Version July 2025
INTRODUCTION —
The degree to which individuals consume alcohol varies greatly, as does alcohol's impact on health and the risk of associated behavioral and medical problems [1]. An estimated 4 to 40 percent of patients with medical and surgical needs experience problems related to alcohol [2]. The annual economic cost of alcohol use is estimated to be over $250 billion [3]. In the years 2020 to 2021 in the United States, excessive alcohol use resulted in 178,000 deaths per year or 488 deaths per day, representing a 29 percent increase from previously [4,5].
Unhealthy alcohol use ranges from use that puts patients at risk of health consequences to use causing multiple medical and/or behavioral problems meeting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision diagnostic criteria for alcohol use disorder [6].
The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of patients with unhealthy alcohol use, including alcohol use disorder, are reviewed here. Screening and brief intervention for unhealthy alcohol use are reviewed separately. Pharmacotherapy, psychosocial treatment, and medically supervised withdrawal for patients with alcohol use disorder are also reviewed separately.
●(See "Screening for unhealthy use of alcohol and other drugs in primary care".)
●(See "Alcohol use disorder: Pharmacologic management".)
●(See "Alcohol use disorder: Psychosocial management".)
●(See "Management of moderate and severe alcohol withdrawal syndromes".)
●(See "Alcohol withdrawal: Ambulatory management".)
TERMINOLOGY —
Many terms have been used to describe alcohol use and alcohol-related problems and disorders; this terminology has continued to evolve over time. The most useful, consistently defined terms are discussed below:
●Unhealthy alcohol use – Unhealthy alcohol use encompasses the spectrum of alcohol use that can result in health consequences [7], including:
•Use of amounts that risk consequences
•Use that has already resulted in consequences but does not yet meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria of alcohol use disorder [6]
•Use accompanied by features meeting DSM-5-TR diagnostic criteria for alcohol use disorder
●Risky use – Risky alcohol use refers to consumption of an amount of alcohol that puts an individual at risk for health consequences. By definition, the consequences people with risky alcohol use face are not severe enough to meet diagnostic criteria for an alcohol use disorder. Individuals with risky alcohol use may go on to develop an alcohol use disorder [8].
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) in the United States has estimated consumption amounts of alcohol that increase health risks [8]:
•Males under age 65
-More than 14 standard drinks per week on average
-More than 4 drinks on any day
•Females (all ages) and males 65 years and older
-More than 7 standard drinks per week on average
-More than 3 drinks on any day
Specifying these thresholds is an inexact science based on epidemiologic evidence. Amounts are based on a "standard drink," which is defined as 14 grams of ethanol, as found in 5 ounces of wine, 12 ounces of beer, or 1.5 ounces of 80 proof spirits. The number and size of drinks that define risky amounts varies internationally.
Smaller amounts of regular alcohol use can constitute risky use in specific groups (eg, pregnant women, or people who experience alcohol-associated injuries or infection with a sexually transmitted diseases).
Synonyms for risky use include hazardous use and at-risk use. Heavy alcohol use, a related term without a well-specified, widely accepted definition, can refer to a pattern over time or to a single episode of heavy drinking.
●Binge drinking – Binge drinking has been defined by the NIAAA as "drinking so much within about two hours that blood alcohol concentration levels reach 0.08 g/dL" [8]. In women, this typically occurs after consuming approximately four standard drinks, and, in men, after approximately five standard drinks. Binge drinking is associated with acute injuries due to intoxication and may be associated with an increased cardiovascular risk [9]. Roughly one-third of alcohol-related deaths result from binge drinking or drinking too much on one occasion [4,5].
●Alcohol use disorder – Alcohol use disorder is defined by the DSM-5-TR as a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by 11 specific psychosocial, behavioral, or physiologic criteria (table 1) [6] (see 'Diagnosis' below). It is important to note that DSM-5-TR definition of alcohol use disorder encompasses previously defined alcohol abuse and alcohol dependence, which are now outdated terms.
EPIDEMIOLOGY
Alcohol use — Alcohol use is common in adults. As an example, among individuals over the age of 12 years in the United States who participated in the National Survey on Drug Use and Health [10]:
●79 percent used alcohol in their lifetime
●48 percent used alcohol at least once in the past 30 days
●22 percent reported a heavy drinking episode (five or more drinks on one occasion) in the past month (ie, binge episode)
●6 percent reported heavy alcohol use (more than five drinks on five or more occasions) in the past month
Levels of alcohol consumption in resource-rich countries, such as the United States, have stabilized; however, evidence suggests that alcohol consumption is increasing in many resource-limited countries, raising the concern that these countries will face increasing alcohol-related health problems [11-13].
Unhealthy and risky use — Nearly 3 in 10 adults in the United States use alcohol in an unhealthy manner and therefore require some form of intervention as part of their health care. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has reported rates of alcohol consumption among United States adults, with 28 percent exceeding the NIAAA limits for risky use, 19 percent exceeding daily limits, and 9 percent exceeding daily and weekly limits [8].
DSM-5-TR alcohol use disorder — Data from the National Survey on Drug Use and Health showed that 10 percent of adults over 12 years old met criteria for an alcohol use disorder in the past year, with over 90 percent of those in need of treatment not receiving it [10].
Risk factors — Risk factors for lifetime alcohol use disorder include [14]:
●Male gender
●Age 18 to 29
●Being Native American or from a White population
●Significant disability
●Other substance use disorder
●Mood disorder (eg, major depression, bipolar disorder)
●Personality disorder (eg, borderline or antisocial personality)
Higher than average rates of alcohol use disorder have also been reported among transgender populations; one survey suggested that among transgender adults, heavy drinking episodes (binges) were associated with transphobic discrimination (adjusted odds ratio 4.13) [15].
Genetic risk factors are discussed below. (See 'Genetics' below.)
PATHOGENESIS —
The pathogenesis of alcohol use disorder is not known, but its development may be the result of a complex interplay of the following:
●Genetics – It has been estimated that genetic factors are responsible for approximately 50 percent of the vulnerabilities related to alcohol use disorder [16].
●Environmental influences – Environmental influences can be categorized as intrafamilial influences, including prenatal exposure and parenting patterns, and peer influences [17-19].
●Specific personality traits – Personality phenotypes implicated in association with alcohol use disorder includes neuroticism, impulsivity, and extroversion [20].
●Cognitive functioning – Disorders of cognition, especially cognitive dysfunction, may be associated with the development of alcohol use disorders [21].
Several theoretical pathways have emerged to explain why some individuals who drink alcohol go on to develop an alcohol use disorder [20,22,23]. Research suggests that these pathways are not mutually exclusive, which may explain the variable trajectory of alcohol use in the population. Several of these theoretical pathways are described below:
●Stress and negative-affect internalizing pathways suggest that drinking patterns emerge to relieve negative feelings (ie, the self-medication hypothesis) and are associated with exposure to stress and trauma in early development.
●Pharmacologic vulnerability postulates that individuals differ in response to alcohol's acute and chronic effects and recognizes the complex interplay between neurobiology and environmental cues that influence drinking behavior.
●The deviance proneness pathway proposes that alcohol consumption is part of an overall picture of social deviance arising in childhood and resulting from deficient socialization. Additionally, this model suggests that children of parents with alcohol use disorder are at risk for a predisposition to behavioral undercontrol.
Pooled data from six cohort studies of over 39,000 participants found that risky alcohol use over time is associated with increasing extraversion, and decreased emotional stability, agreeableness, and conscientiousness [24].
Genetics — Genetic influences produce alcohol-related phenotypes that, in combination with environmental factors, increase the risk of alcohol-related problems [25]. These phenotypes include:
●A low level of response to alcohol
●Personality characteristics, such as impulsivity and behavioral disinhibition
●Alcohol-related psychiatric symptoms
Some genetic factors may decrease the risk of alcohol use disorder. As an example, a flushing reaction occurs in individuals homozygous for the gene that codes the enzyme aldehyde dehydrogenase (ALDH2), which breaks down acetaldehyde, one of the byproducts of alcohol metabolism [26]. Various specific genes have been proposed as important in these and other factors related to the genetic risk for alcohol problems. Genome-wide association studies have added to the understanding of the genetic predisposition to alcohol use disorder by identifying a heterogenous list of single-nucleotide polymorphisms associated with alcohol-related phenotypes [27].
CLINICAL MANIFESTATIONS
●Medical consequences – Medical consequences of alcohol drinking may manifest in any organ system of the body. Unhealthy alcohol use is also associated with psychologic consequences and may adversely affect social well-being.
Individuals with unhealthy alcohol use may present asymptomatically in general medical settings or with a range of signs or symptoms that they may not readily relate to their alcohol use. Common presentations include the following:
•Sleep disturbance
•Gastrointestinal reflux
•Hypertension
•Incidental abnormal liver enzymes, including elevated gamma-glutamyl transpeptidase
Other behavioral, psychiatric, social, and medical manifestations of unhealthy drinking that are seen in general medical settings include [28-30]:
•Trauma or injury
•Anxiety, depression, suicidality
•Comorbid substance use disorders
•Gastrointestinal symptoms
•Cardiac symptoms
•Central or peripheral neurologic symptoms
•Electrolyte disturbance
•Bone marrow suppression (eg, leukopenia, anemia, or thrombocytopenia)
•Macrocytosis
•Malignancies of various organ systems (eg, oropharynx, gastrointestinal breast)
•Social or legal problems
Clinical manifestations of unhealthy alcohol use range in severity from mild in patients with risky drinking to severe in patients with alcohol use disorder.
●Behavioral manifestations – Patients with alcohol use disorder may display or describe symptoms or behaviors related to their alcohol use, including [6] (see 'Diagnosis' below):
•Recurrent drinking resulting in failure to fulfill role obligations
•Recurrent drinking in hazardous situations
•Continued drinking despite alcohol-related social or interpersonal problems
•Evidence of tolerance
•Evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal
•Drinking in larger amounts or over longer periods than intended
•Persistent desire or unsuccessful attempts to stop or reduce drinking
•Great deal of time spent obtaining, using, or recovering from alcohol
•Important activities given up or reduced because of drinking
•Continued drinking despite knowledge of physical or psychologic problems caused by alcohol
•Alcohol craving
●Acute intoxication – Patients with alcohol use disorder may present in states of acute alcohol intoxication or withdrawal. Signs and symptoms of acute ethanol intoxication vary with severity and can include slurred speech, nystagmus, disinhibited behavior, incoordination, unsteady gait, hypotension, tachycardia, memory impairment, stupor, or coma. Alcohol intoxication is discussed separately. (See "Ethanol intoxication in adults".)
●Withdrawal – Signs and symptoms of withdrawal range from tremulousness to hallucinations, seizures, and death. Withdrawal symptoms generally occur between 4 and 72 hours after the last drink or after a reduction in drinking amounts, peak at approximately 48 hours, and may last up to 5 days. Alcohol withdrawal is discussed separately. (See "Management of moderate and severe alcohol withdrawal syndromes".)
COURSE —
In a given individual, the pattern of alcohol use and severity of alcohol use disorder do not remain stable over time. A longitudinal epidemiologic study of males who drank alcohol found that for a large proportion of patients, the severity of their initial diagnosis was not associated with the patients' clinical status four years later [31]:
Of drinkers initially meeting criteria for alcohol use disorder:
●Over 40 percent were in remission
●24 percent continued to meet the same level of severity
●30 percent progressed to more severe disease
Many adolescents who exhibit signs of alcohol use disorder have normative drinking patterns or abstain from alcohol consumption in adulthood [32]. Some studies have found that patterns of maladaptive alcohol consumption in adolescence may persist at least into young adulthood [33]. Adolescents with problematic alcohol use short of a disorder had a twofold increased risk of having an alcohol use disorder in young adulthood, compared with adolescents with nonproblematic alcohol use. Adolescents with a diagnosed alcohol use disorder had an additional twofold increased risk of an alcohol use disorder persisting into young adulthood, compared with adolescents with problematic alcohol use.
ADVERSE CONSEQUENCES —
Alcohol use disorder has been found to be associated with higher rates of morbidity and mortality.
Mortality
Mortality rates — Excessive alcohol consumption is the third leading preventable cause of death in the United States, with over 178,000 people dying annually because of excess alcohol use. This translates to 488 deaths per day [4]. Excessive drinking, defined as binge drinking, heavy weekly alcohol consumption, and drinking while underage or pregnant, has been found to result in 1 in 10 deaths among working age adults [34]. (See "Overview of the risks and benefits of alcohol consumption", section on 'Mortality'.)
Rates of alcohol-related deaths in the United States have increased over time. Alcohol-related mortality rates increased from 10.7 per 100,000 in 1999 to 21.6 per 100,000 in 2020, according to data from the United States Centers for Disease Control and Prevention [35].
Causes — Deaths related to excessive alcohol use include suicide, exacerbation of medical comorbidities, and fatal accidents.
Suicide — Alcohol use disorder is associated with suicidal ideation and attempted and completed suicides. In a meta-analysis of 31 studies pooling data from over 400,000 participants, alcohol use disorder was associated with suicidal ideation (odds ratio [OR] 1.86, 95% CI 1.38-2.35), suicide attempts (OR 3.13, 95% CI 2.45-3.81), and completed suicide (OR 2.59, 95% CI 1.95-3.23) [36]. As alcohol consumption increases, the associated suicide risk increases proportionally in a dose-response fashion [37]. (See "Suicidal ideation and behavior in adults".)
Alcohol use contributes to a significant proportion of completed suicides in the United States. In 2021, the estimated alcohol-attributable fractions of suicide (defined as suicide in which the decedent had a blood alcohol concentration of ≥0.10 g/dL) were 21 and 18 percent in males and females, respectively, and were higher in those who used a firearm as the means of suicide, compared with other means [38].
Encounters in health care settings are important opportunities to identify active suicidality in patients with unhealthy alcohol use. In persons with alcohol use disorder, suicide is often preceded by recent health care encounters in primary care or specialty outpatient clinics. As an example, a Swedish national survey study of over 250,000 adults with alcohol use disorder examined the health care utilization of 2601 adults in the cohort who died by suicide [39]. The study found that of those persons with alcohol use disorder who died by suicide, 40 percent had a health care encounter within the prior two weeks and 76 percent had an encounter within the prior three months (compared with 6 percent and 25 percent of controls).
Medical comorbidities — The association between alcohol use and cardiovascular and all-cause mortality is discussed separately. (See "Overview of the risks and benefits of alcohol consumption", section on 'Mortality' and "Cardiovascular benefits and risks of moderate alcohol consumption", section on 'Cardiovascular mortality'.)
Fatal accidents — Alcohol use is associated with an increased risk of fatal accidents, including motor vehicle fatalities. This is discussed separately. (See "Overview of the risks and benefits of alcohol consumption", section on 'Accidents and trauma'.)
Morbidity — Alcohol can be a significant contributing factor to many medical conditions [30,40-43]:
●General medical conditions – Common medical conditions that are associated with unhealthy alcohol use are discussed separately. (See "Overview of the risks and benefits of alcohol consumption", section on 'Alcohol effect on specific conditions' and "Cardiovascular benefits and risks of moderate alcohol consumption", section on 'Effect of alcohol on cardiovascular risk'.)
●Psychiatric disorders – Common medical and psychiatric comorbidities associated with unhealthy alcohol use include:
•Depressive disorders
•Anxiety disorders
•Posttraumatic stress disorder
•Eating disorders
•Other substance use disorders
•Sleep disturbances
SCREENING —
All adult primary care patients should be screened for unhealthy alcohol use [44,45]. (See "Screening for unhealthy use of alcohol and other drugs in primary care".)
ASSESSMENT —
We carefully assess alcohol use in any patients presenting with social or legal problems, trauma or injury, mood or anxiety disorders, comorbid substance use disorders, and common alcohol-related medical problems, such as hypertension, gastrointestinal issues, increased liver enzymes including elevated gamma-glutamyl transpeptidase, bone marrow suppression, or macrocytosis.
History — Our assessment of a patient with suspected unhealthy alcohol use includes asking the patient and collateral sources of information about [46]:
●Current and past alcohol use and treatment
●Family history of alcohol problems and treatment
●Detailed history regarding the quantity and frequency of alcohol use
●Symptoms and behaviors associated with:
•Criteria for alcohol use disorder (see 'Diagnosis' below)
•Medical complications (see 'Morbidity' above)
•Psychiatric complications (eg, depression, anxiety, irritability) (see 'Morbidity' above)
•Behavioral complications (eg, controlling temper, risky sexual encounters, impulsivity)
•Other substance use (see "Opioid use disorder: Epidemiology, clinical features, health consequences, screening, and assessment" and "Cocaine use disorder: Epidemiology, clinical features, and diagnosis" and "Methamphetamine use disorder: Epidemiology, clinical features, and diagnosis" and "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment")
Physical examination — Physical features accompanying unhealthy alcohol use range from a normal physical examination to features of alcohol withdrawal (tremor, agitation, clouding of the sensorium) to features of advanced liver disease (eg, spider angiomata, palmar erythema, hepatic or splenic enlargement). They can also include findings related to any of the common co-occurring medical and psychiatric disorders or due to alcohol-related complications. (See 'Morbidity' above.)
Laboratory evaluation — There are several laboratory tests or "biomarkers" related to alcohol consumption, alcohol use disorder or liver disease. Although we do not routinely order these tests to screen for unhealthy alcohol use or diagnose alcohol use disorder, they may aid the clinician in assessing the medical impact of a specific patient's drinking. None are sensitive for unhealthy use. They all tend to require heavy and repeated recent consumption to be elevated. Most are nonspecific, but some have greater specificity [37].
In the absence of other explanations for alterations in these tests, the following laboratory tests may be helpful in the assessment of unhealthy alcohol use:
●Liver enzymes – Aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and albumin to test for liver damage. An AST:ALT ratio of 2:1 is suggestive of alcohol-induced liver disease.
●Hemoglobin, complete blood count – To determine the presence and severity of anemia, pancytopenia, and macrocytosis. A mean corpuscular volume >100 fL constitutes macrocytosis. Pancytopenia and macrocytosis usually require very heavy prolonged use and often liver disease.
●Gamma-glutamyltransferase (GGT) – An indicator of excessive alcohol use when elevated (normal reference ranges: 8 to 40 units/L for females and 9 to 50 units/L for males).
Other tests are more accurate indicators of excessive alcohol use but may not be widely available. These tests may be useful for specific purposes (eg, if elevated from the start they can be used to monitor progress with treatment). However, their utility in clinical settings should only be interpreted as part of a comprehensive and patient-centered treatment and monitoring plan:
●Carbohydrate deficient transferrin (CDT) – A CDT level above 0.12 suggest chronic excessive alcohol use. CDT is fairly specific for excessive use though can be elevated by rarer liver diseases, such as primary biliary cirrhosis. This is more useful than a GGT but is used mostly by specialists or in research settings.
●Phosphatidal ethanol (PEth) – PEth is a metabolite of ethanol that is specific for ethanol use. A concentration greater than 20 ng/dL is evidence of intoxication; it can detect excessive alcohol intake within a two-week period. The results of the PEth should be interpreted in the context of patient factors that may influence the results, including alcohol patterns, body mass index, hemoglobin levels, and liver fibrosis.
DIAGNOSIS —
Alcohol use disorder can be specified as mild, moderate, or severe, based on the number of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria present.
DSM-5-TR diagnostic criteria for alcohol use disorder are described in a table (table 1) [6].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Alcohol use disorders and withdrawal" and "Society guideline links: Alcohol consumption".)
SUMMARY AND RECOMMENDATIONS
●Terminology – Terms used to describe alcohol use and alcohol-related problems and disorders include the following (see 'Terminology' above):
•Unhealthy alcohol use – Encompasses the spectrum of alcohol use that can result in health consequences including risky use and alcohol use disorder. Nearly 3 in 10 adults in the United States use alcohol in an unhealthy manner.
•Risky use – This refers to consumption of an amount of alcohol that puts the individual at risk for health consequences.
•Alcohol use disorder – A disorder characterized by a problematic pattern of alcohol use leading to distress or impairment.
•Binge drinking – Drinking so much within two hours that the blood alcohol concentration reaches 0.08 g/dL.
●Pathogenesis – Alcohol use disorder is believed to stem from the interplay of genetics, environmental influences, and specific personality traits. It has been estimated that genetic factors are responsible for approximately 50 percent of the vulnerabilities related to the disorder. (See 'Pathogenesis' above.)
●Clinical manifestations – Individuals with unhealthy alcohol use seen in the general medical setting may present with injury/trauma, depression or anxiety, hypertension, abuse of other substances, gastrointestinal symptoms, increased liver enzymes, macrocytosis, and social or legal problems. (See 'Clinical manifestations' above.)
Individuals with unhealthy alcohol use may present asymptomatically in general medical settings, or with a range of signs or symptoms that they may not readily relate to their alcohol use.
Physical features accompanying unhealthy alcohol use range from a normal examination to features of alcohol withdrawal, to features of advanced liver disease.
●Laboratory data – Laboratory data including liver enzymes, complete blood count, hemoglobin level, gamma-glutamyltransferase, carbohydrate deficient transferrin, and phosphatidyl ethanol, may be helpful in identifying unhealthy alcohol use. (See 'Laboratory evaluation' above.)
●Mortality – Excessive alcohol consumption is the third leading preventable cause of death in the United States. More than 140,000 deaths a year in the United States are directly attributed to alcohol use, including resulting medical illness, traffic fatalities, drowning, and suicide. (See 'Adverse consequences' above.)
●Screening – We recommend screening all adults in primary care settings for unhealthy alcohol use. (See "Screening for unhealthy use of alcohol and other drugs in primary care".)
●Assessment – We include the patient and collateral sources, when possible, in our assessment of the individual with suspected unhealthy alcohol use. We ask about current and past alcohol use and treatment, family history of alcohol problems and treatment, a detailed history regarding the quantity and frequency of alcohol use, and symptoms and behaviors associated with alcohol use disorder, related medical and psychiatric conditions, and use of other substances. (See 'Assessment' above.)
ACKNOWLEDGMENTS —
The UpToDate editorial staff acknowledges Mark Gold, MD, and Mark Aronson, MD, who contributed to earlier versions of this topic review.
