Closing the gap in drug treatment for alcohol use disorder (AUD)

Closing the gap in drug treatment for alcohol use disorder (AUD)
Closing the gap in drug treatment for alcohol use disorder (AUD)

Millions of Americans suffer from alcohol abuse, but unfortunately only a small portion of those affected receive any of the FDA-approved, evidence-based treatments that have been shown to reduce the negative consequences of problem drinking. According to data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), 28.8 million adults in the United States will be diagnosed with alcohol abuse in 2023. However, only 7.6% of this group received treatment for their alcohol problems and even fewer—2.2%—received medications to treat alcohol abuse. As a society, we need to do better.

The combination of the widespread prevalence of AUD and low treatment utilization has profound public health implications across the United States. The CDC reports that the number of deaths in the U.S. attributed solely to excessive alcohol consumption has increased sharply over the past two decades. This was particularly acute during the pandemic, when social isolation and economic downturn combined with the improved availability of home and take-out beverages caused a rise in alcohol-related deaths.

Over the past 20 years, we’ve also seen a significant increase in alcohol consumption among women and young people. For the first time, the percentage of women who drink excessively is comparable to that of men, driven by cultural shifts and changes in social norms driven by social media campaigns touting “mommy wine culture.” Among younger adults, the BORG (Blackout Rage Gallon) drinking trend went viral on TikTok and quickly spread to college campuses.

The rise in AUD and alcohol-related deaths is particularly devastating because we know that effective screening and treatment strategies are available. In particular, MAUD combined with psychosocial support such as counseling or therapy has been shown to be helpful for people with AUD to achieve sustainable recovery. Integrating MAUD with evidence-based psychotherapy (such as cognitive behavioral therapy (CBT) relapse prevention, mindfulness-based relapse prevention, dialectical behavior therapy, etc.) and peer support (such as Alcoholics Anonymous (AA) or SMART Recovery) offers the most comprehensive and effective approach. This integrated, holistic philosophy addresses the medical, psychological, and social aspects of AUD and gives people a chance to initiate and maintain recovery.

FDA-approved drugs

There are three FDA-approved medications to treat AUD: disulfiram, naltrexone (oral and long-acting injectable formulations), and acamprosate.

  • Disulfiram is an oral medication that interferes with the body’s ability to metabolize alcohol. If someone drinks after taking it, alcohol levels in the body build up quickly and severe physical reactions occur, including vomiting, severe headaches, and extremely high blood pressure. Because these reactions are very unpleasant, people taking disulfiram avoid alcohol. Disulfiram requires a firm determination to abstain from alcohol, so we usually only recommend it to people who have a strong motivation for abstinence or who need to be abstinent for medical reasons.
  • Naltrexone is an opioid receptor antagonist, meaning it blocks opioid receptors and therefore weakens the euphoric effects of alcohol. It may be an option for people who want to reduce their alcohol consumption or stop altogether. People who take naltrexone report reduced cravings for alcohol, in part because the drug reduces the reinforcing effects of alcohol. Studies have shown that it reduces the number of days per week that people drink, and also the amount they drink on the days they do drink. Naltrexone can be taken daily as an oral medication or as a monthly injection (VIVITROL). Research shows that long-term use of naltrexone in conjunction with psychotherapy can contribute to long-term behavior change and a changed relationship with alcohol.
  • Acamprosate is an oral medication option for people trying to abstain from alcohol or reduce their cravings for alcohol. Although it has less clinical research than other medications for AUD, acamprosate is known to alter the neurological response to the effects of alcohol and reduce cravings. It must be taken three times a day, which can be challenging for some people depending on work and lifestyle commitments.

Although treatments for AUD have been shown to be effective, there are several reasons for their underutilization, including the stigma surrounding alcohol abuse and treatment. Other reasons include inadequate screening and referral practices and a lack of awareness among primary care physicians and other healthcare providers, such as emergency department staff, that these medications are a viable treatment option.

Understanding the complexity of AUD

It’s important to know that AUD is incredibly complex. As a spectrum disorder, it has different levels of severity: mild, moderate, and severe. Every patient is different. Some people may drink infrequently but have trouble controlling their drinking. For example, they may limit their drinking to weekends or other occasions, but find that on the few occasions they do drink, they get boozy. Others drink heavily throughout the day and week. People also drink for different reasons: some to relieve physical pain, others to manage their emotions, and still others to celebrate. Because alcohol is such an integral part of our culture, many people don’t question their relationship with alcohol and may not even be aware that they meet the criteria for AUD. That’s why evaluation by primary care physicians and other healthcare professionals is so important. It’s equally important to remind people that AUD is a chronic medical disorder for which there are treatment options.

Adaptation of treatment to individual needs

Because we understand that AUD is a diagnosable and treatable condition with individualized impact, we can tailor treatments to patients’ specific needs. Effective treatment for AUD is multifaceted and includes medical, psychological and social support.

Conditions such as AUD, which have distinct physical, social and psychological components, are most effectively treated through a combination of behavioral therapy, peer support and MAT. There are many highly effective behavioral treatments – CBT, Community Reinforcement Approach (CRA), mindfulness, motivational interviewing, relapse prevention and Supportive-Expressive Therapy (SET) – that can be integrated with MAUD. With the involvement of a qualified health care team, those affected report feeling able to reframe their relationship with alcohol, learn useful behavioral skills and strategies and find medications that support their goals.

It is also recommended to attend support groups such as AA or SMART Recovery, which can provide community and help those affected stay motivated and pursue their recovery goals.

With the availability of MAT and the support of a therapy and treatment team, many people are able to address their alcohol problems while continuing to work and live at home, rather than having to stay in an inpatient center for weeks or months at a time. Outpatient treatment at a center specializing in addiction and trauma allows people to practice the skills and strategies learned in therapy while being with friends and family and working. They can then return to treatment to discuss how well they were able to implement the skills learned and to receive feedback and support to continue working toward the changes they want.

Primary care physicians can play an active role in helping people recognize and combat excessive drinking by performing routine alcohol use testing as part of an annual physical exam. Early intervention can greatly improve the chances of a successful recovery. Emergency physicians should offer to prescribe MAUD to patients who come to the emergency department for medical problems and accidents related to alcohol use (e.g., acute intoxication or liver cirrhosis). In addition, it may be helpful to learn about outpatient treatment centers that offer MAUD in combination with evidence-based psychotherapy.

Ultimately, AUD should be recognized and treated like other medical conditions in a clinical setting, with care, support, and resources for recovery.

Photo: axelbueckert

Dr. Church, founder and CEO of Wholeview Wellness®, is a clinical psychologist with over 20 years of experience in research, program development, and treatment of patients with substance abuse and co-occurring mental disorders. She is an expert in cognitive behavioral therapy (CBT), community reinforcement approach (CRA), and contingency management.

Prior to founding Wholeview Wellness®, Dr. Church served for 16 years as Executive Director of the Substance Abuse Division at Montefiore Medical Center and Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine. She completed predoctoral training in addictions at Yale University School of Medicine and a postdoctoral year at the Substance Treatment and Research Service (STARS) at Columbia University Medical Center after earning a PhD in clinical psychology from Fordham University and an AB in psychology from Columbia University. Dr. Church was appointed to the NYC-DOHMH Community Services Board by Mayors Bloomberg and De Blasio and serves on the Board of Directors of the Coalition of Medication Assisted Treatment Providers and Advocates (COMPA). She is a past President of the Substance Abuse Division of the New York State Psychological Association (NYSPA). At the international level, she advised the United Nations Office on Drugs and Crime (UNODC) in Vietnam and Afghanistan on the establishment of medication-assisted treatment centres in their countries.

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