Alcohol Units and AUD Pathway

What the patient drank, in units, with AUDIT-C and the risk band. Indian measures · v1

Quantify intake in the measures a patient actually drinks in, by drink type, volume and strength.
Complete the AUDIT-C and record the clinical flags for dependence and for harm.
You get the weekly unit load, the AUDIT-C band, a risk category and a formulation you can put straight into the notes.
Harm outranks the weekly total. Where an organ or dependence flag is ticked, the grading is set by that flag and not by the units.

Alcohol withdrawal: its severity scoring, the benzodiazepine regimen and the thiamine doses. The note below routes you there.
The staging of alcohol-related liver disease.
The full ten-item AUDIT. The screen here is the three-item AUDIT-C.
Drinkers below 18 years. The unit thresholds and the AUDIT-C cut-offs were set in adults.

If the patient has already stopped drinking, this is not the right tool. This one quantifies intake and screens for a use disorder. For a patient who is withdrawing, or who is about to, use the Alcohol Withdrawal: CIWA-Ar and Thiamine Protocol, which scores severity, selects a benzodiazepine regimen and generates the thiamine protocol.

1. Patient Demographics

Biological Sex ?

2. Volumetric Intake (Typical Drinking Day)

Beverage Type ?

Standard Measure ?

Quantity per session

Frequency (Days/Week)

3. AUDIT-C Rapid Screen

How often do you have a drink?

Typical drinks on a drinking day?

How often do you have 6+ drinks on one occasion?

4. Clinical Flags (Dependence & Harm)

Morning tremors, sweating, or needing an "Eye-Opener" Loss of control over intake or profound tolerance Evidence of organ damage (e.g., deranged LFTs, macrocytosis) Significant social, occupational, or familial impairment

Quantitative Intake Analysis

Total Weekly Units

0Units/week

AUDIT-C Score

0/ 12

Teaching point: the medical unit
One standard UK medical unit is 10 ml (8 g) of pure ethanol, and the threshold below which risk is considered low is ≤ 14 units per week for men and for women alike. That figure is the UK Chief Medical Officers' 2016 limit; India sets no unit-based limit of its own. Intake gets underestimated in clinic for two reasons. IMFL is strong at 42.8%, and the measures poured at home are large: a 60 ml large peg is already over 2.5 units.

Carrying this figure to the withdrawal tool. The Alcohol Withdrawal: CIWA-Ar and Thiamine Protocol asks for standard drinks of 10 g each, which is the WHO unit, not the 8 g unit used here. Divide the units on this page by 1.25 to get standard drinks: 40 units a week is 32 standard drinks a week, that is about 4.5 a day. Entering units where standard drinks are asked for overstates the intake by a quarter.

Clinical Formulation

Diagnostic Stratification

Low Risk

Three words that are not interchangeable
Hazardous drinking raises the risk of harm in future. Harmful drinking means the damage to organs or to mental health is already happening. Dependence means the body has come to rely on the alcohol, shown by tolerance and by withdrawal. A dependent patient is never told simply to stop: abrupt cessation carries a real risk of seizures and delirium tremens, so the withdrawal is planned and supervised.

Patient-Friendly Summary

1. What a Unit Is

A unit measures the ethanol itself, not the drink it arrived in. That is the whole point of it: whisky, beer and toddy become comparable, and a history recorded in units can be read by whoever sees the patient next.

Standard definition: 1 unit = 10 millilitres or 8 grams of pure ethanol.
The formula: Units = (Volume in ml × ABV %) / 1000
Limits: the UK Chief Medical Officers' 2016 guidance recommends ≤ 14 units per week, spread over 3 or more days, with several alcohol-free days. India sets no unit-based limit of its own.

2. Volumetrics and the Indian Context

The spirits drunk here are stronger than the ones in Western textbooks and the pours are larger. A history taken in pegs and bottles, converted with the wrong assumptions, puts the patient in a lower risk band than the one they belong in.

Indian Beverage & Measure	ABV (%)	Approx. Medical Units
IMFL (Whisky/Rum/Vodka) - Large Peg (60 ml)	42.8%	2.6 Units (Nearly 1/5th of the weekly limit)
IMFL - "Quarter" / Pauwa (180 ml)	42.8%	7.7 Units (A heavy binge dose)
Strong Beer - Standard Bottle (650 ml)	8.0%	5.2 Units
Standard Beer/Lager - Pint (330 ml)	5.0%	1.7 Units
Country Liquor / Arrack (100 ml)	~35.0%	3.5 Units (Variable; high risk of contaminants)

3. The AUDIT-C Screen

Three questions, score 0 to 12, validated for identifying active alcohol use disorder or hazardous drinking.
Sex-specific cut-offs: ≥ 4 in men or ≥ 3 in women is a positive screen.
A positive AUDIT-C mandates the full 10-question AUDIT and a physical examination.

Practice Pearl: The sex-specific cutoff is routinely ignored in Indian clinical practice. A female patient scoring 3 on the AUDIT-C is positive and requires full evaluation, yet many clinicians apply the male cutoff of 4 universally, missing hazardous drinking in women.

4. Recognising Dependence: CRAVE

Letter	Feature	Bedside Clue
C	Compulsion	Strong, persistent craving or urge to drink
R	Relapse	Repeated failed attempts to cut down
A	Autonomic withdrawal	Morning tremors, sweating, "eye-openers"
V	Volume tolerance	Needs markedly more to feel the same effect
E	Erosion of function	Social, occupational, or familial breakdown

Two or more features, especially A and V together, indicate probable dependence, severe alcohol use disorder by DSM-5.

5. Decoding the Clinical Flags

Tolerance. Markedly increased amounts needed for intoxication, or a markedly diminished effect from the same amount. It marks GABA and NMDA receptor adaptation.
Withdrawal, the "eye-opener". Autonomic hyperactivity on waking, sweating, tachycardia and hand tremor, relieved by a drink. It is the single most telling finding here. Never advise abrupt cessation: these patients need a tapered benzodiazepine protocol such as CIWA-Ar to prevent seizures and delirium tremens.
The De Ritis ratio. In alcoholic liver disease AST is raised disproportionately to ALT, and a ratio above 2:1 strongly suggests an alcohol aetiology. It follows from alcohol-induced mitochondrial damage and a relative deficiency of pyridoxal-5'-phosphate, the active form of vitamin B6.
Macrocytosis. A raised MCV from direct bone marrow toxicity, often independent of B12 or folate deficiency. An MCV above 100 fL in a drinker should prompt a frank conversation even if the patient denies excessive intake.

6. Differentiating the Liver Disease Aetiologies

Feature	ALD	NAFLD/MASLD	Viral Hepatitis (B/C)
Key History	Sustained heavy drinking (>14 U/wk)	Metabolic syndrome, obesity, T2DM	Transfusion, IVDU, endemic region, vertical transmission
AST:ALT Ratio	> 2:1 (classic)	< 1:1 (ALT usually higher)	Variable; ALT often dominant
GGT	Markedly elevated (often >3x ULN)	Mildly elevated	Variable
MCV	Elevated (> 100 fL)	Usually normal	Usually normal
Confirmatory Test	History + CDT + exclusion	FibroScan, USS, FIB-4	HBsAg, Anti-HCV, viral load

7. Indian Practice: Errors Worth Preventing

Thiamine before glucose, and the one exception: a glucose load drives the enzymes that thiamine is the cofactor for, so giving dextrose first to a thiamine-deplete patient can exhaust what little remains and precipitate Wernicke encephalopathy. Thiamine goes in first. The exception is the patient who is hypoglycaemic now. Treat the hypoglycaemia at once and give the thiamine immediately afterwards: hypoglycaemia causes harm within minutes, and that risk does not wait behind a theoretical one. The same sequence, with the same exception, is set out in the Alcohol Withdrawal: CIWA-Ar and Thiamine Protocol, which also carries the doses.

The withdrawal plan that is not a plan: a dependent patient sent home with a few chlordiazepoxide tablets "SOS" for sleep or tremor has not been treated. Withdrawal needs a severity assessment against a scale (CIWA-Ar) and a written tapering schedule. Delirium tremens can declare itself 48 to 72 hours after the last drink, by which time nobody is watching.

Thiamine that never gets given: injectable thiamine is often not stocked in government hospitals. Where it is not, start oral thiamine (100 mg TDS) at once and procure the injectable form urgently for anybody in whom Wernicke encephalopathy is suspected. The classic triad of confusion, ataxia and ophthalmoplegia is complete in only 16% of cases, so treat on suspicion rather than waiting for all three.

Abbreviations

ABV (Alcohol by Volume) · ADH (Alcohol Dehydrogenase) · ALD (Alcoholic Liver Disease) · ALT (Alanine Aminotransferase) · Anti-HCV (Antibody to Hepatitis C Virus) · AST (Aspartate Aminotransferase) · AUD (Alcohol Use Disorder) · AUDIT (Alcohol Use Disorders Identification Test) · AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) · AWS (Alcohol Withdrawal Syndrome) · CDT (Carbohydrate-Deficient Transferrin) · CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) · CNS (Central Nervous System) · DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) · DT (Delirium Tremens) · FIB-4 (Fibrosis-4 Index) · GABA (Gamma-Aminobutyric Acid) · GGT (Gamma-Glutamyl Transferase) · HBsAg (Hepatitis B Surface Antigen) · IMFL (Indian Made Foreign Liquor) · IV (Intravenous) · IVDU (Intravenous Drug Use) · LFT (Liver Function Test) · MASLD (Metabolic Dysfunction-Associated Steatotic Liver Disease) · MCV (Mean Corpuscular Volume) · NAFLD (Non-Alcoholic Fatty Liver Disease) · NMDA (N-methyl-D-aspartate) · PAWSS (Prediction of Alcohol Withdrawal Severity Scale) · SOS (Si Opus Sit, If Required) · T2DM (Type 2 Diabetes Mellitus) · TDS (Three Times Daily) · ULN (Upper Limit of Normal) · USS (Ultrasonography)

References

Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158(16):1789-1795.
Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31(7):1208-1217.
Indian Council of Medical Research (ICMR). Standard Treatment Workflows (STW) - Management of Alcohol Use Disorders. New Delhi, India; 2022.
Munjal YP, Nadkar MY, Shah SN, Kamath SA, editors. API Textbook of Medicine, 12th Edition. Mumbai: Association of Physicians of India; 2022.
National Institute of Mental Health and Neuro-Sciences (NIMHANS). Clinical Practice Guidelines for the Management of Substance Use Disorders. Bengaluru, India; 2016.
World Health Organization. Global status report on alcohol and health 2018. Geneva: WHO; 2018.
Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Care. 2nd ed. Geneva: World Health Organization; 2001.
Department of Health, United Kingdom. UK Chief Medical Officers' Low Risk Drinking Guidelines. London: Department of Health; 2016.
Indian Psychiatric Society. Clinical Practice Guidelines for the Management of Substance Use Disorders. Basu D, Ghosh A, Subodh BN, Mattoo SK. The same guideline is cited by the Alcohol Withdrawal: CIWA-Ar and Thiamine Protocol, so the two tools rest on one national source.
Harper CG, Giles M, Finlay-Jones R. Clinical signs in the Wernicke-Korsakoff complex: a retrospective analysis of 131 cases diagnosed at necropsy. J Neurol Neurosurg Psychiatry. 1986;49(4):341-345.

How to Cite This Tool

DOIhttps://doi.org/10.5281/zenodo.22401544

AMA Style:Umakanth S. Alcohol Units and AUD Pathway. Version 1. MEDiscuss Clinical Decision Support System. Published 2026. Accessed . https://mediscuss.org/cdss/alcohol-assessment. doi:10.5281/zenodo.22401544

Vancouver Style:Umakanth S. Alcohol Units and AUD Pathway [Internet]. Version 1. MEDiscuss.org; 2026 [cited ]. Available from: https://mediscuss.org/cdss/alcohol-assessment. doi:10.5281/zenodo.22401544

Category Risk Scores & Diagnostic PathwaysPathway

Specialties Internal Medicine, Gastroenterology & Hepatology, Toxicology, Psychiatry

Written and maintained by

Dr Shashikiran Umakanth

Last revised 24 August 2026

How these tools are written and reviewed