Alcohol Use Disorder

Definition

Substance-Related and Addictive Disorders is a category of conditions in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5).

Alcohol-Related Disorders are included in the category of Substances-Related and Addictive Disorders.

Alcohol-Related Disorders are divided into two categories: Alcohol Use Disorders and Alcohol-Induced Disorders.

Alcohol Use Disorder is the primary condition for which entitlement may be granted.

The Alcohol-Induced Disorders are considered under Section B or Section C in the Entitlement Considerations of this Entitlement Eligibility Guideline (EEG).

The essential feature of Alcohol Use Disorder is a cluster of cognitive, behavioral, and physiologic symptoms indicating that the individual continues using alcohol despite significant alcohol-related problems.

Criteria Sets for Alcohol Use Disorders

The Alcohol Use Disorder criteria set is derived from the DSM-5.

Alcohol Use Disorder:

Criterion A

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

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.
    2. Alcohol (or a closely related substance, such as a benzodiazepene) is taken to relieve or avoid withdrawal symptoms.

*Refer to the DSM-5 for the diagnostic criteria for Alcohol Withdrawal.

Diagnostic Standard

A diagnosis from a qualified medical practitioner (family physician or psychiatrist) or a registered/licensed psychologist is required.

The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible.

If a claim for alcoholism, or alcohol addiction, is submitted VAC will rule on Alcohol Use Disorder if the DSM-5 criteria are met. Consultation with Medical Advisory for diagnosis clarification is strongly recommended.

NOTE: Entitlement should be granted for a chronic condition only. For VAC purposes, "chronic" means the signs and symptoms of the condition has existed for at least six months. Signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane over the six month period and thereafter.

Entitlement Considerations

A. Causes And/Or Aggravation

Causal or Aggravating Factors versus Predisposing Factors

Causal or aggravating factors directly result in the onset or aggravation of the claimed psychiatric condition.

Predisposing factors do not cause a claimed condition. Predisposing factors are experiences or exposures which affect the individual's ability to cope with stress. Predisposing factors makes an individual more susceptible to developing the claimed condition. For example, the presence of a remote history of severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life.

Partial entitlement should only be considered for non-service related causal or aggravating factors.

Partial entitlement should not be considered for predisposing factors.

If it is unclear if a factor is a causal or aggravating factor versus a predisposing factor consultation with Medical Advisory is strongly recommended.

NOTE: The factors listed in Section A of the Entitlement Considerations include specific timelines for the clinical onset or aggravation of Alcohol Use Disorder. The timelines are not binding. Each case should be adjudicated on the evidence provided and its own merits. If the medical evidence indicates an alternate timeline, consultation with Medical Advisory is strongly recommended.

NOTE: The following list of factors is not all inclusive. Factors, other than those listed in Section A, may be claimed to cause or aggravate Alcohol Use Disorder. Other factors may be considered based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

1. Having a clinically significant psychiatric condition at the time of clinical onset or aggravation of Alcohol Use Disorder
   
   A clinically significant psychiatric condition is a mental disorder as defined in the DSM-5.
2. Directly experiencing a traumatic event(s) within the five years before the clinical onset or aggravation of Alcohol Use Disorder
   
   Traumatic events include, but are not limited to:
   1. exposure to military combat
   2. threatened physical assault or being physically assaulted
   3. threatened sexual assault or being sexually assaulted
   4. being kidnapped
   5. being taken hostage
   6. being in a terrorist attack
   7. being tortured
   8. incarceration as a prisoner of war
   9. being in a natural or human-made disaster
   10. being in a severe motor vehicle accident
   11. killing or injuring a person in a non-criminal act
   12. experiencing a sudden, catastrophic medical incident
3. Witnessing, in person, a traumatic event(s) as it occurred to another person(s) within the five years before the clinical onset or aggravation of Alcohol Use Disorder
   
   Witnessed traumatic events include, but are not limited to:
   1. threatened or serious injury to another person
   2. an unnatural death
   3. physical or sexual abuse of another person
   4. a medical catastrophe in a close family member or close friend.
4. Experiencing repeated or extreme exposure to aversive details of a traumatic event(s) before the clinical onset or aggravation of Alcohol Use Disorder
   
   Exposures include, but are not limited to:
   1. viewing and/or collecting human remains
   2. viewing and/or participating in the clearance of critically injured casualties
   3. repeated exposure to the details of abuse and/or atrocities inflicted on another person(s)
   4. dispatch operators exposed to violent or accidental traumatic event(s)

   Note: Factor 4 applies to exposure through electronic media, television, movies and pictures only if the exposure is work related.

5. Living or working in a hostile or life-threatening environment for a period of at least four weeks before the clinical onset or aggravation of Alcohol Use Disorder
   
   Situations or settings which have a pervasive threat to life or bodily integrity including but not limited to:
   1. being under threat of artillery, missile, rocket, mine or bomb attack
   2. being under threat of nuclear, biologic or chemical agent attack
   3. being involved in combat or going on combat patrols
6. Having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability within the five years before the clinical onset or aggravation of Alcohol Use Disorder
7. Experiencing the death of a close family member or close friend within the five years before the clinical onset or aggravation of Alcohol Use Disorder
8. Having experienced severe childhood abuse before the clinical onset of Alcohol Use Disorder
   
   Severe childhood abuse is:
   1. serious physical, emotional, psychological or sexual harm to a child under the age of 16 years; or
   2. neglect involving a serious failure to provide the necessities for health, physical and emotional development, or well being of a child under the age of 16 years;
   where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around the child, or any other adult in contact with the child.
9. Inability to obtain appropriate clinical management of Alcohol Use Disorder

B. Medical Conditions Which Are To Be Included In Entitlement/Assessment

NOTE: If specific conditions are listed for a category, only these conditions are included in the entitlement and assessment of Alcohol Use Disorder.

If no conditions are listed for a category, all conditions within the category are included in the entitlement and assessment of Alcohol Use Disorder.

• Alcohol Intoxication
• Alcohol Withdrawal
• Other Substance-Related and Addictive Disorders
• Trauma- and Stressor-Related Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Depressive Disorders
• Bipolar and Related Disorders
• Schizophrenia Spectrum and other Psychotic Disorders
• Personality Disorders
• Feeding and Eating Disorders
• Dissociative Disorders
• Somatic Symptom and Related Disorders
  • Somatic Symptom Disorder
  • Illness Anxiety Disorder
  • Conversion Disorder
• Pain Disorders/Chronic Pain Syndrome (DSM-IV-TR Axis I Diagnosis)
• Sleep-Wake Disorders
  • Insomnia Disorder
  • Hypersomnolence Disorder
• Neurodevelopmental Disorders
  • Attention-Deficit/Hyperactivity Disorder
• Decreased Libido - if the medical information indicates decreased libido is a symptom of a psychiatric condition.

Separate entitlement is required for a DSM-5 condition not included in Section B of the Alcohol Use Disorder Entitlement Eligibility Guideline.

C. Common Medical Conditions Which May Result In Whole Or In Part From Alcohol Use Disorder And/Or Its Treatment

Section C medical conditions may result in whole or in part as a direct result of Alcohol Use Disorder, from the treatment of Alcohol Use Disorder or the combined effects of Alcohol Use Disorder and its treatment.

Conditions listed in Section C of the Entitlement Considerations are only granted entitlement if the individual merits and medical evidence of the case determines a consequential relationship exists. Consultation with Medical Advisory is strongly recommended.

If it is claimed a medication required to treat Alcohol Use Disorder resulted in whole, or in part, in the clinical onset or aggravation of a medical condition the following must be established:

1. The individual was receiving the medication at the time of the clinical onset or aggravation of the medical condition.
2. The medication was used for the treatment of the Alcohol Use Disorder.
3. The medication is unlikely to be discontinued or the medication is known to have enduring effects after discontinuation.
4. The individual's medical information and the current medical literature support the medication can result in the clinical onset or aggravation of the medical condition.
5. Note: Individual medications may belong to a class, or grouping, of medications. The effects of a specific medication may vary from the grouping. The effects of the specific medication should be considered and not the effects of the group.

The list of Section C conditions is not all inclusive. Conditions, other than those listed in Section C, may be claimed to have a consequential relationship to Alcohol Use Disorder and/or its treatment. Other conditions may be considered for entitlement based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

• Chronic Gastritis / Peptic Ulcer Disease
• Gastroesophageal Reflux Disease
• Chronic Pancreatitis
• Chronic Hepatitis
• Cirrhosis of the Liver
• Chronic Cerebellar Degeneration
• Alcohol-Induced Persisting Amnestic Disorder (Korsakoff's Syndrome)
• Alcohol-Induced Persisting Dementia
• Peripheral Neuropathy
• Hypertension
• Alcoholic Cardiomyopathy
• Bronchiectasis (as a result of aspiration pneumonia)
• Dupuytren's Contractures
• Chronic Alcohol-induced Sexual Dysfunction (e.g. Erectile Dysfunction)
• Obstructive Sleep Apnea

References for Alcohol Use Disorder

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4^th ed. Text Revision (DSM-IV-TR) Washington: American Psychiatric Association, 2000.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5^th ed. (DSM-5) Washington: American Psychiatric Association, 2013.
3. Australia. (2009). Statement of principles concerning alcohol dependence and alcohol abuse. No. 1 of 2009.
4. Australia. (2009). Statement of principles concerning alcohol dependence and alcohol abuse. No. 2 of 2009.
5. Australia. (2014). Amendment statement of principles concerning alcohol use disorder abuse. No. 29 of 2014.
6. Australia. (2014). Amendment statement of principles concerning alcohol use disorder abuse. No. 30 of 2014.
7. Canada. (2002). Entitlement Eligibility Guidelines for Chronic Pancreatitis. Veterans Affairs Canada.
8. Canada. (2005). Entitlement Eligibility Guidelines for Gastroesophageal Reflux Disease. Veterans Affairs Canada.
9. Canada. (2002). Entitlement Eligibility Guidelines for Hypertension. Veterans Affairs Canada.
10. Goldman, L., & Schafer, A. (2012). Goldman's Cecil medicine 24^th ed. Philadelphia: Elsevier Saunders.
11. Goetz, C. G. (2007). Textbook of clinical neurology. Philadelphia: Saunders.
12. Harrison, T. R. (2012). Harrison's principles of internal medicine 18^th ed. New York: McGraw-Hill Medical.
13. Moore, D. P., & Jefferson, J. W. (2004). Handbook of medical psychiatry. St. Louis: Mosby.
14. Regier D. A., Farmer M. E., Rae D. S., Locke B. Z., Keith S. J., Judd L. L., et al. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA.
15. Sadock, B. J., Sadock, V. A., & Kaplan, H. I. (2005). Kaplan & Sadock's comprehensive textbook of psychiatry. Philadelphia: Lippincott Williams & Wilkins.
16. Thompson, J. M. (2009). Opinion regarding time to onset of alcohol misuse after exposure to severe psychological stress. Veterans Affairs Canada.