Alcohol Abuse

  • Diagnosis
  • Screening
  • Monitoring
  • Background
  • Lab Tests
  • References
  • Related Content

Indications for Testing

  • Suspicion of alcohol abuse – patient meets World Health Organization (WHO) criteria for diagnosis from the International Classification of Diseases 10th Revision (ICD-10) and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
  • Trauma-related injury
  • Monitoring of patient in substance abuse treatment
  • Follow-up testing to investigate abnormalities of other biomarkers suggestive of alcohol abuse
    • Gamma glutamyl transferase (GGT)
    • Mean corpuscular volume (MCV)
    • High-density lipoprotein (HDL) cholesterol
    • Aspartate aminotransferase (AST)
    • Alanine aminotransferase (ALT)

Criteria for Diagnosis

  • ICD-10 criteria for diagnosis of alcoholism
    • ICD-10 defines 1 unit of alcohol equal to 8-10 g
      • 8 oz of beer, 5 oz of wine, 1 oz of hard liquor
  • CDC – patterns of alcohol consumption
    • Binge drinking
      • Women – ≥4 drinks on a single occasion
      • Men – ≥5 drinks on a single occasion
    • Heavy drinking
      • Women – >1 drink/day on average
      • Men – >2 drinks/day on average
  • DSM-5 criteria for alcohol dependency
    • Three or more of the following for ≥1 month or repeatedly over the past 12 months
      • Strong desire or compulsion to drink
      • Difficulty in controlling drinking in terms of onset, termination, or extent of use
      • Physiologic withdrawal when use is reduced – tremor, sweating, tachycardia, anxiety, insomnia
      • Drinking to avoid withdrawal state
      • Evidence of alcohol tolerance – increasing amount required to produce same effects
      • Progressive neglect of other interests
      • Persistent use despite awareness of harmful effects

Laboratory Testing

  • Nonspecific testing
    • CBC
      • MCV
        • May show macrocytosis
        • More sensitive test in females – not specific for alcohol abuse
        • Limited as a screening test – reduced sensitivity with B12 and folate deficiencies, liver disease, concomitant tobacco abuse, and hypothyroidism
        • Not a suitable marker for following abstinence – normalization of MCV may require 2-4 months of abstinence
      • Platelet count – thrombocytopenia present in ~30% of alcohol-abuse patients
        • Rapidly normalizes with abstinence
      • HDL – increases with regular consumption of 3-5 drinks per day
        • Decreases within 1-2 weeks of abstinence
      • Ferritin – increases with low levels of alcohol consumption
      • Albumin  – low concentrations in chronic alcoholic liver disease
      • Urate – increases with low levels of alcohol consumption
      • Immunoglobulin A – increased in chronic alcoholic liver disease
    • Liver function tests
      • Aspartate transaminase (AST) and alanine transaminase (ALT)
        • May not be elevated – not highly sensitive or specific
        • AST:ALT ratio – >2 suggests alcoholic etiology for elevation
        • ALT is fairly specific for liver injury, although AST may also be elevated with skeletal muscle and cardiac muscle injury
      • Gamma glutamyl transferase (GGT)
        • Sensitive and inexpensive indirect marker of alcohol consumption
          • Even moderate drinkers (<60 g/week), especially men, show higher levels than abstainers
          • May be a less-sensitive marker in young drinkers
        • Nonspecificity for alcohol abuse limits usefulness – may also be elevated with nonalcoholic fatty liver disease, drug intoxication, obesity, diabetes, hepatobiliary disorders
        • Age dependent – levels increase with age, even in abstinent patients
        • Normalization requires 2-3 weeks of abstinence
  • Specific testing
    • Ethanol levels – blood, urine, or breath specimens
      • Use for patients with suspected acute alcohol consumption
      • Suggestive of dependence
        • Levels >0.15 g/dL (>1.5%) without evidence of intoxication
        • >3.0 g/dL (>3.0%) without death
        • Positive level during daytime hours

Differential Diagnosis

  • Ethanol (serum, breath, or urine) – best screen for acute alcohol ingestion
  • Carbohydrate deficient transferrin (CDT)
    • Can detect ≥40 g/day ethanol consumption for ≥2 weeks
      • Estimates longer term alcohol consumption over the past 2-5 weeks
    • ≥1.6% – considered elevated and associated with active alcohol use
      • Levels between 1.4-1.6% should be retested in 3-4 weeks
    • Sensitivity
      • Moderately sensitive and specific for longer-term alcohol use
      • More sensitive test in men – especially >40 years of age
      • May be a sensitive marker of relapse in chronic abusers
      • Highest sensitivity may be achieved in combination with one or all of the following
        • GGT
        • MCV
        • Ethyl glucuronide
  • Ethyl glucuronide
    • Detects short term ethanol exposure – 1-4 days post ingestion (up to 80 hours)
      • Ethanol dose may be as low as ≤0.25 g/kg at day 1 testing or ≤0.5 g/kg at day 2 testing
      • Aids in monitoring alcohol abstinence – negative test confirms abstinence during ~2 previous days
    • Specimens
      • Urine – most available testing with quantitation
      • Hair – may be better indicator of long-term alcohol consumption
    • False-positive results
      • May reflect use of ethanol-containing personal care products (eg, cough syrup, mouth wash, hand sanitizer)
      • Urine specimen with high glucose level from diabetics
      • Storage of specimen >12 hours
  • Phosphatidyl ethanol (PEth)
    • Detects longer term exposure (up to 4 weeks)

Approximately 20% of primary care patients in the U.S. drink alcohol (ethanol) at levels harmful to health.

Epidemiology

  • Incidence – 20-30% of hospital admissions and health-care costs are due to alcohol abuse
  • Age – usually young adults
  • Sex – M>F

Pathophysiology

  • Alcohol consumption has toxic effects on the liver and the hematologic system
    • Liver enzymes are induced by alcohol and may increase during the ensuing hepatocyte injury
    • Suppresses albumin production by the liver
    • Toxic to the hematologic precursor cells and may affect red blood cell morphology

Clinical Presentation

  • May present with signs of acute intoxication – slurred speech, altered sense of consciousness, coma
  • Other nonspecific signs in non-intoxicated patients – depression, anxiety
  • Complications
    • Withdrawal signs and symptoms – tremor, tachycardia, nausea, anxiety, sweating, insomnia
      • Delirium tremens – clouding of consciousness, psychomotor agitation, fear, delusions, hallucinations
    • Wernicke-Korsakoff syndrome – caused by alcohol-induced thiamine deficiency
    • Impaired cognition and learning, confabulation, ataxia, nystagmus
    • Cirrhosis
    • Pancreatitis
    • Esophageal varices
    • Coagulopathy – due to vitamin K deficiency
    • Ascites
    • Megaloblastic anemia – vitamin B12 and folate deficiency

Indications for Laboratory Testing

Tests generally appear in the order most useful for common clinical situations.
Click on number for test-specific information in the ARUP Laboratory Test Directory

Ethanol, Serum or Plasma - Medical 0090120
Method: Quantitative Gas Chromatography/Enzymatic

Limitations

Assay detection limit – varies based on instrumentation

Alcohols 0090131
Method: Quantitative Gas Chromatography

Limitations

Assay detection limit – 5 mg/dL

Drugs of Abuse Test, Alcohol, Urine - Screen with Reflex to Confirmation/Quantitation 0092280
Method: Semi-Quantitative Alcohol Dehydrogenase/ Qualitative Gas Chromatography-Flame Ionization Detection

Limitations

Sensitivity and specificity with urine are relatively poor; not valid for forensic use

Positive cutoff 40 mg/dL

Alcohol, Urine, Quantitative 2010136
Method: Quantitative Gas Chromatography

Limitations

Sensitivity and specificity with urine are relatively poor; not valid for forensic use

Positive cutoff 5 mg/dL

Carbohydrate Deficient Transferrin for Alcohol Use 0070412
Method: Quantitative Electrophoresis

Limitations

Cannot be used in patient suspected of having congenital glycosylation disorders

Advanced liver damage (including severe chronic viral hepatitis) and anti-epileptic drug therapy can increase CDT levels

Ethyl Glucuronide Screen Only, Urine 2012695
Method: Qualitative Enzyme Immuonassay

Ethyl Glucuronide Screen with Reflex to Confirmation, Urine 2007912
Method: Qualitative Enzyme Immunoassay/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Limitations

False-positive results –microbial formation or fermentation, ethanol-containing products (eg, hand sanitizer, mouth wash)

False-negative results – bacterial degradation, >4 days since ethanol ingestion

Ethyl Glucuronide and Ethyl Sulfate, Urine, Quantitative 2007909
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Limitations

Incidental exposure from ethanol containing products may be detected

Phosphatidylethanol (PEth)  2012130
Method: Quantitative Liquid Chromatography/Tandem Mass Spectrometry

Additional Tests Available

CBC with Platelet Count 0040002
Method: Automated Cell Count

Comments

Initial test to determine macrocytosis

Hepatic Function Panel 0020416
Method: Quantitative Enzymatic/Quantitative Spectrophotometry

Comments

Initial screen for suspected chronic alcohol related hepatic injury

Panel includes albumin, alkaline phosphatase, AST, ALT, direct bilirubin, total protein, and total bilirubin

Gamma Glutamyl Transferase, Serum or Plasma 0020009
Method: Quantitative Enzymatic

Comments

May be useful as an indirect marker of alcohol abuse

May be less sensitive marker in young drinkers

Not specific for alcohol abuse; may be elevated with nonalcoholic fatty liver disease, drug intoxication, or other liver diseases

Ethanol, Urine, Qualitative - Medical 0090518
Method: Quantitative Enzymatic

Comments

Urine test to identify acute alcohol ingestion

HDL Cholesterol 0020053
Method: Detergent Solubilization/Enzymatic

Comments

Assay interference (negative) may be observed when high concentrations of N-acetylcysteine (NAC) are present

Negative interference has also been reported with NAPQI (an acetaminophen metabolite), but only when concentrations are at or above those expected during acetaminophen overdose

Albumin, Serum or Plasma by Spectrophotometry 0020030
Method: Quantitative Spectrophotometry

Uric Acid, Urine 0020481
Method: Quantitative Spectrophotometry

Comments

Aids in diagnosis of kidney stones; aids in monitoring uric acid levels in patients at risk for kidney stone development (eg, gout)

Immunoglobulin A 0050340
Method: Quantitative Nephelometry

Comments

Determine whether to use IgA or IgG tTG and DGP assays

Alkaline Phosphatase, Serum or Plasma 0020005
Method: Quantitative Enzymatic

Bilirubin, Total, Serum or Plasma 0020032
Method: Spectrophotometry

Aspartate Aminotransferase, Serum or Plasma 0020007
Method: Quantitative Enzymatic

Alanine Aminotransferase, Serum or Plasma 0020008
Method: Quantitative Enzymatic

Albumin by Nephelometry 0050671
Method: Quantitative Nephelometry

Ferritin 0070065
Method: Quantitative Chemiluminescent Immunoassay

Comments

Aids in the diagnosis of iron deficiency anemia and iron overload; monitor treatment of hemochromatosis

Guidelines

Alcoholic liver disease. American Association for the Study of Liver Diseases - Nonprofit Research Organization; American College of Gastroenterology - Medical Specialty Society. 2010 Jan NGC: 007577

General References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington: Virginia: Amer Psychiatric Pub Inc., 2013.

Bortolotti F, De Paoli G, Tagliaro F. Carbohydrate-deficient transferrin (CDT) as a marker of alcohol abuse: a critical review of the literature 2001-2005. J Chromatogr B Analyt Technol Biomed Life Sci. 2006; 841(1-2): 96-109. PubMed

Crunelle C, Yegles M, van Nuijs A, Covaci A, De Doncker M, Maudens K, Sabbe B, Dom G, Lambert W, Michielsen P, Neels H. Hair ethyl glucuronide levels as a marker for alcohol use and abuse: a review of the current state of the art. Drug Alcohol Depend. 2014; 134: 1-11. PubMed

Delanghe J, De Buyzere M. Carbohydrate deficient transferrin and forensic medicine. Clin Chim Acta. 2009; 406(1-2): 1-7. PubMed

Ingall G. Alcohol biomarkers. Clin Lab Med. 2012; 32(3): 391-406. PubMed

Lande G, Marin B, Chang A. Clinical application of ethyl glucuronide testing in the U.S. Army. J Addict Dis. 2011; 30(1): 39-44. PubMed

Neels H, Yegles M, Dom G, Covaci A, Crunelle C. Combining serum carbohydrate-deficient transferrin and hair ethyl glucuronide to provide optimal information on alcohol use. Clin Chem. 2014; 60(10): 1347-8. PubMed

Sterneck M, Yegles M, von G, Staufer K, Vettorazzi E, Schulz K, Tobias N, Graeser C, Fischer L, Nashan B, Andresen-Streichert H. Determination of ethyl glucuronide in hair improves evaluation of long-term alcohol abstention in liver transplant candidates. Liver Int. 2014; 34(3): 469-76. PubMed

Waszkiewicz N, Szajda S, Kępka A, Szulc A, Zwierz K. Glycoconjugates in the detection of alcohol abuse. Biochem Soc Trans. 2011; 39(1): 365-9. PubMed

Weykamp C, Wielders J, Helander A, Anton R, Bianchi V, Jeppsson J, Siebelder C, Whitfield J, Schellenberg F, IFCC Working Group on Standardization of Carbohydrate-Deficient Transferrin. Harmonization of measurement results of the alcohol biomarker carbohydrate-deficient transferrin by use of the toolbox of technical procedures of the International Consortium for Harmonization of Clinical Laboratory Results. Clin Chem. 2014; 60(7): 945-53. PubMed

Medical Reviewers

Last Update: January 2016