Alcohol Abuse

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

Markers for Monitoring Ethanol Exposure


Carbohydrate Deficient Transferrin (CDT)

Ethyl Glucuronide (EtG)

Ethyl Sulfate (EtS)

Phosphatidyl Ethanol (PEth)

Metabolite of ethanol


Direct minor metabolite (<0.1% of ethanol disposition)

Direct ethanol metabolite

Test description

Long term marker of heavy ethanol abuse or abuse relapse

Heavy ethanol abuse increases fractions of CDT; consumption of 50-80 g/day for 1-2 weeks elevates CDT above baseline

Detects chronic use (≥40 g/day ethanol consumption for 2 weeks) 

≥1.7% considered elevated and associated with active alcohol use

  • Levels between 1.4-1.6% considered inconclusive and should be retested in 3-4 weeks

Most useful for long-term abstinence monitoring (up to 2 weeks)

Good marker of acute alcohol ingestion

Detects short term ethanol exposure – 1-4 days post ingestion (up to 80 hours in urine)

  • Ethanol dose may be as low as ≤0.25 g/kg at day 1 testing or ≤0.5 g/kg at day 2 testing
  • May be useful in short-term monitoring of abstinence – negative test confirms abstinence during ~2 previous days

Detects longer term exposure (up to 4 weeks)

Distinguishes between heavy (>60 g/day) and less heavy use – tool for chronic heavy drinking


Moderately sensitive and specific for longer-term alcohol use

More sensitive in men – especially >40 years

  • Sensitivity decreases with high BMI, female gender, and smoking

Useful for long-term abstinence monitoring (up to 2 weeks)

Relatively sensitive marker of relapse in chronic abusers

Highest sensitivity may be achieved in combination with one or all of the following

  • Gamma glutamyl transferase  (GGT)
  • Mean corpuscular volume (MCV)
  • Ethyl glucuronide (EtG)

Highest in heavy drinkers

Sensitivity wanes after 24 hours and with lower doses (Nanau, 2015)

Results do not accurately correlate with amount or frequency of ethanol use

Correlates best with heavy drinking in last 1-4 days

Correlates well with EtG but not CDT or GTP




  • Most available testing with quantitation


  • May be better indicator of long-term alcohol consumption


  • May be detected up to 36 hours (Nanau, 2015)

Whole blood


Intervals based on methodology

Cannot be used in individuals suspected of having congenital glycosylation disorders

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

Amount of ethanol consumed – sensitivity highest in heavy drinkers

Cutoff points

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 hrs

Bacterial degradation, >4 days since ethanol ingestion

Renal disease leads to higher levels for longer and may misrepresent consumption

Amount of ethanol consumed over last 7 days (most PEth resides in red blood cell membranes)

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


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


  • 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
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

Alcohols 0090131
Method: Quantitative Gas Chromatography

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


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

Alcohol, Urine, Quantitative 2010136
Method: Quantitative Gas Chromatography


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

Carbohydrate Deficient Transferrin for Alcohol Use 0070412
Method: Quantitative Electrophoresis


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

Interference in quantitation may be caused by severe icterus, genetic variants of transferrin, excess monoclonal or polyclonal immunoglobulins

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


Results do not accurately correlate with amount or frequency of ethanol use

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


Results do not accurately correlate with amount or frequency of ethanol use

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


Results do not accurately correlate with amount or frequency of ethanol use

Incidental exposure from ethanol containing products may be detected

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


O'Shea RS, Dasarathy S, McCullough AJ, Practice Guideline Committee of the American Association for the Study of Liver Diseases, Practice Parameters Committee of the American College of Gastroenterology. Alcoholic liver disease Hepatology. 2010; 51(1): 307-28. PubMed

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 CL, Yegles M, van Nuijs AL, Covaci A, De Doncker M, Maudens KE, Sabbe B, Dom G, Lambert WE, 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 JR, De Buyzere ML. Carbohydrate deficient transferrin and forensic medicine. Clin Chim Acta. 2009; 406(1-2): 1-7. PubMed

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

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

Nanau RM, Neuman MG. Biomolecules and Biomarkers Used in Diagnosis of Alcohol Drinking and in Monitoring Therapeutic Interventions Biomolecules. 2015; 5(3): 1339-85. PubMed

Neels H, Yegles M, Dom G, Covaci A, Crunelle CL. 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 GR, 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 SD, 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 RF, Bianchi V, Jeppsson J, Siebelder C, Whitfield JB, 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: October 2016