ICD-116C40	DISORDERS DUE TO USE OF ALCOHOL Disorders due to use of alcohol
ICD-10F10	Mental and behavioural disorders due to use of alcohol
DSM-5-TRF10.20	Alcohol Use Disorder, Moderate or Severe

1. Definition and nosology

Alcohol Use Disorders (ICD-11: 6C40; DSM-5-TR: F10.20 Alcohol Use Disorder, AUD) — a group of disorders characterized by impaired control over alcohol use, continued use despite physical or psychological harm. ICD-11 subtypes: harmful pattern of use (6C40.1), alcohol dependence (6C40.2), intoxication (6C40.3), withdrawal syndrome (6C40.4), alcohol-induced delirium, psychotic, mood, anxiety disorders.

2. History

• Jellinek E.M. (1960) — ‘The Disease Concept of Alcoholism’ — alcoholism as a disease.
• DSM-IV — ‘Abuse’ and ‘Dependence’ as separate categories.
• DSM-5 (2013) — unified ‘Alcohol Use Disorder’ (mild, moderate, severe).
• ICD-11 — episodic harmful use or addiction pattern separated.

3. Epidemiology

• Lifetime prevalence: 14–29% (NIAAA NESARC); annual 5–14%.
• Sex: 2–3 times higher in males, but increasing in females.
• Mortality: 3 million deaths per year worldwide (WHO).
• Comorbidity: MDD, anxiety, PTSD, BPD, other substance use, liver disease, cardiovascular.

4. Aetiology and pathogenesis

• Heritability ~49% (95% CI 43–53) (Verhulst B. et al. Psychol Med 2015).
• Neurobiological — dopamine reward circuit, GABA, glutamate, opioid systems.
• Environment — peers, stress, alcohol availability, cultural norms.
• Genetic markers — ADH1B, ALDH2 (protective in Asian population).

5. Clinical features

5.1 Dependence syndrome (DSM-5-TR criteria, ≥ 2 out of 11)

• More/prolonged use;
• Attempts to reduce are unsuccessful;
• Most time spent obtaining, using, recovering from substance
• Craving;
• Work/school disruption;
• Continues despite social-interpersonal problem.
• Refusal of important activities;
• Use in a dangerous situation;
• Continuation despite physical/psychological problem;
• Tolerance;
• Withdrawal syndrome.

5.2 Intoxication

• Disinhibition, dysarthria, ataxia, nystagmus, cognitive impairment.
• Severe intoxication — coma, respiratory depression, hypoglycemia, death.

5.3 Withdrawal

• Mild: tremor, sweating, tachycardia, anxiety, nausea (6–24 hours after last drink).
• Moderate: autonomic hyperactivity, hallucinations (alcoholic hallucinosis).
• Severe: delirium tremens (DT) — 48–96 hours; altered consciousness, hallucinations, autonomic crisis; mortality ~1–4% among hospitalised patients (Schuckit M.A. N Engl J Med 2014); substantially higher in historical untreated series; seizures.

5.4 Complications

• Wernicke-Korsakoff (B1 deficiency), alcoholic liver disease, cardiomyopathy, polyneuropathy, FAS during pregnancy.

6. Diagnosis

6.1 Unified diagnostic criteria

DSM-5-TR — ≥2 of 11 criteria (mild 2–3, moderate 4–5, severe ≥6); ICD-11 — pattern of use (single episode of harmful use, harmful pattern of use, dependence); hazardous use belongs to QE10, not to 6C4x. ICD-11 duration requirement: harmful pattern of use — at least 12 months if use is episodic, at least 1 month if continuous; dependence — at least 12 months, or at least 3 months if use is continuous (daily or almost daily).

6.2 Source-specific clarifications

• WHO AUDIT (Saunders 1993) — 10-item screening.
• NICE CG115 — diagnosis and treatment of alcohol disorders.
• SAMHSA TIP — international protocols.

6.3 Diagnostic algorithm

1. AUDIT, AUDIT-C screening at primary care level.
2. Clinical interview — TLFB (Timeline Followback) use pattern.
3. Laboratory: GGT, AST/ALT, MCV, CDT (carbohydrate-deficient transferrin), complete blood count.
4. Comorbidity (MDD, anxiety, PTSD, somatic illnesses).
5. Withdrawal risk (CIWA-Ar).

6.4 Differential diagnosis

7. Examination and assessment

• AUDIT, CIWA-Ar (withdrawal severity).
• GGT, MCV, CDT, transaminases.
• Thiamine level.
• EKG, cardiac USG (cardiomyopathy).
• Comorbidity screening.

8. Treatment

8.1 General principles (NICE CG115 · SAMHSA TIP 49 · APA 2018)

1. Detoxification:
   • Mild (CIWA-Ar <10) — outpatient;
   • Moderate-severe — inpatient (hospitalization);
   • Benzodiazepine (lorazepam, diazepam) — gold standard for withdrawal treatment;
   • Thiamine 100–300 mg IV/IM × 3–5 days (Wernicke prophylaxis — BEFORE glucose).
   • Hydration, electrolyte correction.
2. Pharmacotherapy for relapse prevention:
   • Naltrexone (oral 50 mg or IM Vivitrol 380 mg monthly) — first-line; reduces cravings.
   • Acamprosate (666 mg × 3 times/day) — first line; maintenance of abstinence.
   • Disulfiram — second-line; in motivated patient; aversive reaction.
   • Topiramate, gabapentin — off-label.
3. Psychosocial: Motivational Interviewing (MI), CBT, 12-Step facilitation (AA, NA), contingency management.
4. SAMHSA — co-occurring substance use disorder and psychiatric comorbidity (dual diagnosis).
5. Long-term relapse prophylaxis.

8.2 Source-specific clarifications

• NICE CG115 (2011).
• APA Practice Guideline for the Pharmacological Treatment of Patients with Alcohol Use Disorder (2018).
• SAMHSA TIP 49 (2009).

Treatment methods

1. Motivational Interviewing (MI) — Miller W.R., Rollnick S — Enhancing readiness for behavior change; targets “ambivalence”.
2. CBT for substance use — Trigger recognition, cravings management, coping skills, relapse prevention.
3. Naltrexone, Acamprosate, Disulfiram — Pharmacotherapy against relapse.
4. 12-Step Facilitation (AA, NA) — Project MATCH RCT — comparative effectiveness of CBT and MI.
5. AUDIT, CIWA-Ar — Screening and withdrawal severity.

9. Prognosis

• With multimodal approach, 40–50% long-term remission.
• Comorbid MDD, BPD, other substance — poor prognosis.

10. Myths and misconceptions

Myth 1: “Alcoholism is a character weakness”

Evidence: Jellinek 1960; WHO — alcohol use disorder is a medical condition; heritability 50–60%.

Myth 2: “Detoxification alone is treatment”

Evidence: Detoxification is the initial step; intervention against relapse is required; detox alone leads to 90%+ relapse.

Myth 3: “Naltrexone makes alcohol ‘unacceptable’”

Evidence: Naltrexone reduces craving and diminishes alcohol's ‘reward’ effect; differs from disulfiram.

Myth 4: “The patient must hit ‘rock bottom’ before treatment begins”

Evidence: Early intervention is more effective; the “rock bottom” concept is not evidence-based.

Myth 5: “Alcohol is the safest substance, requires no treatment”

Evidence: WHO — alcohol causes 2.6 million deaths annually (WHO 2024, 2019 data); DT mortality is ~1–4% among hospitalised patients (Schuckit M.A. N Engl J Med 2014); substantially higher in historical untreated series.

Myth 6: “‘A little alcohol is safe’ in pregnant women”

Evidence: CDC, AAP — any amount of alcohol during pregnancy creates a risk of FAS; there is no ‘safe’ dose.

11. Sources

1. WHO. ICD-11. 6C40 Disorders due to use of alcohol. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG115. Alcohol-use disorders: diagnosis, assessment and management. 2011.
4. APA. Practice Guideline for the Pharmacological Treatment of Patients with AUD. 2018.
5. SAMHSA. TIP 49: Incorporating Alcohol Pharmacotherapies Into Medical Practice. 2009.
6. Anton R.F. et al. COMBINE trial. JAMA 2006;295(17):2003–2017.
7. Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity. J Stud Alcohol 1997;58(1):7–29.
8. Verhulst B., Neale M.C., Kendler K.S. The heritability of alcohol use disorders: a meta-analysis of twin and adoption studies. Psychol Med 2015;45(5):1061–1072.
9. Schuckit M.A. Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med 2014;371(22):2109–2113.
10. Saunders J.B., Aasland O.G., Babor T.F. et al. Development of the Alcohol Use Disorders Identification Test (AUDIT). Addiction 1993;88(6):791–804.
11. Miller W.R., Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York: Guilford Press, 2013.