Alcoholism (Alcohol Use Disorder)

What alcohol use disorder is

Doctors no longer divide people into "alcoholics" and "non-alcoholics". Alcohol use disorder is a spectrum. Repeated heavy drinking changes the brain's reward, stress and self-control systems, making it progressively harder to stop even when drinking causes harm. This is why AUD is considered a medical condition, not a lack of willpower.

In the US, NIAAA defines heavy drinking as more than 4 drinks on any day or 14 a week for men, and more than 3 drinks on any day or 7 a week for women. A standard drink is 14 grams of alcohol: 12 oz (355 ml) of regular beer, 5 oz (150 ml) of wine, or 1.5 oz (44 ml) of spirits.

Signs and symptoms

The DSM-5-TR lists 11 criteria. Having 2 or more in the past 12 months indicates AUD:

1. Drinking more, or for longer, than you intended
2. Wanting to cut down or stop, but not managing to
3. Spending a lot of time drinking, getting alcohol or recovering
4. Cravings or strong urges to drink
5. Drinking interfering with home, work or school responsibilities
6. Continuing to drink despite relationship problems it causes
7. Giving up activities you used to enjoy in order to drink
8. Drinking in dangerous situations, such as driving or swimming
9. Continuing to drink despite depression, anxiety, health problems or blackouts it causes
10. Tolerance: needing more alcohol for the same effect
11. Withdrawal: shakiness, sweating, nausea, racing heart, anxiety or sleep problems when alcohol wears off, or drinking to avoid them

Other signs family members may notice include hiding alcohol, drinking alone or early in the day, mood swings, irritability, missed commitments, and frequent minor injuries.

Causes and risk factors

• Genetics: family history accounts for about half of the risk.
• Starting young: drinking before age 15 greatly increases later risk.
• Mental health conditions: depression, anxiety, PTSD, bipolar disorder and ADHD.
• Trauma and adverse childhood experiences.
• Social environment: heavy-drinking peers, easy access, stress, isolation.
• Pattern of drinking: frequent binge drinking.

Health effects

Long-term heavy drinking affects nearly every organ:

• Liver: fatty liver, alcoholic hepatitis and cirrhosis
• Pancreas: acute and chronic pancreatitis
• Heart and blood vessels: high blood pressure, atrial fibrillation, cardiomyopathy and stroke
• Brain and nerves: memory problems, Wernicke encephalopathy and Korsakoff syndrome from thiamine deficiency, neuropathy and cerebellar degeneration
• Cancer: mouth, throat, esophagus, liver, colon and breast cancers
• Stomach: gastritis, ulcers and bleeding
• Mental health: depression, anxiety, insomnia and higher suicide risk
• Pregnancy: fetal alcohol spectrum disorders
• Injuries: falls, road crashes, violence and burns

Alcohol withdrawal

People who drink heavily every day can develop alcohol withdrawal when they stop or cut down sharply:

Diagnosis

A primary care doctor can screen for unhealthy drinking with short questionnaires such as AUDIT-C. They will ask about how much and how often you drink, the 11 criteria above, past withdrawal and other substances. Blood tests (liver enzymes, a full blood count with red cell size, and sometimes phosphatidylethanol) and an examination check for alcohol-related health effects.

Treatment

Treatment is tailored to severity and goals, which may be stopping completely or, for some people with milder AUD, cutting down.

Medically managed withdrawal

Detox treats withdrawal symptoms safely. It is the first step, not the whole treatment.

Medicines

FDA-approved medicines reduce cravings and relapse and are underused:

• Naltrexone: reduces the rewarding effect of alcohol and heavy drinking days. Available as a daily tablet or monthly injection. Not suitable for people taking opioids.
• Acamprosate: helps maintain abstinence after stopping. Needs dose adjustment in kidney disease.
• Disulfiram: causes an unpleasant reaction if alcohol is consumed. Works best with supervised dosing.

Other medicines such as topiramate and gabapentin are sometimes used off-label.

Behavioral treatments

• Cognitive behavioral therapy: identifies triggers and builds coping skills.
• Motivational enhancement therapy: strengthens motivation to change.
• Contingency management and couples or family therapy.
• Brief interventions by primary care for milder drinking problems.

Support and rehabilitation

• Mutual support groups: Alcoholics Anonymous, SMART Recovery and others.
• Outpatient, intensive outpatient and residential programs for moderate to severe AUD.
• Treating co-occurring mental health conditions improves outcomes.
• Thiamine supplements to protect the brain.

Outlook and recovery

AUD is a chronic condition, and relapse is common, especially in the first year, but it is part of recovery rather than failure. About a third of people who receive treatment have no further symptoms 1 year later, and many more significantly reduce their drinking and its harms. Liver, heart and brain function often improve after stopping, though cirrhosis and some nerve damage may be permanent.

Helping someone with a drinking problem

• Choose a calm, sober moment to talk, and describe specific behaviors and your concern.
• Avoid labels, blame or threats you will not follow through on.
• Offer to help find a doctor, counselor or support group.
• Look after yourself: Al-Anon and similar groups support family members.
• Call 911 for signs of alcohol poisoning or severe withdrawal.

Frequently asked questions

What are the signs of alcoholism?

Common signs include cravings, drinking more than intended, failed attempts to cut down, tolerance, withdrawal symptoms such as shaking or sweating, neglecting responsibilities, giving up activities, and continuing to drink despite problems. Two or more signs in a year suggest alcohol use disorder.

Is alcoholism the same as alcohol use disorder?

Yes, in everyday language. "Alcohol use disorder" is the current medical term. It covers mild, moderate and severe forms, while "alcoholism" usually refers to the more severe end.

Is it dangerous to stop drinking suddenly?

It can be for people who drink heavily every day. Withdrawal can cause seizures and delirium tremens, which can be fatal. Speak to a doctor before stopping, so withdrawal can be managed safely with medicines if needed.

What is the best treatment for alcoholism?

The most effective approach combines medicines such as naltrexone or acamprosate with counseling and ongoing support. Treatment is tailored to the person, and treating depression, anxiety or other conditions at the same time improves results.

Can alcohol use disorder be cured?

It is usually viewed as a long-term condition that can go into lasting remission. Many people recover fully and stay alcohol-free or drink safely for life. Ongoing support, recognizing triggers and early help after a slip all reduce the risk of relapse.