Alcohol Use Disorder: From Risk to Diagnosis to Recovery

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    Takeaways

    • Alcohol use disorder (AUD) is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as "a problematic pattern of alcohol use leading to clinically significant impairment or distress," and is diagnosed as mild, moderate, or severe based on the number of symptoms, out of a possible 11, in the past 12 months.
    • As it progresses in severity, AUD can cause brain changes that make it difficult to stop drinking, but with prolonged abstinence, at least some AUD-induced brain function changes may improve.
    • A combination of genetic and environmental factors contributes to a person’s vulnerability to AUD.
    • People with AUD can receive effective, science-backed treatment in a variety of settings, including primary care.
    • A small proportion of patients with AUD will need a few days of "detox" to manage potentially dangerous withdrawal symptoms before starting a long-term care plan.
    • Individual paths to recovery vary widely and the majority of people with AUD reduce or resolve their drinking problems over time.

    Whether you care for youth or adults, you are likely to encounter patients with alcohol use disorder (AUD) regularly in your practice. According to a 2019 national survey, about 1 in 14 men, 1 in 25 women, and 1 in 60 adolescents (aged 12-17) meet the diagnostic criteria for AUD.1 Thus, it is important to know how to identify this often-undetected condition, to have a plan for managing it, and to encourage patients that they can recover.

    Here, we briefly share the basics about AUD, from risk to diagnosis to recovery. This article introduces a number of AUD topics that link to other Core articles for more detail.

    A note on drinking level terms in this Core article: Heavy drinking has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

    What is AUD?

    AUD is a medical condition that is characterized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),2 as “a problematic pattern of alcohol use leading to clinically significant impairment or distress.” AUD can be mild, moderate, or severe, depending on the number of symptoms a patient has experienced in the previous 12 months (see next section on symptoms of AUD). As AUD progresses in severity, alcohol-induced changes in the brain can make it very difficult to cut down or quit.3 With prolonged abstinence, however, at least some AUD-induced brain function changes may improve and even reverse4 as other neurocircuits compensate for those compromised by alcohol.5–7 Evidence-based treatment can help people achieve abstinence and facilitate these brain changes. (See Core articles on neuroscience and treatment.)

    Previously, AUD has been referred to as alcohol abuse, alcohol dependence, alcohol addiction, and, colloquially, alcoholism. It is important to note that the terms “alcohol abuse” and “alcoholism” may increase stigma, whereas using the diagnostic term “alcohol use disorder” with patients may help reduce stigma. (See Core article on stigma.)

    The term “addiction” is widely used but is not a diagnosis. When drinking becomes compulsive, it can be considered an addiction.8 In the context of addiction, compulsivity can be described as repetitive behaviors that persevere in the face of adverse consequences and are inappropriate to a particular situation. Individuals who suffer from compulsions often recognize that the behaviors are harmful, but they nonetheless perform them anyway to temporarily reduce tension, stress, or anxiety.9,10

    An alcohol addiction aligns symptomatically with the former diagnosis of alcohol dependence (DSM-IV) and the current diagnoses of moderate or severe AUD (DSM-5).11,12 Alcohol addiction can be framed as a three-stage cycle that serves as a model for translating the brain changes associated with AUD to the clinical domain.13,14 In this model, dysregulation occurs in three functional domains, including incentive salience, negative emotionality, and executive function, that overlap with the three stages of the addiction cycle.

    • The first stage, called the binge/intoxication stage, is associated with the development of incentive salience neurocircuits, which link the pleasurable, rewarding experience of drinking with “cues” such that the cues gain motivational significance. These and other neurocircuits help develop and strengthen habitual drinking and may lay the groundwork for compulsive use of alcohol.
    • The second stage, called the withdrawal/negative affect stage, is associated with states such as anxiety, dysphoria, and irritability, and the  person feels alcohol is needed for relief from discomfort and emotional pain.
    • The third stage, called the preoccupation/anticipation stage, is associated with executive function deficits.

    The three stages are hypothesized to be mediated by three major neurocircuitry elements: the basal ganglia, extended amygdala, and prefrontal cortex, respectively. People who drink heavily can enter the addition cycle at any of these stages. (See the Core article on neuroscience.)

    What are the symptoms of AUD?

    The DSM-5 defines AUD as a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 2 of the following 11 symptoms occurring within a 12-month period.2 The number of symptoms determines the severity: 2 to 3 symptoms for mild AUD, 4 to 5 for moderate, and 6 or more for severe.

    1. Alcohol is often taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
    3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
    4. Craving, or a strong desire or urge to use alcohol.
    5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
    6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
    7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
    8. Recurrent alcohol use in situations in which it is physically hazardous.
    9. 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.
    10. Tolerance, as defined by either of the following:
      1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
      2. A markedly diminished effect with continued use of the same amount of alcohol.
    11. Withdrawal, as manifested by either of the following:
      1. The characteristic withdrawal syndrome for alcohol (See the “How is alcohol withdrawal managed?” section for some DSM-5 symptoms of withdrawal).
      2. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

    Healthcare professionals can use an Alcohol Symptom Checklist [PDF – 80 KB] based on these criteria to diagnose AUD and determine its level of severity in patients who screen positive for heavy drinking. (See Core article on screening and assessment.) Routinely integrating such a checklist into primary care may make it easier to hold comfortable, patient-centered, non-judgmental conversations about alcohol that help destigmatize AUD and its treatment.15,16 (See Core article on stigma.)

    Whether or not your patients who drink heavily have AUD, you can help motivate them to cut back or quit17 as needed by providing advice and assistance, to include noting how alcohol­­ may be causing or worsening other health conditions they may have (see Core articles on brief intervention, medical complications, and mental health issues).

    What puts people at risk for developing AUD?

    A complex interplay of genetic and environmental factors influences a person’s risk for AUD. (See Core article on risk factors.) Between 50% and 60% of the vulnerability to AUD is inherited.18,19  This risk is likely due to common variants in many genes, each of small effect.20 Different genes confer risk by affecting a variety of biological processes and mental states and traits, including, for example, addiction-related neurobiology, physiological responses to alcohol and stress, co-morbid psychiatric conditions, and behavioral tendencies such as impulsivity.18,19

    Among the environmental risk factors for AUD, external stress may be one of the most potent.20–22 Your patients who experienced trauma, particularly in childhood, or an accumulation of significant stressors throughout life, may be prone to developing AUD and to relapsing in response to stress during recovery.20,22 The type of stressor combines with a person’s genetic makeup and drinking history to influence the stress response. Furthermore, once moderate to severe AUD is established, the brain’s stress circuits activate during acute and protracted withdrawal, which fuels negative emotional states and helps to maintain the addition cycle. (See Core article on neuroscience.) Indeed, negative emotional states are the leading precipitant of relapse.23,24

    Additional risk factors for AUD include other mental health conditions, heavy drinking, and the age of onset of drinking, each of which can be influenced by a combination of genetic and environmental factors. People with mental health conditions, including anxiety, depression, and PTSD, have a greater risk for AUD, and vice versa. (See Core article on mental health issues.) And the odds of having AUD are markedly increased among those with heavy drinking patterns25 and those who started drinking in adolescence, with earlier onset of drinking linked with greater risk of AUD.26,27

    How is AUD treated?

    One size does not fit all when it comes to treatment for patients with AUD. The good news is, there are more treatment and support options than many people expect. Healthcare professionals offer two evidence-based options—AUD-focused behavioral healthcare and FDA-approved AUD medications. Many patients also benefit from active participation in mutual support groups such as Alcoholics Anonymous (AA) or a number of secular alternatives (see Resources), either on their own or as a complement to professionally offered treatment.28

    The behavioral health and medication options for AUD offered by healthcare professionals are about equally effective28 and can be combined and tailored to the needs of each patient:

    • Behavioral healthcare for AUD includes cognitive-behavioral, motivational enhancement, mindfulness-based, contingency management, 12-step facilitation, and couples or family therapy.
    • Medication options for AUD include newer FDA-approved medications (acamprosate and naltrexone) that some patients may find more appealing than the older medication (disulfiram) that makes people feel sick if they drink alcohol.29 AUD medications are non-addicting and easy to prescribe in primary care. (See prescribing guides in the Resources, below.)

    Healthcare professionals offer AUD care in more settings than just specialty addiction programs. Addiction physicians and therapists in solo or group practices can also provide flexible outpatient care. These and other outpatient options may reduce stigma and other barriers to treatment. Telehealth specialty services and online support groups, for example, can allow people to maintain their routines and privacy and may encourage earlier acceptance of treatment. The NIAAA Alcohol Treatment Navigator can help you connect patients with the full range of evidence–based, professional alcohol treatment providers.

    Active participation in a mutual support group can benefit many people as well.28 Groups vary widely in beliefs and demographics, so advise patients who are interested in joining a group to try different options to find a good fit. In addition to widely recognized 12-step programs with spiritual components such as AA, a number of secular groups promote abstinence as well, such as SMART Recovery, LifeRing, Women for Sobriety, Secular Organizations for Sobriety, and Secular AA (see Resources, below, for links).

    See the Core article on treatment for more details.

    How is alcohol withdrawal managed?

    Alcohol withdrawal can be life threatening if patients who chronically engage in heavy drinking stop drinking suddenly, rather than cutting back gradually or stopping drinking with medical support. (See Core article on treatment.) Up to half of AUD patients will have some withdrawal symptoms when they stop drinking, and a small proportion will need medical care and monitoring, or “detox,” to manage potentially dangerous symptoms.30,31 Alcohol withdrawal accounts for approximately 260,000 emergency department visits32 and 850 deaths each year.33

    According to the DSM-5, symptoms of withdrawal include:

    • Tremors
    • Elevated pulse and blood pressure
    • Insomnia
    • Anxiety
    • Sweating
    • Nausea or vomiting
    • Seizures
    • Delirium tremens

    In addition, many patients with AUD experience dysphoria and irritability when the effects of alcohol are wearing off. (See Core article on neuroscience.)

    Some withdrawal symptoms may be managed in an outpatient detox setting, whereas intensive inpatient detox is needed for patients at risk for potentially life-threatening symptoms. Assessment tools are available to help predict which patients will be at high risk for severe withdrawal symptoms.28,34 Treatment for acute withdrawal symptoms includes benzodiazepines, considered the gold standard with the deepest evidence base,35 along with other possible adjunct treatments.28,34 For more information, see the Alcohol Withdrawal Management Guideline developed by the American Society of Addiction Medicine.36

    Detox can be a critical first step toward recovery but it is not, in itself, “alcohol treatment.” Treatment and continuing care for AUD are measured in months and sometimes years, not just a few days of detox. (See the Core articles on treatment and recovery.)

    What does recovery look like?

    Recovery is a dynamic, individualized process through which a person pursues two clinical goals, cessation from heavy drinking and remission from AUD symptoms (except craving, see Core article on recovery).37 If people achieve both aims and maintain them over time, they are considered clinically recovered from AUD. Importantly, recovery is often marked by additional improvements in physical health, mental health, relationships, spirituality, and other measures of well-being, which in turn, help sustain recovery. NIAAA has developed a recovery definition that reflects these and other aspects of recovery.37

    While individual paths to recovery vary widely, the majority of people with AUD reduce or resolve their drinking problems over time, with studies showing a reliable pattern of improvement that counters views of AUD as an inevitably worsening disorder.38–40 The first year can be a mix of gains and setbacks, but in the long term, quality of life measures typically increase and psychological distress decreases.41

    Some patients with AUD may be hesitant to commit to abstinence, but they may be willing to set a starting goal to cut down on their drinking. You can encourage them by sharing the benefits of cutting down significantly, at least as a first step, while noting that abstinence is the safest strategy. (See Core article on brief intervention.)

    Even people who have some heavy drinking days following treatment often cut their drinking and related problems by more than half42 and may feel and function as well as those who do not drink heavily.43,44 It’s important to acknowledge these marked improvements, which may often be overlooked.45 (See Core article on recovery.)

    As mentioned in this article, you can support recovery by offering patients AUD medication in primary care, referring to healthcare professional specialists as needed, and promoting mutual support groups. See the Core article on recovery for additional, effective strategies that can help your patients prevent or recover from a relapse to heavy drinking, including managing stress and negative moods, handling urges to drink, and building drink refusal skills.

    In closing, as a healthcare professional, you are in a prime position to make a difference in the lives of your patients who are vulnerable to AUD, may be in the process of developing AUD, or currently have AUD, by identifying the condition through alcohol screening and assessment, recommending evidence-based treatment, and supporting patients on their individual paths to recovery. The NIAAA Core Resource on Alcohol can help you each step of the way.

    Resources

    Alcohol Use Disorder Medication Guides

    Alcohol SBIRT Resources Related to this Article

    Mutual Support Groups

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

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    18. Reilly MT, Noronha A, Goldman D, Koob GF. Genetic studies of alcohol dependence in the context of the addiction cycle. Neuropharmacology. 2017;122:3-21. doi:10.1016/j.neuropharm.2017.01.017
    19. Goldman D, Oroszi G, Ducci F. The genetics of addictions: uncovering the genes. Nat Rev Genet. 2005;6(7):521-532. doi:10.1038/nrg1635
    20. Enoch MA. Genetic influences on the development of alcoholism. Curr Psychiatry Rep. 2013;15(11):412. doi:10.1007/s11920-013-0412-1
    21. Anthenelli R, Grandison L. Effects of Stress on Alcohol Consumption. Alcohol Res Curr Rev. 2012;34(4):381-382.
    22. Sinha R. How Does Stress Lead to Risk of Alcohol Relapse? Alcohol Res Curr Rev. 2012;34(4):432-440.
    23. Marlatt GA. Determinants of Relapse: Implications for the Maintenance of Behavior Change. In: Davidson PO, Davidson SM, eds. Behavioral Medicine: Changing Health Lifestyles. Brunner/Mazel; 1980:410-452.
    24. Lowman C, Allen J, Stout RL. Replication and extension of Marlatt’s taxonomy of relapse precipitants: overview of procedures and results. The Relapse Research Group. Addict Abingdon Engl. 1996;91 Suppl:S51-71.
    25. Dawson DA, Li TK, Grant BF. A Prospective Study of Risk Drinking: At Risk for What? Drug Alcohol Depend. 2008;95(1-2):62-72. doi:10.1016/j.drugalcdep.2007.12.00
    26. Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence: age at onset, duration, and severity. Arch Pediatr Adolesc Med. 2006;160(7):739-746. doi:10.1001/archpedi.160.7.739
    27. Hingson R, Heeren T, Zakocs R, Winter M, Wechsler H. Age of first intoxication, heavy drinking, driving after drinking and risk of unintentional injury among U.S. college students. J Stud Alcohol. 2003;64(1):23-31. doi:10.15288/jsa.2003.64.23
    28. Witkiewitz K, Litten RZ, Leggio L. Advances in the science and treatment of alcohol use disorder. Sci Adv. 2019;5(9):eaax4043. doi:10.1126/sciadv.aax4043
    29. Wallhed Finn S, Bakshi AS, Andréasson S. Alcohol consumption, dependence, and treatment barriers: perceptions among nontreatment seekers with alcohol dependence. Subst Use Misuse. 2014;49(6):762-769. doi:10.3109/10826084.2014.891616
    30. Mirijello A, D’Angelo C, Ferrulli A, et al. Identification and management of alcohol withdrawal syndrome. Drugs. 2015;75(4):353-365. doi:10.1007/s40265-015-0358-1
    31. Hall W, Zador D. The alcohol withdrawal syndrome. Lancet Lond Engl. 1997;349(9069):1897-1900. doi:10.1016/S0140-6736(97)04572-8
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    34. Wood E, Albarqouni L, Tkachuk S, et al. Will This Hospitalized Patient Develop Severe Alcohol Withdrawal Syndrome?: The Rational Clinical Examination Systematic Review. JAMA. 2018;320(8):825-833. doi:10.1001/jama.2018.10574
    35. Sachdeva A, Choudhary M, Chandra M. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. J Clin Diagn Res JCDR. 2015;9(9):VE01-VE07. doi:10.7860/JCDR/2015/13407.6538
    36. American Society of Addiction Medicine. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. Published online January 23, 2020. Accessed November 3, 2021. https://journals.lww.com/10.1097/ADM.0000000000000668
    37. Hagman BT, Falk D, Litten R, Koob GF. Defining Recovery From Alcohol Use Disorder: Development of an NIAAA Research Definition. Am J Psychiatry. 2022 Apr 12:appiajp21090963. doi: 10.1176/appi.ajp.21090963. Epub ahead of print. PMID: 35410494.
    38. Kelly JF, Bergman B, Hoeppner BB, Vilsaint C, White WL. Prevalence and pathways of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy. Drug Alcohol Depend. 2017;181:162-169. doi:10.1016/j.drugalcdep.2017.09.028
    39. Fan AZ, Chou SP, Zhang H, Jung J, Grant BF. Prevalence and Correlates of Past-Year Recovery From DSM-5 Alcohol Use Disorder: Results From National Epidemiologic Survey on Alcohol and Related Conditions-III. Alcohol Clin Exp Res. 2019;43(11):2406-2420. doi:10.1111/acer.14192
    40. Tucker JA, Chandler SD, Witkiewitz K. Epidemiology of Recovery From Alcohol Use Disorder. Alcohol Res Curr Rev. 2020;40(3):02. doi:10.35946/arcr.v40.3.02
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    42. Miller WR, Walters ST, Bennett ME. How effective is alcoholism treatment in the United States? J Stud Alcohol. 2001;62(2):211-220. doi:10.15288/jsa.2001.62.211
    43. Falk DE, O’Malley SS, Witkiewitz K, et al. Evaluation of Drinking Risk Levels as Outcomes in Alcohol Pharmacotherapy Trials: A Secondary Analysis of 3 Randomized Clinical Trials. JAMA Psychiatry. 2019;76(4):374-381. doi:10.1001/jamapsychiatry.2018.3079
    44. Witkiewitz K, Pearson MR, Wilson AD, et al. Can Alcohol Use Disorder Recovery Include Some Heavy Drinking? A Replication and Extension up to 9 Years Following Treatment. Alcohol Clin Exp Res. 2020;44(9):1862-1874. doi:10.1111/acer.14413
    45. Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcohol Clin Exp Res. 1998;22(6):1300-1311. doi:10.1111/j.1530-0277.1998.tb03912.x
    Earn CME/CE Credit

    We invite healthcare professionals including primary care physicians, physician assistants, nurses, pharmacists, and psychologists to complete a post-test after reviewing this article to earn FREE continuing education (CME/CE) credit. This CME/CE credit opportunity is jointly provided by the Postgraduate Institute for Medicine and NIAAA.

    CME/CE Activity — Alcohol Use Disorder: From Risk to Diagnosis to Recovery

    Released on 5/6/2022
    Expires on 5/10/2023

    Complete CME/CE Post-Test

    Please note that you will need to log into or create an account on CME University in order to complete this post-test.

    Learning Objectives

    After completing this activity, the participant should be better able to:

    • Describe the DSM-5 diagnosis of AUD, including awareness of major symptoms and levels of severity.
    • Identify major risk factors contributing to the development of AUD.
    • List evidence-based options for treatment of AUD.
    • Describe symptoms of alcohol withdrawal.

    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writers for the full article, content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    NIAAA Writers and Content Contributors

    George F. Koob, PhD
    Director, NIAAA

    Rachel I. Anderson, PhD
    Health Science Policy Analyst, NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    External Reviewers

    Louis E. Baxter Sr., MD, DFASAM
    Assistant Professor Medicine, ADM
    Fellowship Director, Howard University
    Hospital, Washington, DC;
    Assistant Clinical Professor Medicine
    Rutgers Medical School, Newark, NJ

    John H. Krystal, MD
    Chair, Department of Psychiatry
    Yale School of Medicine, New Haven, CT

    Jessica L. Mellinger, MD MSc
    Assistant Professor, Gastroenterology,
    Internal Medicine, Transplant Hepatology,
    Michigan Medicine, Ann Arbor, MI

    Kenneth J. Sher, PhD
    Curators’ Distinguished Professor of
    Psychological Sciences,
    University of Missouri, Columbia, MO

    Katie Witkiewitz, PhD
    Professor, Department of Psychology,
    University of New Mexico, Albuquerque, NM

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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