Sarah Church
Alcohol use disorder (AUD) affects millions of Americans, but unfortunately only a tiny fraction of those who struggle with alcohol receive any of the FDA-approved, evidence-based treatments proven effective in reducing the negative consequences of problematic alcohol use. According to data shared by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), as of 2023 28.8 million U.S. adults were diagnosed with AUD. However, only 7.6% of that group received any treatment for their struggles with drinking, and even fewer – 2.2% – received medications for the treatment of alcohol use disorder (MAUD). As a society, we need to do better.
The combination of widespread prevalence of AUD and low uptake of treatment has profound implications for public health throughout the United States. The CDC reports that U.S. deaths from causes entirely due to excessive alcohol use have surged during the past two decades. This was particularly acute during the pandemic when social isolation and economic downturn combined with increased accessibility through home delivery and take-out drinks caused a spike in alcohol-related deaths.
In the past 20 years we have also seen significant increases in drinking in women and young people. For the first time, the percentage of women binge drinking rivals that observed among men, due to 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 spread rapidly across college campuses.
The increases in AUD and alcohol-related deaths are particularly devastating because we know that effective screening and treatment strategies are available. MAUD, in particular, in combination with psychosocial support, such as counseling or therapy, has been shown to help those living with AUD achieve sustained 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, whole-person philosophy addresses the medical, psychological, and social aspects of AUD, giving people a chance to enter into and maintain recovery.
FDA-approved medications
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 builds up quickly in their body and they experience severe physical reactions including vomiting, severe headaches, and extremely high blood pressure. Because these reactions are very unpleasant, people avoid alcohol when taking it. Disulfiram requires a firm commitment to avoid drinking, so we typically recommend it only for individuals who exhibit strong motivation to abstain, or who need to abstain for medical reasons.
- Naltrexone is an opioid receptor antagonist, meaning it blocks opioid receptors, therefore blunting the euphoric effects of alcohol. It can be an option for people who want to reduce their drinking or stop altogether. People who take naltrexone report a reduction in craving for alcohol, in part because the medication reduces the reinforcing effect of alcohol. Studies have shown that it reduces the number of days a week that people drink, and it also reduces the amount they drink on the days that they choose to drink. Naltrexone can be taken daily as an oral medication or as a monthly injection (VIVITROL). Research indicates that the use of naltrexone over time, paired with psychotherapy, can contribute to long-term behavioral modification and changed relationships with alcohol.
- Acamprosate is an oral medication option for people who are trying to abstain from or reduce their cravings for alcohol. While it is less clinically understood than other medications for AUD, acamprosate is known to modify the neurological response to alcohol’s effects, reducing cravings. It must be taken three times daily, which may pose a challenge for some people, depending on their professional and lifestyle commitments.
Despite the demonstrated efficacy of treatments for AUD, there are multiple reasons for their underutilization, including the stigma surrounding alcohol misuse and treatment. Additional reasons include insufficient screening and referral practices, and the lack of awareness among primary care and other medical providers, such as emergency room personnel, that these medications are viable treatment choices.
Understanding the complexity of AUD
It’s important to note that AUD is incredibly complex. As a spectrum disorder, it has varying degrees of severity: mild, moderate, and severe. Every patient is different. Some people may drink infrequently, but struggle with control when they drink. For example, they may limit consumption to the weekends or other occasions, but find that they binge on the few occasions they choose to drink. Others may drink extensively throughout the day and week. People also drink for different reasons, some to alleviate physical pain, others to manage emotions and others for celebratory reasons. Given that 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, which is why screening by primary care providers and other health professionals is critical. Equally important is reminding people that AUD is a chronic medical disorder for which treatment is available.
Tailoring treatment to individual’s needs
By understanding that AUD is a diagnosable and treatable medical condition with individualized impact, we can tailor treatments to meet patients’ specific needs. Effective treatment for AUD is multifaceted, involving medical, psychological, and social support.
Conditions such as AUD, with distinct physical, social and psychological components, are most effectively addressed 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 healthcare team, individuals report feeling enabled to reframe their relationships with alcohol, learn useful behavioral skills and strategies, and find medications that support their goals.
Participation in peer support groups, such as AA or SMART Recovery, which can provide fellowship and help individuals stay motivated and committed to their recovery goals, is also recommended.
With the availability of MAT and the support of a therapeutic and treatment team, many people can address their alcohol use issues while continuing to work and live at home, rather than having to commit to weeks or months at an inpatient center. Receiving outpatient treatment at a center that specializes in addiction and trauma lets people practice the skills and strategies they learn in therapy while socializing with friends and family and working. They can then return to treatment to discuss how well they were able to implement the skills they learned and to get feedback and support to continue working on making the changes they desire.
Primary care providers can take an active role in helping people identify and address excessive alcohol use by including routine screening for alcohol use as part of an annual physical exam. Early intervention can significantly enhance the chances of successful recovery. Emergency room providers should offer to prescribe MAUD for people who present to the ER for medical issues and accidents that involve alcohol use, for example, acute intoxication or cirrhosis). Further, it may be useful to be aware of outpatient treatment centers that offer MAUD in combination with evidence-based psychotherapy.
Ultimately, AUD should be recognized and treated just the way other medical conditions are treated in a clinical setting, with care, support, and resources for recovery.
Photo: axelbueckert
Dr. Church, the founder and executive director of Wholeview Wellness®, is a clinical psychologist who has more than 20 years of experience in research, program development and treatment of patients with substance use and co-occurring mental health disorders. She is an expert in Cognitive Behavioral Therapy (CBT), Community Reinforcement Approach (CRA) and Contingency Management.
Before starting Wholeview Wellness®, Dr. Church served as the Executive Director of the Division of Substance Abuse at Montefiore Medical Center and as an Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine for 16 years. She completed a predoctoral fellowship in addiction at the Yale University School of Medicine and a postdoctoral year at the Substance Treatment and Research Service (STARS) at Columbia University Medical Center after graduating from Fordham University with a doctorate in clinical psychology and from Columbia University with an AB in psychology. Dr. Church was appointed by Mayors Bloomberg and De Blasio to the NYC-DOHMH Community Services Board and serves on the Board of the Coalition of Medication Assisted Treatment Providers and Advocates (COMPA). She is a Past President for the Division of Substance Abuse at the New York State Psychological Association (NYSPA). Internationally, she has provided consultation to the United Nations Office of Drugs and Crime (UNODC) for both Vietnam and Afghanistan as they develop medication assisted treatment centers in their countries.
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