Alcohol Use Disorder (AUD) is a chronic relapsing substance use disorder characterized by impaired control over alcohol consumption, compulsive alcohol use, continued drinking despite harmful consequences, and physiological changes such as tolerance or withdrawal. The disorder results in clinically significant impairment or distress affecting physical, psychological, social, occupational, or academic functioning.

Epidemiology

• Alcohol Use Disorder is among the most common substance use disorders worldwide

• It contributes substantially to preventable morbidity and mortality

• Harmful alcohol use is associated with injuries, liver disease, cardiovascular disease, mental disorders, and increased healthcare utilization

• Men are generally affected more frequently than women, although the prevalence among women is increasing

Risk Factors

• Family history of alcohol use disorder

• Early initiation of alcohol use

• Genetic susceptibility

• Mental health disorders including depression, anxiety disorders, bipolar disorder, and schizophrenia

• Childhood trauma or adverse childhood experiences

• Peer influence

• Stressful life events

• Easy access to alcohol

• Low socioeconomic status

• Coexisting substance use disorders

Pathophysiology

Alcohol stimulates the brain reward pathway by increasing dopamine release within the mesolimbic system. Chronic alcohol use causes neuroadaptation involving gamma-aminobutyric acid (GABA), glutamate, dopamine, serotonin, and endogenous opioid systems. These changes result in tolerance, physical dependence, withdrawal symptoms, impaired impulse control, and compulsive alcohol-seeking behaviour.

Clinical Presentation

Features of Harmful

Alcohol Use

• Recurrent episodes of excessive alcohol consumption

• Craving or strong desire to drink

• Difficulty controlling alcohol intake

• Continued alcohol use despite harmful consequences

• Neglect of work, family, or social responsibilities

• Recurrent interpersonal or occupational problems

• Declining academic or occupational performance

• Risk-taking behaviours while intoxicated

Features of Dependence

• Tolerance

• Withdrawal symptoms

• Drinking to relieve withdrawal symptoms

• Loss of control over alcohol consumption

• Spending excessive time obtaining or consuming alcohol

• Persistent unsuccessful attempts to stop drinking

Withdrawal Symptoms

• Tremor

• Sweating

• Anxiety

• Insomnia

• Nausea and vomiting

• Irritability

• Tachycardia

• Hypertension

• Hallucinations

• Seizures

• Delirium tremens in severe cases

Diagnostic Criteria (DSM-5)

Diagnosis requires a problematic pattern of alcohol use leading to clinically significant impairment or distress, occurring within a 12-month period, with at least two of the following:

• Alcohol is often consumed in larger amounts or over a longer period than intended

• Persistent desire or unsuccessful efforts to reduce or control alcohol use

• A great deal of time is spent obtaining alcohol, drinking, or recovering from its effects

• Craving or a strong desire to use alcohol

• Recurrent alcohol use resulting in failure to fulfil major obligations at work, school, or home

• Continued alcohol use despite persistent or recurrent social or interpersonal problems caused or worsened by alcohol

• Important social, occupational, or recreational activities are reduced or abandoned because of alcohol use

• Recurrent alcohol use in situations where it is physically hazardous

• Continued alcohol use despite knowledge of persistent or recurrent physical or psychological problems likely caused or worsened by alcohol

• Tolerance, defined by either:

  • Need for markedly increased amounts of alcohol to achieve intoxication or desired effect

  • Markedly diminished effect with continued use of the same amount of alcohol

• Withdrawal, manifested by either:

  • Characteristic alcohol withdrawal syndrome

  • Alcohol is consumed to relieve or avoid withdrawal symptoms

Severity

• Mild: 2–3 criteria

• Moderate: 4–5 criteria

• Severe: 6 or more criteria

Differential Diagnosis

• Harmful alcohol use without dependence

• Acute alcohol intoxication

• Alcohol withdrawal syndrome

• Other substance use disorders

• Major depressive disorder

• Bipolar disorder

• Anxiety disorders

• Personality disorders

• Delirium due to medical illness

Investigations

Investigations assess complications, nutritional status, and comorbid medical conditions.

Laboratory Investigations

• Full blood count

• Liver function tests

• Renal function tests

• Blood glucose

• Serum electrolytes

• Coagulation profile where indicated

• Serum magnesium where available

• Blood alcohol concentration when clinically indicated

• Viral hepatitis screening in high-risk individuals

• HIV testing with appropriate counselling and consent

Additional Investigations

• Electrocardiogram when clinically indicated

• Chest radiograph if aspiration pneumonia is suspected

• Brain imaging only if neurological injury or intracranial pathology is suspected

Management

Treatment Goals

• Achieve and maintain abstinence or reduce harmful alcohol consumption

• Manage withdrawal safely

• Prevent relapse

• Treat alcohol-related complications

• Improve physical, psychological, and social functioning

Non-Pharmacological Management

• Assess the patient's readiness to change using the stages of change model

• Use motivational interviewing to enhance motivation and commitment to treatment

• Provide cognitive behavioural therapy

• Offer relapse prevention counselling

• Encourage participation in Alcoholics Anonymous or other peer-support groups

• Involve family members where appropriate

• Address psychosocial problems including housing, employment, and family relationships

• Provide nutritional counselling and encourage healthy lifestyle practices

• Treat coexisting psychiatric disorders

Pharmacological Management

Management of Alcohol Withdrawal

Mild to Moderate Withdrawal

Diazepam 10–20 mg orally every 6–12 hours, gradually reducing the dose over 5–7 days according to clinical response.

OR

Lorazepam 1–4 mg orally every 6–8 hours when diazepam is contraindicated, particularly in older adults or patients with significant liver disease.

Severe Withdrawal

Patients with severe withdrawal, delirium tremens, withdrawal seizures, or severe autonomic instability require admission for close monitoring.

Diazepam 10–20 mg orally or intravenously every 1–4 hours as required until symptoms are controlled, followed by gradual tapering according to clinical response.

Vitamin

Supplementation

Thiamine 100 mg orally daily in patients with adequate oral intake.

For patients at high risk of Wernicke encephalopathy, malnutrition, or severe alcohol dependence, administer thiamine 100 mg intramuscularly or intravenously daily for 3–5 days before glucose-containing fluids whenever possible, followed by oral supplementation.

Supplement folic acid and multivitamins where nutritional deficiencies are suspected.

Long-Term Pharmacological Treatment

Long-term relapse prevention medicines should be initiated only after withdrawal has been successfully managed and where specialist services are available, according to national treatment protocols.

Referral Criteria

Refer to the next level of care if:

• Severe alcohol withdrawal or delirium tremens

• Alcohol withdrawal seizures

• Recurrent withdrawal episodes

• Severe medical complications including liver failure, pancreatitis, or gastrointestinal bleeding

• Significant psychiatric comorbidity

• Suicidal ideation or self-harm risk

• Pregnancy

• Failure of outpatient treatment

• Requirement for inpatient detoxification

• Diagnostic uncertainty

Complications

• Alcohol withdrawal syndrome

• Withdrawal seizures

• Delirium tremens

• Alcoholic liver disease

• Acute and chronic pancreatitis

• Cardiomyopathy

• Peripheral neuropathy

• Wernicke encephalopathy

• Korsakoff syndrome

• Malnutrition

• Depression

• Anxiety disorders

• Suicide

• Road traffic injuries and violence

• Social and occupational dysfunction

Prevention

• Public education regarding harmful alcohol use

• Screening using validated tools such as AUDIT

• Brief interventions for hazardous drinking

• Early treatment of alcohol misuse

• Restricting access to alcohol in accordance with national policies

• Community support programmes

• Management of mental health disorders

Prognosis

The prognosis depends on disease severity, motivation for recovery, social support, and treatment adherence. Early intervention, psychosocial therapy, and sustained follow-up improve long-term abstinence and reduce relapse. Alcohol Use Disorder is a chronic relapsing condition requiring long-term management.

Patient Education

• Alcohol Use Disorder is a treatable chronic medical condition

• Complete abstinence offers the greatest health benefit for most patients with dependence

• Withdrawal symptoms can be life-threatening and should be managed under medical supervision

• Medicines should be taken exactly as prescribed

• Attend counselling sessions and peer-support groups regularly

• Maintain good nutrition and take prescribed vitamin supplements

• Family support improves recovery outcomes

• Seek immediate medical attention if severe withdrawal symptoms, seizures, confusion, or hallucinations occur