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Meshell D. Johnson, MD


  • Physiologic dependence as manifested by evidence of withdrawal when intake is interrupted.

  • Tolerance to the effects of alcohol.

  • Evidence of alcohol-associated illnesses, such as alcoholic liver disease, cerebellar degeneration.

  • Continued drinking despite strong medical and social contraindications and life disruptions.

  • Impairment in social and occupational functioning.

  • Depression.

  • Blackouts.

Other signs:

  • Alcohol stigmata: alcohol odor on breath, alcoholic facies, flushed face, scleral injection, tremor, ecchymoses, peripheral neuropathy.

  • Surreptitious drinking.

  • Unexplained work absences.

  • Frequent accidents, falls, or injuries of vague origin; in smokers, cigarette burns on hands or chest.

  • Laboratory tests: elevated values of mean corpuscular volume, serum liver biochemical tests, uric acid, and triglycerides.


Alcohol use disorder is a syndrome consisting of two phases: at-risk drinking and moderate to severe alcohol misuse. At-risk drinking is the repetitive use of alcohol, often to alleviate anxiety or solve other emotional problems. A moderate to severe alcohol use disorder is similar to that which occurs following the repeated use of other sedative-hypnotics and is characterized by recurrent use of alcohol despite disruption in social roles (family and work), alcohol-related legal problems, and taking safety risks by oneself and with others. The National Institute on Alcohol Abuse and Alcoholism formally defines at-risk drinking as more than 4 drinks per day or 14 drinks per week for men or more than 3 drinks per day or 7 drinks per week for women. A drink is defined by the Centers for Disease Control and Prevention (CDC) as 12 oz of beer, 8 oz of malt liquor, 5 oz of wine, or 1.3 oz or a “shot” of 80-proof distilled spirits of liquor. Individuals with at-risk drinking are at an increased risk for developing or are developing an alcohol use disorder. Alcohol and other drug abuse patients have a much higher prevalence of lifetime psychiatric disorders. While male-to-female ratios in alcoholic treatment agencies remain at 4:1, there is evidence that the rates are converging. Women delay seeking help, and when they do, they tend to seek it in medical or mental health settings. Adoption and twin studies indicate some genetic influence. Ethnic distinctions are important—eg, 40% of Japanese have aldehyde dehydrogenase deficiency and are more susceptible to the effects of alcohol. Depression is often present and should be evaluated carefully. The majority of suicides and intrafamily homicides involve alcohol. Alcohol is a major factor in rapes and other assaults.

There are several screening instruments that may help identify an alcohol use disorder. One of the most useful is the Alcohol Use Disorder Identification Test (AUDIT) (see Table 1–6 found in Chapter 1-10: Prevention of Substance Use Disorder: Alcohol & Illicit Drugs).

McNeely  J  et al. A brief patient self-administered substance use screening tool for primary care: two-site validation study of the Substance Use Brief Screen (SUBS). Am J Med. 2015;128:784.e9.
[PubMed: 25770031]
McNeely  J ...

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