The Gap in Alcohol Treatment

Alcohol use disorder (AUD) is the umbrella term referring to both alcoholism and alcohol dependence. AUD affects more than 10% of US adults. It is diagnosed when a person’s drinking causes distress and harm.

A recent review of the types of treatments for AUD in The Journal of the American Medical Association (JAMA) found a rather large gap in the treatment options typically available to people seeking to end their dependence on alcohol.

Those diagnosed as alcoholics are physically dependent on alcohol and may show cravings for alcohol. They may be unable to stop drinking once they have started and experience withdrawal symptoms when they stop. They may also develop tolerance to alcohol and require more and more to achieve the same effect.

People with alcohol use disorders are not necessarily physically dependent on alcohol, but put themselves and others in danger because of their binge drinking: they may fail to fulfill work and family obligations, and may experience a variety of social and legal problems stemming from their drinking.

Two AUD-treatment approved medications, acamprosate and naltrexone, were associated with effectively preventing return to any drinking.

AUD is a chronic illness, meaning that it can persist and may require treatment and monitoring throughout a person’s life. But alcohol problems often go unrecognized and untreated.

Less than a third of people with AUD receive any treatment at all, and less than 10% are treated with one of the medications currently available on the market.

Even when they are treated, people with alcohol use disorders tend not to receive the same quality of care — monitoring and follow-up, for example — that those with other chronic conditions such as heart disease or diabetes receive. This is a missed opportunity to decrease death and disability from this disease.

Psychosocial approaches such as the twelve-step program of Alcoholics Anonymous are the most common interventions. But medication can be useful and effective when combined with psychosocial therapy.

When they are treated, people with AUD tend not to receive the same quality care that those with other chronic conditions such as heart disease or diabetes receive. This is a missed opportunity to decrease death and disability from this disease.

University of North Carolina researchers reviewed more than 120 studies involving 23,000 people with alcohol use problems. These studies assessed both medications that were approved for treatment of alcohol disorders and those used off-label (medications that were not primarily indicated for AUD treatment) such as antidepressants, anticonvulsants, antipsychotics and others.

The studies were designed to determine whether the drugs were useful in helping people 1) maintain sobriety; 2) decrease the amount of drinking if the person returned to using alcohol; and 3) improve their overall health outcome.

Two AUD treatment-approved medications, acamprosate and naltrexone, were associated with effectively preventing return to any drinking. Naltrexone was also associated with a decrease in the number of heavy drinking days per month when the patient resumed drinking.

Acamprosate helps people who have stopped drinking large amounts of alcohol (alcoholism) avoid drinking alcohol again. Drinking alcohol for a long time changes the way the brain functions, and acamprosate reverses some of these changes but it does not reduce or prevent the withdrawal symptoms that people may experience when they stop drinking alcohol. It is usually prescribed along with counseling and social support.

Disulfiram, also known as Antabuse, is probably the best-known treatment for alcoholism. The studies showed that it did not prevent a return to drinking, nor did it decrease the amount of alcohol consumed.

Topiramate, a medication typically used for seizures and migraine headaches, was associated with fewer drinking days, as was nalmefene, which is used for reversal of opioid drug effects. Side effects from these medications included headache, vomiting, dizziness, anxiety, and diarrhea.

The researchers concluded that there were several medications that could be effectively used together with psychosocial interventions that would improve overall treatment outcome.

Many people with alcohol use disorders lack access or are unwilling to engage in treatment by specialists such as psychiatrists. At the same time, the study found that the primary care doctors to whom they are likely to go may be unfamiliar with the full range of medications available and their effectiveness. They are also likely to be unable to offer the ongoing psychosocial therapies needed for true multidisciplinary treatment.

The Affordable Care Act may improve patients' options.

On the other hand, many mental health workers who treat alcoholism do not have the medical background or credentials to prescribe medications. This creates a treatment gap for the medical community that needs to be fixed.

An editorial that accompanies the study advocates for patient-centered care in the treatment of AUD and makes the point that the Affordable Care Act may improve patients' options. “Treatment of AUD is considered an essential health benefit under health care reform. More patients with AUDs will have insurance, which could increase their access to evidence-based treatments for AUDs.”

While it may be a while before the types of integrated treatments recommended by the JAMA article are widely available, patients or family members of patients who are struggling with AUD should talk with their health care providers about the advisability of adding a medication to their AUD treatment program.