Psych · Addiction psychiatry
Alcohol use disorder
Also known as Alcohol dependence · Alcoholism · AUD · Alcohol withdrawal · Delirium tremens · Wernicke encephalopathy alcohol · CIWA-Ar
Exam-exhaustive fellowship topic on alcohol use disorder — DSM-5-TR versus ICD-11 nosology, epidemiology, neurobiology of dependence and withdrawal, AUDIT and CIWA-Ar, withdrawal seizures and delirium tremens, Wernicke–Korsakoff and parenteral thiamine, detox algorithms, naltrexone/acamprosate/disulfiram doses, psychosocial interventions, dual diagnosis, special populations, and multi-board guideline deltas. FRANZCP-primary, globally tagged.
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- Delirium tremens — fluctuating consciousness, severe autonomic hyperactivity, hallucinations after heavy use — medical emergency, not a behavioural problem
- Alcohol withdrawal seizure risk peaks roughly 12–48 hours after last drink; prior seizures or DT mandate supervised detox
- Suspected Wernicke encephalopathy — any two of Caine criteria — give high-dose parenteral thiamine immediately; do not wait for the classic triad
- Glucose without concurrent thiamine in a malnourished dependent drinker risks precipitating or worsening Wernicke encephalopathy
- Starting naltrexone while opioids are still on board — precipitate opioid withdrawal and block emergency analgesia
- Unsupervised disulfiram with ongoing drinking or alcohol-containing products — severe aversive reaction and cardiac risk
- Suicide risk spikes in intoxication, early abstinence, and dual diagnosis — always assess
Meet the patient
A 54-year-old carpenter is admitted on Thursday evening with a fractured wrist. The orthopaedic clerking records "social drinker". Nobody writes down when he last had a drink.[9][12]
Saturday morning he is soaked in sweat, pulse 128, blood pressure 178/100, disoriented, pulling at his cannula and telling the nurse there are insects on the curtain.[9][12]
Nothing about him changed. What changed is a clock nobody started. The single most valuable question in this whole topic is "when was your last drink?" — and the examiner will ask you why it matters.[9][12]
Examiners punish three failures on this topic, reliably: thin nosology (DSM versus ICD mixed together), an incomplete grip on the withdrawal and Wernicke emergencies, and vague pharmacology with no agent, dose, route, monitoring or contraindication.[4][6][12]
References20ShowHide
- [1]Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict, 1989.PMID 2597811
- [2]Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA, 2006.PMID 16670409
- [3]Caine D, Halliday GM, Kril JJ, et al. Operational criteria for the classification of chronic alcoholics: identification of Wernicke's encephalopathy. J Neurol Neurosurg Psychiatry, 1997.PMID 9010400
- [4]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. Am J Psychiatry, 2018.PMID 29301420
- [5]Maisel NC, Blodgett JC, Wilbourne PL, et al. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction, 2013.PMID 23075288
- [6]Knox J, Hasin DS, Larson FRR, et al. Prevention, screening, and treatment for heavy drinking and alcohol use disorder. Lancet Psychiatry, 2019.PMID 31630982
- [7]Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA, 2014.PMID 24825644
- [8]Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry, 2015.PMID 26039070
- [9]Mayo-Smith MF Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA, 1997.PMID 9214531
- [10]Volpicelli JR, Alterman AI, Hayashida M, et al. Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry, 1992.PMID 1345133
- [11]Day E, Bentham PW, Callaghan R, et al. Thiamine for prevention and treatment of Wernicke-Korsakoff Syndrome in people who abuse alcohol. Cochrane Database Syst Rev, 2013.PMID 23818100
- [12]Connor JP, Haber PS, Hall WD Alcohol use disorders. Lancet, 2016.PMID 26343838
- [13]Thomson AD, Cook CC, Touquet R, et al. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and Emergency Department. Alcohol Alcohol, 2002.PMID 12414541
- [14]Rösner S, Hackl-Herrwerth A, Leucht S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev, 2010.PMID 20824837
- [15]Garbutt JC, Kranzler HR, O'Malley SS, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA, 2005.PMID 15811981
- [16]Saunders JB, Aasland OG, Babor TF, et al. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption--II. Addiction, 1993.PMID 8329970
- [17]Galvin R, Bråthen G, Ivashynka A, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol, 2010.PMID 20642790
- [18]Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med, 2002.PMID 12020181
- [19]Amato L, Minozzi S, Vecchi S, et al. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev, 2010.PMID 20238336
- [20]Fuller RK, Gordis E Does disulfiram have a role in alcoholism treatment today? Addiction, 2004.PMID 14678055