 31. PMID: 21454917; PMCID: PMC3204582.
  4. Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  5. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.
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