Approach
Alcohol-related problems are a significant source of morbidity and mortality. Early identification of unhealthy alcohol use can reduce morbidity and mortality. Routine screening for unhealthy alcohol use may help clinicians identify unhealthy alcohol use, perform brief interventions for those with at-risk use, and treat alcohol-use disorder. Characteristic history, examination findings, and laboratory studies can be helpful in diagnosing alcohol-use disorder.
History/interview
When discussing alcohol use, the way a clinician asks a question affects a patient’s answer. Patients may be anxious about discussing the subject, and clinicians may be reluctant to upset the patient or not know how to approach the conversation. Researchers have categorised four types of questions commonly asked when discussing substance use: open-ended ('Tell me about your drinking'); normalising ('When was the last time you drank?'); closed-ended ('Do you drink?'); and leading towards non-use ('Now you’re not drinking are you?').[33] Open-ended and normalising questions had the greatest sensitivity, while closed-ended and leading questions missed more than 50% of patients who were using substances. In addition, it is important to use person-first and non-stigmatising language (e.g., person with alcohol-use disorder and not alcoholic, addict, or drinker) to obtain the best history and approach conversations related to substances without judgement.
Validated screenings that are sensitive and specific for unhealthy alcohol use include the single question unhealthy alcohol use screener and the Alcohol Use Disorders Identification Test (AUDIT).[34] The single question screener has been validated in primary care settings and asks how many times in the past year someone has had 4 drinks (for women) or 5 drinks (for men). Any answer other than 0 is considered consistent with unhealthy alcohol use. The AUDIT is a 10-question screener developed by the World Health Organization, which has been translated into many different languages.[35] [ Alcohol Consumption Screening AUDIT Questionnaire Opens in new window ] A score of 8-15 may indicate at-risk alcohol use, 16-19 mild alcohol-use disorder, and ≥20 probable moderate to severe alcohol-use disorder. A shorter three-question version of the test, the AUDIT-C, is also sensitive and specific for unhealthy alcohol use screening.[36]
For patients with unhealthy alcohol use or with suspected alcohol-use disorder an interview using the DSM-5-TR criteria is used to diagnose alcohol-use disorder.[3] See Criteria.
The Structured Clinical Interview for DSM (SCID) can assist in the diagnostic assessment.[37] Enquire about: frequency of alcohol use; number and type of drinks; time spent obtaining, using, and recovering from the effects of alcohol; desire or efforts to cut down on alcohol use; any attempts to reduce or stop alcohol use; use of alcohol in hazardous situations; effects of alcohol on social, occupational, and recreational activities; effects on interpersonal relationships; ability to fulfil obligations at home and work; any physical or psychological problems that might be caused by, or exacerbated by alcohol use; and symptoms of tolerance or withdrawal.
Enquire about symptoms of other psychiatric conditions and other substance use. Alcohol-use disorder is associated with increased risk of substance use disorders, major depression, bipolar affective disorder, antisocial personality disorder, borderline personality disorder, generalised anxiety disorder, specific phobia, and panic disorder.[7]
Physical examination
While the diagnosis of alcohol-use disorder is made by a comprehensive and compassionate history, physical examination can help establish stigmata of alcohol use.
Vital signs may reveal tachycardia and/or hypertension.
When cirrhosis due to alcohol intake has occurred, other features can be present, including underweight status/anorexia; jaundice; enlarged, tender liver or diminished liver size; and ascites.
Indicators of neurological damage related to alcohol use may be present in heavy use. These may include altered sensation (peripheral neuropathy, particularly in lower extremities), muscle tenderness to palpation (myopathy), and a broad-based gait.
For patients with elevated vital sign measures and a recent period of decreased alcohol use, evaluating for withdrawal is indicated. The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is the standard assessment instrument used to quantify the severity of alcohol withdrawal symptoms.[38]
Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA- Ar)
Opens in new window Patients with a CIWA-Ar score of 8-10 or higher are usually treated with pharmacological agents to diminish the intensity of the alcohol withdrawal syndrome.
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See Alcohol withdrawal (Management).
Laboratory studies
There are no laboratory tests to diagnose alcohol-use disorder. However, several tests can be useful in identifying alcohol-related sequelae and for following patient progress. Given that no laboratory test is diagnostic, a history is always indicated.
Alcohol (ethanol) levels in blood, breath, or other body fluids can provide information about current blood alcohol concentrations.[39] A high blood alcohol concentration (e.g., >200 mg/dL) with minimal signs of intoxication may indicate tolerance to alcohol effects, but does not diagnose alcohol-use disorder.
Several tests can indicate cumulative alcohol exposure over longer time periods. Liver function tests (alanine aminotransferase [ALT], aspartate aminotransferase [AST], and gamma glutamyl transpeptidase [gamma-GT]) may be useful for assessing liver damage. Elevated gamma-GT, in particular, correlates with alcohol consumption and is sometimes used to monitor drinking behaviour. In the authors’ experience, gamma-GT should normalise within 2-6 weeks of abstinence, while AST and ALT remain elevated for variable amounts of time and may not return to baseline.
Urine ethyl glucuronide testing by liquid chromatography-mass spectrometry can detect very small levels of alcohol in the urine within several days of consumption, but incidental use of alcohol-containing products (e.g., hand sanitisers, cosmetics, etc.) can lead to false positives.[40]
A full blood count can assess alcohol-related bone marrow suppression, particularly macrocytosis.
The most sensitive test for heavy drinking is carbohydrate-deficient transferrin (CDT), which utilises alcohol inhibition of the transfer of sugars to glycoproteins.[41] CDT is less sensitive in women.
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