For many people, alcohol seems inextricably linked with a social life. Friends gather for after-work drinks, spouses have cocktails together for “date nights” or some may just be in the habit of ending the day with a beer or a glass of wine—or two—or more. It can be hard to identify the lines between casual and occasional drinking and unhealthy alcohol use including alcohol use disorder.
In general, when people continue to drink alcohol despite negative social, health, and possibly legal consequences, it can be said that their drinking is “unhealthy.” Whether it takes the form of frequent or daily alcohol use or binge drinking, excessive drinking increases the risk of developing alcohol use disorder (AUD)—previously referred to as alcoholism—a chronic brain disease that can go into remission, but not cured.
Alcohol use disorder is common. In 2019, an estimated 14.5 million people in the United States had an AUD. What’s more, according to the Centers for Disease Control and Prevention (CDC), excessive alcohol use leads to over 95,000 deaths in the U.S. every year.
Fortunately, AUD is a treatable disease. With the use of appropriate medications and behavioral therapies, people can recover from AUD.
“Treatments for AUD are sorely underused, despite decades of research supporting their effectiveness and safety," says Stephen R. Holt, MD, associate professor of medicine, internal medicine, at the Yale School of Medicine. “These medications and behavioral approaches are the gold standard of care, and are increasingly available in both specialist and primary care settings.”
What is alcohol use disorder?
Like many other substance use disorders, alcohol use disorder is a chronic and sometimes relapsing condition that reflects changes in the brain. This means that when people with the disorder are abstaining from alcohol, they are still at increased risk of resuming unhealthy alcohol consumption, even if years have passed since their last drink.
People who have AUD may continue to use alcohol even though they know it is causing social, health, economic, and possibly even legal problems in their life.
It is important to remember that AUD is not due to an individual’s lack of self-discipline or resolve. Rather, it is a brain disease that can be inherited. Long-term alcohol use can produce changes in the brain that can cause people to crave alcohol, lose control of their drinking and require greater quantities of alcohol to achieve its desired effects. It can also cause people to experience withdrawal symptoms if they discontinue alcohol use.
What is unhealthy drinking?
People who drink too much alcohol are at risk of developing a host of health conditions and disorders including certain types of cancer, liver disease, and heart disease. Excessive alcohol consumption can damage the brain and other organs, and it also increases the chances of developing sleep problems, depression, and other mental health problems. Alcohol can interfere with a person’s ability to care for their other medical conditions or make other medical conditions worse.
So, what constitutes “too much” alcohol? In general, alcohol consumption is considered too much—or unhealthy—when it causes health or social problems. This broad category of alcohol consumption comprises a continuum of drinking habits including at-risk drinking, binge drinking, and AUD.
At-risk (or risky) drinking. Drinking a quantity of alcohol that increases the risk for alcohol-related health problems. At-risk drinking is sometimes referred to as hazardous or heavy drinking, and it is generally defined by the amount of alcohol someone drinks, on average, in a day or week:
- Men: more than 4 drinks/day, or more than 14 drinks/week
- Women: more than 3 drinks/day, or more than 7 drinks/week
- Men and Women over age 65: More than 3 drinks/day, or more than 7 drinks/week
Binge drinking. Defined by the amount of alcohol a person drinks over a period of 2 to 3 hours. Binge drinking is common and can result in injuries and death from accidents and violence while also raising the risk for cancer, heart disease, and other chronic conditions.
- Men: 5 or more drinks in a 2- to 3-hour period
- Women: 4 or more drinks in a 2- to 3-hour period
Though at-risk and binge drinking can result in a range of adverse consequences, not all people who engage in these kinds of unhealthy alcohol use have alcohol use disorder. They are, however, at increased risk for it.
How is alcohol use disorder diagnosed?
A person who regularly consumes alcohol who has two or more of the following signs and symptoms within a period of one year may be diagnosed with AUD:
- Consuming alcohol in greater quantities or for longer than planned
- Unsuccessful attempts to reduce or manage alcohol use
- Expending a lot of time acquiring, using, or recovering from alcohol
- Feeling compelled to consume alcohol
- Alcohol use recurrently hinders ability to successfully complete important tasks at home, work, or school
- Continuing alcohol use despite problems it causes in interacting with others
- Foregoing or limiting participation in important activities at home, work, or school
- Repeated use of alcohol in physically dangerous circumstances (e.g., while operating a motor vehicle)
- Continuing to use alcohol despite knowing that it is the cause of or exacerbates mental or physical problems
- Developing tolerance to alcohol, meaning that greater quantities of alcohol are required to become intoxicated
- Experiencing symptoms of withdrawal if alcohol use is stopped, or consuming alcohol to alleviate symptoms of withdrawal
The severity of the disorder ranges from mild to severe, depending on how many signs and symptoms a person has experienced:
- Mild: 2–3 symptoms
- Moderate: 4–5 symptoms
- Severe: 6 or more symptoms
What are the risk factors for alcohol use disorder?
A number of factors increase the chances that someone will develop an alcohol use disorder:
- Family history of alcohol use disorder and other substance use disorders
- Availability of alcohol
- Heavy alcohol use
- Binge drinking
- Permissive societal attitudes towards alcohol use
- History of childhood abuse
- History of conduct or mood disorder in childhood
- Having mental health conditions such as depression or post-traumatic stress disorder
How is alcohol use disorder treated?
Treatments for alcohol use disorder include medications as well as counseling and behavioral therapies. Treatment plans often incorporate a combination of medication therapy and behavioral approaches. Treatment may take place in an outpatient setting or at a part- or full-time residential facility.
In general, treatments for alcohol use disorder aim to alleviate withdrawal symptoms, stop or reduce alcohol use, and give patients behavioral skills and knowledge that can help them either stop drinking or maintain a healthy level of alcohol use.
Withdrawal and Detoxification. For people who have alcohol use disorder, stopping their drinking is an important first step. This process, however, can bring about the unpleasant and potentially serious symptoms of alcohol withdrawal syndrome. These include increased heart rate, sweating, anxiety, tremors, nausea and vomiting, heart palpitations, and insomnia. In more severe cases, people may also have seizures or hallucinations.
The most severe form of alcohol withdrawal is known as alcohol withdrawal delirium or delirium tremens, often referred to as the DTs. Symptoms (which are typically experienced in addition to others caused by alcohol withdrawal) include delirium (confusion), high blood pressure, and agitation. Delirium tremens can be fatal.
Medically managed withdrawal or detoxification can be safely carried out under medical guidance. Medications, such as benzodiazepines, are given to help control withdrawal symptoms. If necessary, patients may receive intravenous fluids, vitamins, and other medications to treat hallucinations or other symptoms caused by withdrawal.
After withdrawal, doctors recommend that patients continue treatment to address the underlying alcohol use disorder and help them maintain abstinence from or achieve a reduction in alcohol consumption.
Medications. The Food and Drug Administration (FDA) has approved three medications for the treatment of alcohol use disorder. In general, these medications aim to reduce cravings and consumption of alcohol:
- Naltrexone. By blocking alcohol from interacting with certain receptors in the brain, naltrexone reduces the pleasurable feelings brought on by alcohol consumption and lessens cravings for alcohol. Naltrexone is often provided as a monthly injection.
- Acamprosate. Consumption of alcohol can disturb the balance of certain chemicals in the brain. By helping to re-balance these chemicals, acamprosate lessens the craving for alcohol.
- Disulfiram. This medication discourages alcohol use by causing uncomfortable symptoms including nausea, diarrhea, and vomiting when alcohol is consumed.
- Family counseling. For people with alcohol use disorder and their families, this form of therapy helps all involved to identify and face consequences of alcohol use in order to support reduction in or abstinence from alcohol consumption.
- Mutual help groups. These include 12-step facilitation therapy programs like Alcoholics Anonymous in which participants actively help and support one another in their recovery from alcohol use disorder.
Counseling and behavioral therapy.
- Cognitive-behavioral therapy (CBT). This form of therapy is based on the principle that one’s thoughts, feelings, and behaviors can all influence one another. The goal is to help patients reduce or stop alcohol use by adjusting patterns of thinking and feeling that can lead to consumption of alcohol.
- Motivational enhancement therapy. This therapy helps people identify and accept ambivalent feelings about drinking with the goal of strengthening a commitment to reduced drinking or abstinence.
Is alcohol use disorder treatment different for pregnant women and mothers of newborns?
Consumption of alcohol can affect both mother and fetus. In fact, the consumption of alcohol by pregnant women is the leading cause of preventable birth defects in the U.S., and it can cause a particular constellation of problems called fetal alcohol syndrome. Women who have alcohol use disorder may benefit from treatment with medications and behavioral therapies, and in general, discontinuation of alcohol consumption during pregnancy improves outcomes for the baby.
What is the outlook for people who have alcohol use disorder?
Alcohol use disorder is a chronic brain disease, and people who have the disorder and stop drinking are prone to relapse. AUD is associated with a range of health problems, from liver disease to heart disease to certain types of cancer to depression, to name a few.
But AUD is a treatable disease and remission is possible. Medications can make detoxification safe while avoiding the worst symptoms of withdrawal. And medications and behavioral therapies can help people with AUD reduce alcohol intake or abstain from alcohol altogether.
What makes Yale Medicine’s approach to alcohol use disorder unique?
Yale Medicine’s approach to alcohol use disorder is evidence-based, integrated, and individualized. Our specialists utilize a range of medication and behavioral methods with demonstrated efficacy for helping individuals change their drinking habits and maintain these changes long-term. Care is integrated with patients’ other health care to improve treatment access, reduce costs, and promote better physical and mental health outcomes.
“We tailor treatment plans to patients’ individual needs and preferences from alcohol abstinence to alcohol harm reduction strategies,” says Lisa Fucito, PhD, an associate professor of psychiatry at Yale School of Medicine.