Understanding the Spectrum of Alcohol Use Disorder: A Practical Guide for Clinicians

Alcohol remains one of the most widely used psychoactive substances in Australia, with more than 75% of adults reporting alcohol use in the past year according to the National Drug Strategy Household Survey (2022). While many individuals consume alcohol at low or moderate levels without immediate harm, a significant proportion will experience a pattern of use that progresses to riskier or more harmful levels. For clinicians, recognising where a patient falls on the spectrum of alcohol use is critical in providing timely, effective, and appropriate care.

This article explores the spectrum of Alcohol Use Disorder (AUD), with practical strategies for assessment, brief intervention, withdrawal management, and relapse prevention. It is designed to equip healthcare professionals with a structured and compassionate framework for addressing alcohol-related harm in the general practice setting.

Understanding Alcohol Use as a Spectrum

The concept of a spectrum or continuum is now widely accepted in both clinical and public health models of substance use. Rather than viewing alcohol problems through a binary lens of “addicted” or “not addicted,” AUD is better understood as a range of behaviours, symptoms, and consequences that vary in intensity and impact.

The DSM-5 defines AUD as a problematic pattern of alcohol use leading to significant impairment or distress, as evidenced by at least two out of eleven criteria occurring within a 12-month period. These criteria are grouped into four domains:

• Impaired control: Unsuccessful attempts to cut down, drinking more than intended, or spending excessive time using or recovering from alcohol.

• Social impairment: Failing to meet obligations at work or home, interpersonal problems, or withdrawing from activities.

• Risky use: Continuing to drink despite known physical dangers or exacerbation of medical conditions.

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• Pharmacological indicators: Development of tolerance and the experience of withdrawal symptoms.

Severity is classified based on the number of criteria met:

• Mild: 2–3 criteria

• Moderate: 4–5 criteria

• Severe: 6 or more criteria
  APA DSM-5 Resource

Importantly, many patients with mild or moderate AUD do not self-identify as having a problem and may still function well in daily life. Yet they are at heightened risk for health complications, accidents, and future progression if not addressed early.

Identifying Risk in Clinical Practice

Routine alcohol screening is a crucial but often underutilised component of primary care. Alcohol use is a contributing factor to over 60 different health conditions, including hypertension, liver disease, cancer, mental health disorders, and cognitive decline. Screening can help identify patients who might benefit from education, brief intervention, or structured treatment before more serious harm occurs.

When to screen:

• As part of annual health checks

• During consultations for sleep disturbance, gastrointestinal symptoms, or mood issues

• In the context of chronic disease management (e.g. diabetes, liver disease)

• Before prescribing medications that interact with alcohol (e.g. benzodiazepines, opioids)

• Antenatal and pre-conception visits

Validated tools:

• AUDIT (Alcohol Use Disorders Identification Test): A 10-question screening tool developed by WHO. A score of 8 or more suggests harmful or hazardous drinking.
  WHO AUDIT

• AUDIT-C: A three-question version suitable for routine use in busy consultations.

• CAGE questionnaire: Brief but less sensitive for early-stage problem use.

Documentation of drinking patterns in standard drinks per week, binge frequency, and age of onset can also help guide risk stratification.

The Role of Brief Intervention

For patients who fall into the low to moderate risk categories, brief interventions are both cost-effective and clinically impactful. These are short, structured conversations aimed at increasing a patient’s awareness of the risks of alcohol use and motivating change.

The 5 A’s framework is widely adopted in primary care:

1. Ask about alcohol use using a validated tool

2. Advise patients about the health risks and recommend reduction or abstinence where appropriate

3. Assess the patient’s readiness to change using open-ended questions

4. Assist with goal setting, self-monitoring, or referral

5. Arrange follow-up support or review

Motivational interviewing skills are highly effective in this context. Rather than confronting patients, clinicians guide them to explore their own reasons for change, increasing their internal motivation.

Withdrawal Management in Primary Care

Alcohol withdrawal can range from mild anxiety and tremors to life-threatening seizures and delirium tremens. For this reason, a careful risk assessment is essential before initiating community-based withdrawal.

Patients suitable for outpatient detox generally meet the following criteria:

• Mild to moderate withdrawal symptoms based on CIWA-Ar score (<15)

• No history of alcohol withdrawal seizures or delirium tremens

• Stable medical and psychiatric comorbidities

• Adequate support at home

• Reliable follow-up and monitoring plan

Medications commonly used:

• Diazepam: First-line for withdrawal symptom control. Long-acting with smoother taper.

• Thiamine: Prescribe before glucose-containing fluids to prevent Wernicke’s encephalopathy.

• Ondansetron or metoclopramide: For nausea if needed.

Clear protocols and daily reviews are essential in the first 72 hours. Patients with any uncertainty around safety should be referred for inpatient or specialist care.
NSW Withdrawal Guidelines

Long-Term Pharmacotherapy Options

After detox, many patients struggle with relapse without further support. Pharmacotherapy can improve outcomes when combined with psychosocial interventions.

Evidence-based medications include:

• Naltrexone (oral or depot): Reduces cravings and the euphoric effects of alcohol

• Acamprosate: Best for patients who have achieved abstinence and need support maintaining it

• Disulfiram: Creates an aversive reaction to alcohol; useful in motivated individuals under supervision

• Baclofen: GABA-B agonist with emerging evidence, particularly in patients with liver disease or contraindications to other agents

Prescribers should be aware of contraindications, side effect profiles, and the need for ongoing monitoring. Shared decision-making is critical in aligning treatment with patient goals.

Holistic and Culturally Safe Care

Alcohol use does not exist in isolation. Many patients also experience mental health disorders, trauma histories, chronic pain, housing instability, or interpersonal violence.

Integrated care may involve:

• Mental health care plans and counselling referrals

• Access to social workers or housing support

• Involvement of family or peer support networks

• Collaboration with AOD specialist services

For Aboriginal and Torres Strait Islander patients, care should be culturally safe, trauma-informed, and offered in partnership with local Aboriginal Community Controlled Health Services.

Clinical Education and Upcoming Events

To help bridge knowledge into practice, clinicians are encouraged to attend practical, evidence-based training opportunities.

Meducate Alcohol Masterclass – Free CPD Event

“Understanding, Managing & Supporting Change”
📅 Saturday, August 2nd, 9:00am – 1:00pm
📍 The Cullen Hotel, Prahran, VIC

This half-day, face-to-face masterclass brings together leaders in addiction medicine, psychiatry, and general practice to cover:

• Differentiating low-risk, hazardous, and dependent drinking

• Implementing safe withdrawal protocols in primary care

• Relapse prevention and psychosocial recovery planning

Speakers include:

• Dr Ferghal Armstrong – Addiction Medicine Specialist & GP

• Dr Richard Bradlow – Consultant Psychiatrist in Addiction

• Dr Anna Cunningham – Addictions Psychiatrist with experience in rural and urban detox programs

🧠 CPD-accredited
🩺 Interdisciplinary
🔒 Limited seats – Register now