Behavioral Health

Alcohol use disorder: SBIRT screening and treatment

Clinical Overview and When to Suspect Alcohol Use Disorder

— Alcohol use disorder (AUD) is a chronic, relapsing DSM-5 diagnosis requiring ≥2 of 11 criteria over 12 months (mild 2–3, moderate 4–5, severe ≥6)

— Affects ~14% of US adults annually; 4th leading preventable cause of death

— Unhealthy alcohol use spectrum: risky use → AUD, with risky use defined as >14 drinks/week or >4/occasion (men ≤65), or >7/week or >3/occasion (women and all adults >65)

— Recurrent HTN refractory to therapy, new-onset AF, macrocytosis (MCV >100), unexplained AST:ALT ratio ≥2:1, GGT elevation

— Insomnia, anxiety/depression refractory to SSRIs, GERD, chronic pancreatitis, peripheral neuropathy

— Repeat MVCs, falls, work absenteeism, IPV, child neglect, financial/legal trouble

— Pre-operative patient with unexplained tachycardia or post-op delirium

— Screen all adults ≥18, including pregnant women, for unhealthy alcohol use in primary care

— Provide brief behavioral counseling interventions for those screening positive (SBIRT framework)

— Screening (validated tool) → Brief Intervention (5–15 min motivational counseling) → Referral to Treatment for moderate/severe AUD

— Reimbursable under CPT 99408/99409 (commercial) and G0396/G0397 (Medicare); HCPCS H0049/H0050 (Medicaid)

Definition & epidemiology

When to suspect in ambulatory practice

USPSTF mandate (Grade B)

SBIRT defined

Step 3 management: On any annual wellness visit or new-patient intake, document a validated alcohol screen (AUDIT-C or single-question screen) before ordering routine labs — exam stems love the "next best step" being screening, not LFTs, in an asymptomatic adult.

Board pearl: AUD is now a unified spectrum diagnosis — the old DSM-IV split of "abuse" vs "dependence" is obsolete; do not pick those answer choices.

Presentation Patterns and Key History

— Single-item screen (NIAAA): "How many times in the past year have you had X or more drinks in a day?" (X = 5 men, 4 women/≥65). Any answer ≥1 is positive

— AUDIT-C (3 items, score 0–12): positive ≥4 men, ≥3 women

— AUDIT (10 items, 0–40): ≥8 hazardous use; ≥15 likely AUD; ≥20 severe

— CAGE (Cut down, Annoyed, Guilty, Eye-opener): ≥2 positive; less sensitive for early/risky use and not recommended in pregnancy

— T-ACE or TWEAK: preferred in pregnancy (CAGE misses fetal-risk drinking)

— CRAFFT: adolescents 12–21

— Impaired control: larger/longer use, cravings, failed cutdown, time consumed

— Social impairment: role failure, interpersonal problems, activities given up

— Risky use: hazardous situations, continued use despite harm

— Pharmacologic: tolerance, withdrawal

— Quantify in standard drinks (14 g ethanol = 12 oz beer 5%, 5 oz wine 12%, 1.5 oz spirits 40%)

— Pattern: daily vs binge; time of first drink; eye-opener; blackouts

— Last drink (critical for withdrawal timing), prior withdrawal seizures/DTs

— Co-use: benzodiazepines, opioids, cannabis, stimulants, tobacco

— Psychiatric: depression, PTSD, bipolar, SI; ACEs

— Social: driving, firearms, custody, employment, housing

Validated screening tools (memorize cutoffs)

DSM-5 criteria clusters (≥2/11 in 12 months)

History essentials

Key distinction: A patient drinking 3 beers nightly screens positive AUDIT-C (men: 21/week) — they may have zero DSM-5 criteria yet still warrant brief intervention. Risky use ≠ AUD, but both trigger SBIRT's "BI" step.

Board pearl: A pregnant patient with any alcohol use this trimester gets brief intervention — there is no safe threshold in pregnancy per ACOG/CDC.

Physical Exam Findings (and Hemodynamic Assessment when relevant)

— Disheveled, alcohol on breath, parotid enlargement (sialosis), facial telangiectasias, rhinophyma

— Cachexia or central adiposity with sarcopenia; poor dentition

— Intoxication: hypotension, bradycardia, hypothermia, depressed respirations (especially with co-ingestion)

— Withdrawal (6–24 h): HTN, tachycardia, hyperthermia, tremor, diaphoresis — autonomic hyperactivity is the hemodynamic signature

— DTs (48–96 h): severe tachycardia, fever, hypertension, delirium — medical emergency, mortality 1–5%

— Scleral icterus, conjunctival injection

— Nystagmus, ophthalmoplegia (CN VI palsy), ataxia, confusion → Wernicke triad (only ~10% have all 3 — treat empirically)

— Peripheral neuropathy (stocking-glove), cerebellar gait, Dupuytren contracture

— Irregularly irregular pulse (holiday heart AF), displaced PMI (dilated cardiomyopathy), S3

— Hepatomegaly early; small nodular liver late; splenomegaly, ascites (shifting dullness, fluid wave), caput medusae, spider angiomata (>5 = abnormal in men), palmar erythema, gynecomastia, testicular atrophy

— Epigastric tenderness (pancreatitis, gastritis)

— Bruising (coagulopathy, falls, IPV); cigarette burns; jaundice

— Asterixis suggests hepatic encephalopathy

General appearance

Vital signs (active intoxication vs withdrawal)

HEENT/Neuro

Cardiopulmonary

Abdominal

Skin/MSK

CCS pearl: In a CCS case of suspected withdrawal, order vitals q1–4h and a CIWA-Ar score q1h as part of monitoring; clock will not advance withdrawal severity unless you check. Also order fingerstick glucose — alcoholics are prone to hypoglycemia.

Board pearl: Give thiamine BEFORE glucose in any malnourished/alcoholic patient to avoid precipitating Wernicke encephalopathy.

Diagnostic Workup — Initial Labs / Imaging / ECG / Biomarkers

— CBC: macrocytosis (MCV >100) — direct toxic effect on RBC precursors plus folate deficiency; thrombocytopenia (marrow suppression, splenic sequestration)

— CMP: AST:ALT ≥2:1 with both <500 (alcoholic hepatitis pattern); elevated bilirubin, decreased albumin, prolonged INR signal advanced disease

— GGT: elevated in 70% of heavy drinkers; sensitive but not specific

— Lipase if abdominal pain

— Magnesium, phosphate, potassium: commonly depleted; replete proactively

— Glucose, lactate, ketones (alcoholic ketoacidosis: anion gap, β-hydroxybutyrate predominant, normal/low glucose)

— CDT (carbohydrate-deficient transferrin): >2% suggests ≥4–5 drinks/day × 2 weeks; ~70% sensitive, highly specific

— PEth (phosphatidylethanol): detects use over prior 3–4 weeks; >20 ng/mL = moderate, >200 = heavy use; most sensitive/specific biomarker, gold standard for monitoring abstinence (transplant, custody, return-to-work)

— EtG (ethyl glucuronide) in urine: detects use within 80 hours; very sensitive (catches even hand-sanitizer exposure — beware false positives)

— BAC: legal intoxication 0.08%; clinical: >0.30 stuporous, >0.40 may be fatal in non-tolerant

— AF/flutter (holiday heart), prolonged QT (especially with hypoMg/K), LVH

— RUQ US for hepatomegaly, steatosis, cirrhosis, HCC surveillance

— CT head for trauma, altered mental status, focal deficits, or first seizure

Core labs in suspected AUD

Biomarkers of recent/chronic use

ECG

Imaging (selective)

Step 3 management: A positive AUDIT-C plus elevated GGT/MCV does not require a biopsy or specialty referral first — next step is brief intervention + offer pharmacotherapy. Labs are supportive, not diagnostic.

Key distinction: AST:ALT >2:1 with low transaminases = alcoholic; ALT >> AST with values in thousands = viral or toxic hepatitis.

Diagnostic Workup — Advanced or Confirmatory Studies

— FibroScan (transient elastography): noninvasive fibrosis assessment; kPa >12.5 suggests cirrhosis

— FIB-4 index and APRI: calculated from age, AST, ALT, platelets — risk-stratify for advanced fibrosis before referring for elastography or biopsy

— Liver biopsy: reserved for diagnostic uncertainty (overlap with NAFLD, autoimmune, viral) or to confirm alcoholic hepatitis pre-steroid trial

— Maddrey discriminant function (MDF) ≥32 or MELD >20 identifies severe alcoholic hepatitis candidates for prednisolone; check Lille score at day 7 — >0.45 = nonresponse, stop steroids

— PAWSS (Prediction of Alcohol Withdrawal Severity Scale): ≥4 predicts complicated withdrawal (seizures, DTs) → admit, scheduled benzodiazepines

— CIWA-Ar: 10-item, 0–67; used for symptom-triggered dosing; only valid in patients who can communicate (intubated, demented, language-barrier patients need fixed-dose protocols)

— HIV, HCV, HBV (shared risk behaviors, transmission)

— TB if homeless or incarcerated history

— STI screen as indicated

— PHQ-9, GAD-7, PCL-5 (PTSD), C-SSRS for suicidality

— Tobacco, opioid, stimulant screening

— Bone density in chronic users (osteoporosis risk)

— Nutritional: thiamine, folate, B12, vitamin D, prealbumin

— MoCA if cognitive concerns; MRI brain showing mammillary body atrophy or cerebellar atrophy supports Wernicke-Korsakoff

Liver disease staging

Withdrawal severity prediction

Co-condition screening (every AUD diagnosis)

Neurocognitive

Board pearl: PEth is the answer when the stem asks for the best biomarker to confirm sustained abstinence in a liver-transplant candidate — outperforms CDT, GGT, and self-report.

Step 3 management: Every newly diagnosed AUD patient gets HCV antibody, HIV, HBsAg/anti-HBs, and PHQ-9 as part of the first-visit workup, alongside the AUD pharmacotherapy discussion.

Risk Stratification or First-Line Management Logic

— Negative screen: reinforce, rescreen annually

— Risky use, no AUD (AUDIT-C+ but <2 DSM criteria): Brief Intervention only — 5 A's (Ask, Advise, Assess, Assist, Arrange) or FRAMES (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy); single 5–15 min session reduces drinking ~12% at 1 year (USPSTF Grade B)

— Mild AUD: BI + offer pharmacotherapy + behavioral therapy (CBT, MET, 12-step facilitation); consider mutual-help groups (AA, SMART Recovery)

— Moderate–severe AUD: BI + pharmacotherapy is first-line + structured psychosocial treatment + referral to addiction specialty care

— Outpatient ambulatory detox appropriate if: mild–moderate symptoms (CIWA <10), no seizure/DT history, no severe comorbidity, reliable support, no co-ingestion, can attend daily f/u

— Inpatient detox required if: CIWA ≥15, PAWSS ≥4, prior DTs/seizures, pregnancy, severe medical/psychiatric comorbidity, hepatic dysfunction, suicidality, homelessness

— Abstinence remains gold standard, but reduced drinking is an evidence-based intermediate goal (WHO risk-level reduction reduces mortality and cirrhosis progression)

— Use shared decision-making — patient autonomy increases retention

SBIRT decision tree by screening result

Setting of withdrawal management

Goals of care discussion

Step 3 management: When asked for "next best step" in a moderate–severe AUD patient who is medically stable, start naltrexone (or acamprosate) at the same visit — do not defer pharmacotherapy waiting for behavioral therapy enrollment. Combined treatment > either alone.

Board pearl: AUD pharmacotherapy is underused — only ~2% of eligible patients receive it. Stems will reward the answer that initiates medication concurrently with counseling referral.

Pharmacotherapy — First-Line Drug Regimen

— Opioid mu-receptor antagonist; reduces craving and reward of drinking

— Oral 50 mg daily or IM depot 380 mg q4 weeks (Vivitrol — preferred for adherence issues)

— Start anytime; abstinence not required to initiate

— Contraindicated: current opioid use (precipitates withdrawal — needs 7–10 d opioid-free), acute hepatitis or hepatic failure

— Monitor LFTs; warn re: blunted response to opioid analgesics

— Modulates glutamate/GABA; reduces post-acute withdrawal symptoms (insomnia, anxiety, dysphoria)

— 666 mg PO TID (2 tablets TID)

— Renally cleared: adjust if CrCl 30–50; contraindicated CrCl <30

— Best for patients with hepatic disease or on opioids (no liver or opioid interactions)

— Requires abstinence at initiation for best results

— Aldehyde dehydrogenase inhibitor — flushing, vomiting, tachycardia, hypotension on alcohol ingestion

— 250–500 mg daily; requires ≥12 h abstinence before first dose

— Best for highly motivated patients with supervised administration (spouse, court)

— Contraindicated: CAD, severe hepatic disease, psychosis, pregnancy

— Avoid alcohol-containing products (mouthwash, cologne, sauces)

— Topiramate (start 25 mg, titrate to 150–300 mg/day): reduces heavy drinking; SE: cognitive slowing, paresthesia, weight loss, stones

— Gabapentin (900–1800 mg/day divided): reduces craving, improves sleep; especially useful with withdrawal-related insomnia/anxiety

— Baclofen: option in advanced liver disease

FDA-approved for AUD (3 agents)

Naltrexone (first-line, most evidence)

Acamprosate

Disulfuram

Off-label evidence-based options

Step 3 management: Patient with AUD and chronic pain on opioids → acamprosate (naltrexone contraindicated). Patient with cirrhosis → acamprosate or baclofen (avoid naltrexone if active hepatitis; avoid disulfiram).

Board pearl: Naltrexone reduces heavy drinking days more than abstinence days; acamprosate is better for maintaining abstinence once achieved.

Procedures / Revascularization / Invasive Management (Expanded: Withdrawal Pharmacology)

— 6–12 h: tremor, anxiety, GI upset, mild autonomic

— 12–24 h: alcoholic hallucinosis (visual/tactile, intact sensorium)

— 24–48 h: withdrawal seizures (generalized tonic-clonic, usually single)

— 48–96 h: delirium tremens — global confusion, severe autonomic instability, mortality 1–5% treated, up to 20% untreated

— Long-acting agents (diazepam, chlordiazepoxide): smoother taper, self-tapering pharmacokinetics; preferred in healthy liver

— Short-acting (lorazepam, oxazepam): preferred in elderly, hepatic dysfunction, delirium — no active metabolites (LOT drugs: Lorazepam, Oxazepam, Temazepam metabolized by glucuronidation)

— Symptom-triggered dosing (CIWA-Ar) reduces total benzo dose and length of stay vs fixed schedule

— Sample: lorazepam 2 mg IV/PO q1h for CIWA ≥10

— Front-loading with diazepam 10–20 mg q1–2h until CIWA <10 in severe withdrawal

— Escalate to ICU; phenobarbital adjunct or monotherapy; propofol or dexmedetomidine drip (adjuncts, not monotherapy — don't treat the underlying GABA hypofunction)

— Avoid haloperidol alone (lowers seizure threshold)

— Thiamine 500 mg IV TID × 3 days, then 250 mg IV/IM × 5 days for suspected/established Wernicke; 100 mg IV/IM × ≥3 days prophylaxis in all

— Folate, multivitamin

— Replete Mg (target >2), K, phosphate; correct hypoglycemia

— IV fluids judiciously (many are euvolemic/overhydrated)

— Paracentesis for new ascites (SAAG, cell count, culture — rule out SBP)

— EGD for variceal bleed; band ligation; octreotide, ceftriaxone

Alcohol withdrawal syndrome (AWS) timeline

Benzodiazepines = cornerstone of treatment

Refractory DTs / benzo-resistant withdrawal

Adjunctive critical care

Procedural considerations

CCS pearl: In a CCS DT case, the order set should include: IV access, NS or D5NS, thiamine BEFORE dextrose, folate, multivitamin, Mg/K/Phos repletion, lorazepam symptom-triggered, CIWA q1h, telemetry, ICU transfer if CIWA persistently >20 or hemodynamic instability.

Special Populations — Elderly and Renal/Hepatic Impairment

— Lower NIAAA limits: ≤1 drink/day, ≤7/week, never >2/occasion

— Increased BAC per drink due to decreased total body water, lean mass, hepatic metabolism

— Higher risk of falls, hip fracture, polypharmacy interactions (benzos, opioids, sleep aids)

— Cognitive impairment may mimic or mask AUD — screen with single-item or AUDIT-C, not CAGE (insensitive)

— Withdrawal: prefer lorazepam or oxazepam (no active metabolites); use lower doses, longer intervals

— Pharmacotherapy: naltrexone and acamprosate both acceptable; check renal function for acamprosate dosing; disulfiram avoid (cardiac comorbidity)

— Compensated cirrhosis (Child A): naltrexone caution but acceptable; acamprosate preferred; avoid disulfiram

— Decompensated cirrhosis / active alcoholic hepatitis: acamprosate or baclofen first-line; avoid naltrexone if AST/ALT >3–5× ULN or active hepatitis; avoid disulfiram absolutely

— Withdrawal: lorazepam/oxazepam (LOT drugs) — bypass CYP metabolism via glucuronidation

— Severe alcoholic hepatitis (MDF ≥32): prednisolone 40 mg daily × 28 days if no contraindication (GI bleed, sepsis, AKI); check Lille at day 7; pentoxifylline no longer recommended

— Liver transplant: most centers require 6 months sobriety, but early transplant in severe alcoholic hepatitis is increasingly accepted with rigorous selection

— Acamprosate: dose-reduce to 333 mg TID if CrCl 30–50; contraindicated <30

— Naltrexone: no adjustment needed but use caution in severe renal disease

— Disulfiram: no specific renal adjustment; caution

Elderly (≥65)

Hepatic impairment

Renal impairment

Step 3 management: Elderly patient with CKD stage 4 and AUD → naltrexone is the answer (acamprosate contraindicated, disulfiram poor choice given comorbidity).

Key distinction: Active alcoholic hepatitis with bilirubin 8 and INR 1.9 → acamprosate, NOT naltrexone — and never disulfiram.

Special Populations — Pregnancy, Pediatrics, and Other Subgroups

— No safe amount, no safe trimester, no safe type of alcohol — ACOG/CDC/AAP unified position

— Universal screening at first prenatal visit using T-ACE, TWEAK, or AUDIT-C (CAGE insufficient)

— Any positive screen → brief intervention; moderate–severe AUD → specialty referral

— FAS spectrum disorders: growth restriction, midfacial hypoplasia, smooth philtrum, thin vermilion, short palpebral fissures, neurodevelopmental impairment — leading preventable cause of intellectual disability

— Withdrawal in pregnancy = admit; untreated withdrawal causes fetal distress, miscarriage, preterm labor

— Use benzodiazepines for withdrawal — risk of untreated AWS > teratogenicity risk; short courses lorazepam/diazepam

— Pharmacotherapy: all 3 FDA agents are pregnancy data-limited; naltrexone has emerging safety data and may be considered after risk-benefit discussion; disulfiram contraindicated (teratogen); acamprosate limited data

— Breastfeeding: advise pumping/dumping if drinking; naltrexone compatible

— CRAFFT screen (Car, Relax, Alone, Forget, Friends, Trouble): ≥2 positive

— Any use under age 21 is unhealthy; confidentiality within state law limits

— Family-based therapy (e.g., A-CRA, MDFT) is first-line behavioral; pharmacotherapy off-label

— Concurrent treatment of PTSD + AUD; prazosin for nightmares; sertraline/paroxetine; avoid benzodiazepines for chronic management

— Higher unmet treatment need; consider telehealth MAT, culturally-tailored programs

Pregnancy

Adolescents (12–21)

Veterans / PTSD comorbid

LGBTQ+, racial/ethnic minorities, rural

Board pearl: Pregnant patient with positive T-ACE → brief intervention at the visit, not wait for OB referral; document teratogenicity counseling.

Step 3 management: Adolescent with positive CRAFFT → confidential brief intervention + parental involvement with patient assent unless safety issue; refer to adolescent SUD program.

Complications and Adverse Outcomes

— Steatosis (reversible) → alcoholic hepatitis → fibrosis → cirrhosis → HCC

— Acute alcoholic hepatitis: jaundice, fever, leukocytosis, AST:ALT >2:1; treat with prednisolone if MDF ≥32

— Portal HTN: variceal bleed, ascites, SBP, hepatorenal syndrome, hepatic encephalopathy

— Gastritis, esophagitis, Mallory-Weiss tears, Boerhaave

— Acute and chronic pancreatitis (alcohol = #2 cause after gallstones)

— Malabsorption, malnutrition

— Cancers: oropharyngeal, esophageal (SCC), gastric, colon, hepatocellular, breast (dose-dependent)

— Holiday heart syndrome (AF after binge)

— Dilated cardiomyopathy, HTN, hemorrhagic stroke

— Light-moderate use no longer considered cardioprotective per recent meta-analyses

— Wernicke encephalopathy (acute, reversible) → Korsakoff syndrome (chronic, confabulation, anterograde amnesia)

— Cerebellar degeneration, peripheral neuropathy, central pontine myelinolysis (from rapid Na correction)

— Withdrawal seizures, DTs

— Subdural hematoma (falls + coagulopathy + brain atrophy)

— Macrocytic anemia, thrombocytopenia, coagulopathy (decreased clotting factor synthesis)

— Hypoglycemia, alcoholic ketoacidosis, hypomagnesemia, hypophosphatemia, hypocalcemia, osteoporosis, hypogonadism, infertility

— Depression (secondary > primary in heavy users — often improves with abstinence), suicide (alcohol present in 30%+ of completed suicides), IPV, child abuse/neglect, MVCs (alcohol involved in 30% fatal crashes), unemployment, homelessness, incarceration

Hepatic

GI/Pancreatic

Cardiovascular

Neurologic

Hematologic

Endocrine/Metabolic

Psychosocial

Board pearl: New AF in a previously healthy 45-year-old after a weekend wedding = holiday heart — manage rate, monitor; usually self-resolves with abstinence.

Key distinction: Wernicke = ophthalmoplegia + ataxia + confusion (acute, reversible). Korsakoff = amnesia + confabulation (chronic, irreversible). Treat aggressively with thiamine to prevent transition.

When to Escalate Care — ICU, Consult, or Inpatient Triage

— CIWA-Ar persistently ≥10–15 despite outpatient management

— PAWSS ≥4

— History of prior complicated withdrawal (DTs, seizures)

— Significant comorbidity: cirrhosis, CHF, COPD, CAD, pregnancy

— Unable to tolerate oral intake; severe electrolyte derangement

— Failed outpatient detox attempt

— Suicidal ideation requiring monitoring

— CIWA-Ar >25 or requiring >40 mg lorazepam-equivalent in first 4 hours

— Established DTs with hemodynamic instability

— Withdrawal seizures recurrent or with status epilepticus

— Need for phenobarbital, propofol, or dexmedetomidine infusion

— Respiratory compromise (intubation for airway protection)

— Severe alcoholic hepatitis with MELD >25, AKI, GI bleed, or sepsis

— Concurrent pancreatitis with SIRS, hepatorenal syndrome

— Addiction medicine / psychiatry: moderate–severe AUD, treatment-resistant, dual diagnosis, pharmacotherapy initiation in complex patients

— Hepatology: cirrhosis, MELD ≥15, alcoholic hepatitis candidate for steroids, transplant evaluation

— GI: variceal bleed, refractory ascites, pancreatitis

— Cardiology: new AF, cardiomyopathy

— Social work: housing, IPV, child welfare, insurance, MAT linkage

— Witnessed seizure, hallucinations, confusion, hyperthermia, tachycardia >120, BP >180/110

— Suicidality, homicidality, psychosis

— Inability to keep down oral benzodiazepine or fluids

Admit to floor

ICU admission criteria

Specialty consultations

Transfer triggers from outpatient → ED

CCS pearl: In a CCS case where a patient on outpatient detox develops a witnessed generalized seizure → call 911 / transfer to ED, advance clock minimally, then order: IV access, lorazepam 2–4 mg IV, glucose check, thiamine 500 mg IV, CT head, admit telemetry/ICU based on response.

Step 3 management: A patient with CIWA 22, HR 130, BP 175/100, tactile hallucinations, prior DT history → direct ICU admission, scheduled + symptom-triggered benzodiazepines, thiamine, telemetry, call ICU before the next CIWA check.

Key Differentials — Same-Category Causes (Substance/Behavioral)

— Withdrawal indistinguishable from alcohol (same GABA mechanism); ask specifically about prescription and recreational benzo use

— Z-drug (zolpidem) withdrawal also possible with chronic high doses

— Treatment overlap: long-acting benzo taper; cross-tolerance allows substitution

— Withdrawal: lacrimation, rhinorrhea, mydriasis, piloerection, diarrhea, myalgia — autonomic but not life-threatening (vs alcohol/benzo, which can kill)

— Co-occurring with AUD in ~25%; screen all AUD patients with PDMP + urine opioid screen

— Affects pharmacotherapy choice (naltrexone contraindicated if active opioid use)

— Intoxication mimics alcohol withdrawal autonomically (tachycardia, HTN, agitation) but pupils dilated, no tremor in same pattern; toxicology screen distinguishes

— Withdrawal: hypersomnia, hyperphagia, depression — opposite picture

— Withdrawal: irritability, insomnia, decreased appetite — mild, not life-threatening

— Frequently co-occurs; gummy/edible/vape forms increase detection difficulty

— Comorbid with ~75% of AUD; offer varenicline or nicotine replacement concurrently — does not destabilize sobriety

— DSM-5 behavioral addiction; screen with NODS-CLiP; treatment overlap with AUD (naltrexone has evidence)

— Common; complicates withdrawal management — treat each component

Sedative-hypnotic use disorder (benzodiazepines, barbiturates, GHB)

Opioid use disorder

Stimulant use disorder (cocaine, methamphetamine)

Cannabis use disorder

Tobacco use disorder

Gambling disorder

Polysubstance use

Board pearl: A patient with seizure 36 hours after hospital admission and no alcohol history → consider benzodiazepine withdrawal (especially elderly on chronic alprazolam not reconciled at admission). Med-rec failure is a classic Step 3 patient-safety stem.

Key distinction: Life-threatening withdrawal occurs with alcohol, benzodiazepines, and barbiturates (GABAergic). Opioid, stimulant, and cannabis withdrawals are uncomfortable but rarely lethal in adults.

Key Differentials — Other-Category Causes (Medical Mimics)

— Thyroid storm: fever, tachycardia, tremor, agitation — check TSH/free T4; treat with PTU/methimazole, β-blocker, steroids

— Pheochromocytoma: episodic HTN, headache, palpitations, diaphoresis; plasma metanephrines

— Sepsis: fever, tachycardia, hypotension, leukocytosis; lactate, cultures

— Sympathomimetic toxicity: cocaine, meth, MDMA; tox screen

— Serotonin syndrome / NMS: medication history, clonus (serotonin) vs lead-pipe rigidity (NMS)

— Hypoglycemia: fingerstick glucose first in any altered/tremulous patient

— Hypoglycemia, hyponatremia, hypercalcemia, uremia

— Hepatic encephalopathy: asterixis, elevated ammonia; treat with lactulose, rifaximin

— Subdural hematoma: falls + coagulopathy + atrophy; CT head for any AMS with focal findings or trauma

— Meningitis/encephalitis: fever, neck stiffness; LP

— Wernicke encephalopathy: ophthalmoplegia, ataxia, confusion — empirical thiamine

— Post-ictal state from withdrawal seizure

— Stroke (hemorrhagic risk elevated)

— Alcoholic liver disease (classic 2:1, values <500)

— Cirrhosis of any cause (ratio reverses as fibrosis advances)

— NAFLD with advanced fibrosis

— Wilson disease (young patient, low ceruloplasmin)

— Muscle source (rhabdomyolysis — check CK)

— Hemochromatosis, autoimmune hepatitis (check iron studies, ANA, ASMA, IgG)

— B12/folate deficiency, hypothyroidism, MDS, hemolysis (reticulocytosis), drugs (methotrexate, hydroxyurea, zidovudine, phenytoin), liver disease

Differential for tremor + autonomic hyperactivity

Differential for altered mental status in known alcoholic

Differential for AST/ALT elevation with AST>ALT

Differential for macrocytosis

Step 3 management: Alcoholic patient with AMS — always check glucose, order CT head, and give empirical thiamine + naloxone before assuming withdrawal or intoxication is the sole cause. Anchoring bias is a tested patient-safety theme.

Board pearl: AST >500 in an alcoholic = look for another cause (acetaminophen, ischemia, viral) — alcoholic hepatitis typically stays <300.

Secondary Prevention / Discharge Medications / Long-Term Plan

— AUD pharmacotherapy initiated before discharge (key quality metric): naltrexone, acamprosate, or disulfiram chosen by patient/clinical profile

— Thiamine 100 mg PO daily, folate 1 mg daily, multivitamin

— Taper off benzodiazepines completely before discharge — never discharge on a benzo taper if avoidable (diversion, overdose risk)

— Reconcile all home medications; remove unnecessary CNS depressants

— Warm handoff to outpatient program: IOP (intensive outpatient, 9–20 h/week), PHP (partial hospitalization), residential for severe cases

— Evidence-based modalities: CBT, MET, 12-Step Facilitation, Contingency Management, Community Reinforcement Approach

— Mutual-help: AA, SMART Recovery, LifeRing — offer choices; AA not for everyone

— Couples/family therapy where appropriate

— Treat depression/anxiety/PTSD concurrently — do not wait for sobriety; SSRIs safe, avoid benzodiazepines for chronic anxiety

— Tobacco cessation (varenicline, NRT) concurrent — improves AUD outcomes

— Pain management without opioids when possible

— Hepatitis C treatment — modern DAAs work even in active drinkers; do not gate on sobriety

— Hepatitis A and B (if nonimmune), pneumococcal, annual influenza, COVID-19, Td/Tdap

— Nutrition counseling, sleep hygiene, exercise, stress management, social support rebuilding

Discharge bundle after withdrawal admission

Behavioral treatment linkage

Comorbidity management

Vaccinations

Lifestyle

Step 3 management: A patient completing inpatient detox should leave with: (1) a prescription (naltrexone preferred unless contraindicated), (2) a scheduled follow-up within 1 week, (3) a specific outpatient program with intake appointment, (4) naloxone if any opioid co-use, and (5) thiamine + multivitamin.

Board pearl: Initiating MAT before discharge doubles the likelihood of 6-month retention — this is the highest-yield intervention in transitions of care.

Follow-Up, Monitoring Parameters, and Rehab/Counseling

— Within 1 week of detox discharge, then weekly × 4 weeks, biweekly × 2 months, then monthly through 6 months minimum; quarterly thereafter

— IM naltrexone clinic visit q4 weeks for injection

— Frequent early contact predicts retention

— AUDIT-C at each visit to track use trajectory; or timeline followback for past 30 days

— PEth q3 months if objective monitoring needed (transplant list, custody, professional licensing)

— LFTs at baseline, 1 month, 3 months, then per stability (especially with naltrexone)

— Renal function for acamprosate patients

— PHQ-9, GAD-7 every visit; C-SSRS if suicidality concerns

— Weight, BP, HbA1c if diabetic

— HCC surveillance: if cirrhotic, RUQ US ± AFP q6 months

— Variceal screening at cirrhosis diagnosis, then per Baveno criteria

— DEXA for osteoporosis screening

— Relapse prevention: identify triggers (people, places, emotions), develop coping plan, "play the tape forward"

— Recognize post-acute withdrawal syndrome (PAWS): insomnia, mood lability, anhedonia lasting weeks–months; acamprosate helps

— Cravings: urge surfing, distraction, calling sponsor, "HALT" check

— Realistic expectations: AUD is chronic relapsing disease like diabetes — relapse is not failure but a clinical event to re-engage treatment

— Outpatient counseling (weekly), IOP, PHP, residential (28-day, 90-day), sober living

— Telehealth MAT increasingly used post-COVID — improves access

Follow-up cadence

Monitoring parameters

Counseling content

Rehab programs

Step 3 management: A patient on naltrexone returns at 1 month reporting 2 heavy drinking days down from 20/month → continue naltrexone, intensify counseling; do not switch agent yet — reduction in heavy drinking is a valid clinical response.

Board pearl: Relapse rates ~60% in first year — frame as treatable, expected clinical event; harm reduction (reduced quantity, safer drinking) is legitimate progress.

Ethical, Legal, and Patient Safety Considerations

— Federal regulation grants heightened protection to SUD treatment records from federally-assisted programs — stricter than HIPAA

— Written, signed consent required for most disclosures, including to other treating clinicians

— 2024 amendments aligned more with HIPAA for TPO (treatment/payment/operations) with patient consent

— Implication: primary care notes documenting "AUD" not bound by 42 CFR Part 2 unless from a designated SUD program, but treat sensitively

— Suspected child abuse/neglect in a household with active AUD: mandated reporter duty to call CPS — does not require patient consent

— Impaired driving: state-dependent reporting laws (some require physician report of unfit drivers); document counseling not to drive

— Impaired professional (physician, pilot, commercial driver): state PHP programs and licensing board reporting requirements vary

— Pregnancy: some states mandate reporting of prenatal substance use; know your state law

— Discuss black-box warnings (naltrexone hepatotoxicity), disulfiram-alcohol reaction risk, opioid-blockade implications for emergency analgesia (wallet card for naltrexone patients)

— Intoxicated patients cannot give informed consent for elective procedures; emergent care under emergency exception

— Patients can refuse treatment for AUD while sober and decisional — even if "irrational" by clinician view

— Medication reconciliation at every transition — missing home benzodiazepines causes inpatient withdrawal seizures

— Ensure discharge prescription filled before leaving (meds-to-beds programs)

— Provide naloxone to any patient with opioid co-exposure

— Use "person with AUD" not "alcoholic"; "positive/negative" toxicology not "clean/dirty"

Confidentiality — 42 CFR Part 2

Mandatory reporting

Informed consent for pharmacotherapy

Capacity assessment

Transitions-of-care safety

Stigma and language

Step 3 management: A patient discloses driving drunk to pick up children. Counsel against, document, assess child safety, and in most states file CPS report if children are endangered — clinical duty to protect minors supersedes confidentiality.

Board pearl: 42 CFR Part 2 protections are a favorite Step 3 ethics topic — when in doubt, obtain written patient consent before sharing SUD records, even with other physicians.

High-Yield Associations and Rapid-Fire Clinical Facts

— Standard drink = 14 g ethanol

— Risky use limits: men ≤65 (≤14/week, ≤4/occasion); women & ≥65 (≤7/week, ≤3/occasion); pregnancy = 0

— AUDIT-C cutoffs: ≥4 men, ≥3 women

— AUDIT score: 8/15/20 = hazardous/AUD/severe

— BAC: 0.08 legal, 0.30 stupor, 0.40 potentially fatal

— MDF ≥32 = severe alcoholic hepatitis (steroid candidate)

— Lille ≤0.45 at day 7 = responder, continue steroids

— AST:ALT >2:1 with values <500 → alcoholic hepatitis

— MCV >100 + GGT elevation → heavy drinking

— Thiamine before glucose

— LOT benzodiazepines (Lorazepam, Oxazepam, Temazepam) in liver disease/elderly

— PEth = best biomarker for sustained abstinence monitoring

— Naltrexone reduces heavy drinking days > abstinence days

— Acamprosate maintains abstinence in those already abstinent

— Disulfiram requires supervised motivated patient

— Holiday heart = AF after binge

— Wernicke triad: ophthalmoplegia + ataxia + confusion (only 10% complete)

— Korsakoff: anterograde amnesia + confabulation

— Withdrawal seizures 24–48 h; DTs 48–96 h

— Boerhaave = alcoholic after retching with subQ emphysema

— Acetaminophen + chronic alcohol → hepatotoxicity at lower doses

— Disulfiram + metronidazole → disulfiram-like reaction (avoid combo)

— Alcohol + benzos/opioids → respiratory depression

— Naltrexone + opioids → precipitated withdrawal

— Thiamine (B1) → Wernicke

— Niacin (B3) → pellagra (dermatitis, diarrhea, dementia)

— Folate → macrocytic anemia

— Zinc → dysgeusia, poor wound healing

— Vitamin D → osteoporosis

— Oropharyngeal, esophageal SCC, gastric, colon, HCC, breast (women, dose-dependent even at low levels)

Numbers to know

Pearls

Drug interactions

Vitamin deficiencies

Cancer associations

Board pearl: Female breast cancer risk rises linearly from the first drink — even "moderate" use; this is now part of cancer-prevention counseling.

Board Question Stem Patterns

— 38-year-old man at annual physical drinks "a few beers" daily. Most appropriate next step?

— Answer: Validated screen (AUDIT-C / single-item NIAAA), not LFTs or referral

— AUDIT-C of 6 in a healthy woman; no DSM-5 criteria. Next step?

— Answer: Brief intervention (5 A's / FRAMES), not pharmacotherapy yet

— Patient meets 5 DSM-5 criteria, motivated to cut down. Best initial pharmacotherapy?

— Answer: Naltrexone (oral or IM); acamprosate if hepatic disease/opioid use; disulfiram if highly motivated/supervised

— Child B cirrhosis, wants to stop drinking. Best pharmacotherapy?

— Answer: Acamprosate (or baclofen). Avoid disulfiram; naltrexone caution

— Pregnant patient drinks 1 glass wine/week. Counsel?

— Answer: No safe amount in pregnancy; brief intervention now

— Day 2 of admission, tremor, HR 110, BP 160/95, CIWA 18. Order?

— Answer: Symptom-triggered lorazepam (or chlordiazepoxide), thiamine, folate, Mg/K/Phos

— Day 3, confused, hallucinating, HR 140, T 38.5, on lorazepam q1h. Next step?

— Answer: ICU transfer, escalate benzodiazepine, consider phenobarbital

— Found down, hypothermic, hypoglycemic. Order before D50?

— Answer: Thiamine 500 mg IV

— Completing detox tomorrow. Most important intervention to reduce relapse?

— Answer: Initiate naltrexone (or acamprosate) before discharge + outpatient appointment within 1 week

— Alcoholic father drives kids drunk. Action?

— Answer: Counsel, document, CPS report for child endangerment

— Transplant candidate, monitoring abstinence. Best test?

— Answer: PEth

Stem 1 — The asymptomatic adult

Stem 2 — The positive screen + risky use

Stem 3 — Moderate-severe AUD asking for medication

Stem 4 — Cirrhotic with AUD

Stem 5 — Pregnant patient

Stem 6 — Withdrawal management

Stem 7 — DTs

Stem 8 — AMS in alcoholic

Stem 9 — Discharge planning

Stem 10 — Ethics

Stem 11 — Biomarker

Board pearl: Most-missed Step 3 answer: initiating MAT for AUD in primary care — exam rewards the PCP who prescribes naltrexone, not the PCP who only refers.

One-Line Recap

Alcohol use disorder is a chronic, treatable disease that every primary care clinician must screen for universally (USPSTF Grade B, AUDIT-C or single-item), respond to with brief intervention for risky use, and treat with first-line pharmacotherapy — naltrexone, acamprosate, or disulfiram — combined with behavioral therapy and structured follow-up.

— AUDIT-C ≥4 men / ≥3 women, or NIAAA single item ≥1 → positive

— Use T-ACE/TWEAK in pregnancy, CRAFFT in adolescents

— CAGE is outdated for risky use

— Risky use → brief intervention only

— AUD → BI + pharmacotherapy + behavioral therapy concurrently

— Naltrexone first-line; acamprosate if liver disease or on opioids; disulfiram if supervised + motivated

— Initiate medication at the diagnostic visit — do not defer

— Thiamine before glucose

— Long-acting benzodiazepines (diazepam, chlordiazepoxide) standard; LOT drugs (lorazepam, oxazepam) in elderly/hepatic disease

— Symptom-triggered (CIWA-Ar) dosing reduces total benzo exposure

— Escalate to ICU for CIWA >25, DTs, recurrent seizures, hemodynamic instability

— Discharge with pharmacotherapy + 1-week follow-up + outpatient program intake + naloxone if opioid co-exposure

— Treat psychiatric comorbidity concurrently (SSRIs safe; avoid chronic benzos)

— HCV/HIV/HBV screening; vaccinate; HCC surveillance if cirrhotic

— Mandatory reporter duties (child welfare, impaired drivers, impaired professionals) override confidentiality when public safety threatened

— Use person-first, non-stigmatizing language and harm-reduction framing

Screen everyone, every year

Match treatment to severity and comorbidity

Manage withdrawal safely

Bridge transitions and prevent relapse

Step 3 management: The single highest-yield action across the AUD spectrum on this exam is starting MAT in primary care at the same visit as diagnosis — outperforms any single test, referral, or counseling intervention in trial data.