ALCOHOL USE DISORDER































  • Reference [1]
DSM-5 Alcohol Use Disorder Criteria
Alcohol use disorder is diagnosed based on the presence (within the past 12 months) of the 11 symptoms detailed below. The severity of AUD is defined as follow:
  • Mild: 2 to 3 symptoms present
  • Moderate: 4 to 5 symptoms present
  • Severe: ≥ 6 symptoms present
  • Alcohol is often taken in larger amounts or over a longer period than was intended
  • There is a persistent desire or unsuccessful efforts to cut down or control alcohol use
  • A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects
  • Craving, or a strong desire or urge to use alcohol
  • Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home
  • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
  • Important social, occupational, or recreational activities are given up or reduced because of alcohol use
  • Recurrent alcohol use in situations in which it is physically hazardous
  • Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
Tolerance, as defined by either of the following:
  • A need for markedly increased amounts of alcohol to achieve intoxication or desired effects
  • A markedly diminished effect with continued use of the same amount of alcohol
Withdrawal, as manifested by either of the following:
  • The characteristic withdrawal syndrome for alcohol
  • Alcohol (or closely related substance, such as benzodiazepine) taken to relieve or avoid withdrawal symptoms





  • Reference [5,6]
Alcohol withdrawal symptoms
(typically begin within 24 - 48 hours)
Mild symptoms
  • Anxiety / Irritability / Agitation
  • Tremor
  • Insomnia
  • Headache
  • Palpitations
  • Nausea and vomiting
  • Decreased appetite
Moderate symptoms
  • Sweating
  • Increase in blood pressure
  • Shortness of breath
  • Tachycardia
  • Difficulty focusing or concentrating
  • Mild confusion
  • Sensitivity to light, sound, or tactile sensations
Severe symptoms (delirium tremens)
  • Disorientation / Confusion
  • Hallucinations (visual or auditory)
  • Delusions (usually paranoid or persecutory)
  • Hyperthermia
  • Seizures





  • References [5,9,10,12,13,14,15]
Medications for acute alcohol withdrawal
Chlordiazepoxide (Librium®)
  • Dosage form - capsule
    • 5 mg
    • 10 mg
    • 25 mg
  • Fixed dose regimen
    • Day 1: 25 - 100 mg four times daily
    • Day 2: 25 - 100 mg three times daily
    • Day 3: 25 - 100 mg twice daily
    • Day 4: 25 - 100 mg at bedtime
  • Symptom-triggered regimen
    • Day 1: 25 - 100 mg every 4 - 6 hours as needed
    • Day 2: 25 - 100 mg every 6 - 8 hours as needed
    • Day 3: 25 - 100 mg every 12 hours as needed
    • Day 4: 25 - 100 mg at bedtime as needed
  • Dose amount based on CIWA-Ar
    • CIWA-Ar < 10: 25 - 50 mg
    • CIWA-Ar 10 - 18: 50 - 100 mg
    • CIWA-Ar ≥ 19: 75 - 100 mg
  • Other
    • Peak plasma concentration: 2 hours
    • Half-life: 24 - 48 hours
    • Disulfiram increases chlordiazepoxide exposure
    • See chlordiazepoxide for more
Diazepam (Valium®)
  • Dosage form - tablet
    • 2 mg
    • 5 mg
    • 10 mg
  • Fixed dose regimen
    • Day 1: 10 mg three or four times a day
    • Day 2: 10 mg three times daily
    • Day 3: 10 mg twice daily
    • Day 4: 10 mg at bedtime
    • Day 5: 5 mg at bedtime
  • Symptom-triggered regimen
    • Day 1: 10 mg every 6 hours as needed
    • Day 2: 10 mg every 8 hours as needed
    • Day 3: 10 mg every 12 hours as needed
    • Day 4: 5 - 10 mg every 12 hours as needed
    • Day 5: 5 mg every 12 hours as needed
  • Other
    • Peak plasma concentration: 1 - 1.5 hours
    • Half-life:
      • Diazepam - up to 48 hours
      • Active metabolite - up to 100 hours
      • Half-life increases by approximately 1 hour for each year of age beginning with a half-life of 20 hours at 20 years of age
    • Disulfiram decreases the clearance of diazepam
    • See diazepam for more
Lorazepam (Ativan®)
  • Dosage form - tablet
    • 0.5 mg
    • 1 mg
    • 2 mg
  • Fixed dose regimen
    • Day 1: 2 mg every 8 hours
    • Day 2: 2 mg every 8 hours
    • Day 3: 1 mg every 8 hours
    • Day 4: 1 mg every 12 hours
    • Day 5: 1 mg at bedtime
  • Symptom-triggered regimen
    • Day 1: 2 mg every 6 hours as needed
    • Day 2: 2 mg every 6 hours as needed
    • Day 3: 1 mg every 8 hours as needed
    • Day 4: 1 mg every 12 hours as needed
    • Day 5: 1 mg every 12 hours as needed
  • Other
    • Peak plasma concentration: 2 hours
    • Half-life: 12 hours
    • Lorazepam undergoes minimal hepatic metabolism and may be preferred in patients with liver disease
    • Disulfiram does not appear to affect the metabolism of lorazepam
    • See lorazepam for more
Gabapentin (Neurontin®)
  • Dosage form
    • Tablet
      • 100 mg
      • 300 mg
      • 400 mg
      • 600 mg
      • 800 mg
    • Capsule
      • 100 mg
      • 300 mg
      • 400 mg
  • Dosing
    • Small studies have looked at the use of gabapentin for treating alcohol withdrawal. In general, these studies have found that gabapentin is effective in patients with mild to moderate symptoms but should probably not be used in patients with severe symptoms. For outpatient treatment of mild to moderate symptoms, gabapentin may be a good choice for those at risk for benzodiazepine abuse. A study that compared gabapentin to lorazepam (N=100) found that gabapentin was equally effective in treating withdrawal symptoms. [PMID 19485969] Dosing used in that trial was as follows:
      • Days 1 - 3: 300 - 400 mg three times daily
      • Days 4 and on: 300 - 400 mg twice daily
      • Rescue packs were provided that contained two 100 mg doses and one 300 mg dose for use on Day 1. The 300 mg dose was to be reserved for evening or night use. On Days 2 - 4 the gabapentin rescue packs provided three 100 mg doses.
  • Other
    • Peak plasma concentration: 2 - 3 hours [11]
    • Half-life: 5 - 7 hours
    • See gabapentin for more
Carbamazepine (Tegretol®)
  • Dosage form (tablet)
    • 100 mg
    • 200 mg
    • 300 mg
    • 400 mg
  • Dosing
    • Small studies have found carbamazepine to be effective at treating alcohol withdrawal symptoms. For outpatient treatment, carbamazepine may be a good choice for patients who are at risk for benzodiazepine abuse. A study that compared carbamazepine to lorazepam (N=136) in outpatients with moderate alcohol withdrawal found that carbamazepine was equally effective in treating withdrawal symptoms and superior at preventing rebound symptoms and post-treatment drinking. [PMID 12047731] Typical dosing in trials was as follows:
      • Starting dose of 600 - 800 mg/day tapered to 200 mg/day over 5 - 9 days. Carbamazepine can be given in 3 - 4 divided doses.
  • Other






















  • Includes pain, tenderness, induration, swelling, erythema, bruising, or pruritus
  • Reference [13]
Side effect Naltrexone 380 mg IM
(N=205)
Placebo
(N=214)
Injection site reactions 69% 50%
Nausea 33% 11%
Headache 25% 18%
Decreased appetite 14% 3%
Vomiting 14% 6%
Insomnia 14% 12%
Dizziness 13% 4%
Diarrhea 13% 10%
Anxiety 12% 8%
Arthralgia 12% 5%
Abdominal pain 11% 8%
Muscle cramps 8% 1%
Depression 8% 4%
Rash 6% 4%
Somnolence 4% 1%




  • NS - result was statistically nonsignificant
  • Reference [16]
Outcome % decrease compared to placebo
Naltrexone 50 mg/day oral
Return to any drinking 5%
Return to heavy drinking 9%
% drinking days 5.4%
% heavy drinking days 4.1%
Naltrexone injection
Return to any drinking 4% (NS)
Return to heavy drinking 1% (NS)
% drinking days 8.6%
% heavy drinking days 4.6%
  • Analysis of the 4 trials (N=1141) that directly compared acamprosate to naltrexone found no significant difference between the two drugs