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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- AUD is diagnosed by >=2 DSM-5-TR substance-use criteria in 12 months; mild 2-3, moderate 4-5, severe >=6
- Screen with AUDIT-C or single-question screening; assess withdrawal risk before abrupt cessation
- First-line medications: naltrexone or acamprosate; disulfiram for selected supervised patients
- Give thiamine before glucose in malnourished/high-risk patients
- Withdrawal management alone is not AUD treatment
Overview
Alcohol use disorder includes impaired control, social impairment, risky use, tolerance, and withdrawal related to alcohol. Assessment includes quantity/frequency, binge episodes, blackouts, injuries, driving risk, withdrawal history, medical complications, psychiatric comorbidity, pregnancy status, and goals.
Epidemiology
Alcohol is a major preventable cause of morbidity and mortality. AUD is associated with liver disease, pancreatitis, hypertension, cardiomyopathy, cancer, trauma, suicide, depression, anxiety, fetal alcohol spectrum disorders, and intimate partner violence.
Clinical Features
Symptoms
Craving, inability to cut down, time spent using/recovering
Role failure, interpersonal conflict, hazardous use such as driving intoxicated
Tolerance and withdrawal: tremor, sweating, insomnia, nausea, anxiety, seizures
Blackouts, injuries, pancreatitis, gastritis, liver disease, neuropathy
Suicidality, intoxication with trauma/respiratory depression, pregnancy, severe withdrawal history
Signs
Alcohol odor, tremor, hypertension, tachycardia, diaphoresis, ataxia
Hepatomegaly, jaundice, ascites, spider angiomas, palmar erythema
Wernicke: confusion, ophthalmoplegia/nystagmus, ataxia
Peripheral neuropathy, cerebellar gait, malnutrition, bruising
Investigations
First-line
Screening/DSM-5-TR assessmentAUDIT-C/AUDIT; severity by DSM-5-TR criteria
Withdrawal riskPrior seizures/DTs, daily heavy use, time since last drink, CIWA-Ar when symptomatic
Baseline labsCBC, CMP/LFTs, INR, Mg, phosphate, hepatitis/HIV when indicated, pregnancy test
Second-line
Alcohol biomarkersPEth, CDT, GGT, AST:ALT >2 support assessment but do not diagnose
Comorbidity screenDepression, suicide, anxiety, PTSD, other SUDs, domestic violence
Complication workupLiver, pancreatitis, neuropathy, cardiomyopathy evaluation based on symptoms
Specialist
Addiction medicine/psychiatrySevere AUD, pregnancy, polysubstance use, high withdrawal risk, failed outpatient care
Inpatient detoxificationHistory of DTs/seizures, severe symptoms, serious medical illness, pregnancy, lack of support
1
Engagement
- Use motivational interviewing and harm-reduction framing
- Do not advise unsupervised abrupt cessation if dependent or prior severe withdrawal
- Plan around intoxication, driving, firearms, and suicidality
2
Medication
- Naltrexone PO or monthly IM reduces heavy drinking/craving; avoid current opioid use, acute hepatitis, liver failure
- Acamprosate supports abstinence; preferred with liver disease but limited by renal impairment
- Disulfiram causes acetaldehyde reaction; use only when highly motivated and supervised
3
Recovery and nutrition
- CBT, motivational enhancement, contingency management, family therapy, AA/SMART Recovery
- Treat depression/anxiety after assessing alcohol contribution
- Thiamine before glucose; add folate, multivitamin, Mg/phosphate when needed
Complications
- Alcohol withdrawal, seizures, DTs:
- Wernicke-Korsakoff syndrome:
- Steatosis, alcoholic hepatitis, cirrhosis, varices, HCC:
- Pancreatitis/gastritis:
- Hypertension, atrial fibrillation, cardiomyopathy:
- Depression, anxiety, suicide:
USMLE Step 2 CK Exam Tips
- 1Thiamine before glucose
- 2Naltrexone cannot be used with current opioids
- 3Acamprosate is liver-friendly but renal-limited
- 4Disulfiram is not first-line for most
- 5Prior withdrawal seizure/DT = monitored withdrawal
- 6Macrocytosis and AST:ALT >2 are classic clues
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