New Considerations on the Treatment of Alcohol Use Disorder: Problems and Solutions

A recent study (1) suggests that alcohol use disorder (AUD) remains underdiagnosed, despite the availability of effective therapies and medications. Key points highlighted include addressing stigma, improving screening, and investing in new approaches to increase access to treatments.

Alcohol use disorders (AUDs) are a large-scale public health issue, affecting more than 29 million people in the United States and leading to over 140,000 deaths annually. The most severe form of these disorders is alcoholism. It is described by a heuristic model encompassing three interconnected stages: heavy drinking/intoxication, withdrawal/negative affect, and concern/anticipation. This model provides a framework to understand the complexity of the disorder and its various manifestations in relation to treatment.

Defined as a chronic and recurring disorder, alcoholism is characterized by compulsive consumption, loss of control, and negative emotional states in the absence of alcohol. AUDs are classified as mild, moderate, or severe. In the neurobiological realm, AUDs involve three main domains: incentive salience/pathological habits, negative emotional states, and executive function, which are linked to the activation of brain circuits such as the basal ganglia, extended amygdala, and prefrontal cortex. The article also highlights that excessive alcohol consumption deregulates the brain's reward system and alters stress systems, reinforcing the cycle of dependence.

Despite the existence of effective treatments, such as behavioral interventions and approved medications, these resources remain widely underused, highlighting the need for actions to address existing gaps, including broadening the criteria for medication approval, increasing the use of screening and brief interventions, combating stigma, defining a clear and culturally sensitive “recovery” criterion, and promoting both public and professional education.

Evidence-based treatments include a wide range of behavioral therapies, such as cognitive-behavioral therapy, motivational interviewing, acceptance/mindfulness-based approaches, and the 12-step approach, used by mutual aid groups like Alcoholics Anonymous. Combining therapies and medications enhances treatment efficacy, helping to modify alcohol-related attitudes and behaviors.

Among FDA-approved medications, disulfiram, naltrexone, and acamprosate stand out for their different methods of reducing consumption and promoting abstinence. While disulfiram causes severe adverse reactions to alcohol consumption to create unpleasant sensations during drinking, but also making adherence to treatment more difficult, naltrexone blocks the rewarding effects of alcohol; both have proven efficacy in reducing excessive consumption. Acamprosate, on the other hand, helps maintain abstinence by alleviating severe withdrawal symptoms. Additionally, repurposed “off-label” medications such as topiramate and gabapentin also show efficacy, reducing excessive consumption and aiding sleep initiation and maintenance.

Despite the proven effectiveness of treatments, fewer than 8% of adults with AUD receive any form of intervention, and less than 2% have access to approved medications. Significant barriers, such as a lack of public policies, inadequate screening, and stigma, further hinder access. Although the SBIRT model (Screening, Brief Intervention, and Referral to Treatment) is effective for early detection, it remains underused and still rarely implemented by healthcare professionals, whether in public or private systems. Additionally, the lack of appropriate facilities, delays in the approval of new medications, and insufficient investment by the pharmaceutical industry in developing addiction treatments compared to other areas represent additional challenges.

The stigma associated with AUD is particularly damaging, as individuals with this disorder often face judgment that holds them accountable for their condition, which negatively impacts their willingness to seek help. This contributes to fewer than 1 in 10 individuals with AUD receiving treatment annually, while about 20% avoid seeking help due to the fear of being stigmatized. Stigma also affects patients in need of liver transplants and can limit participation in clinical trials due to prejudice.

The article emphasizes that, to address these challenges, it is essential to develop a variety of treatments that recognize individual responses to different approaches, whether behavioral therapies or medications. The definition of recovery has been refined to include not only the remission of AUD but also the cessation of excessive alcohol consumption and biopsychosocial well-being. Early diagnoses and interventions at the initial stages of AUD can prevent its progression to more severe forms, while educational resources such as the Healthcare Professional’s Core Resource on Alcohol and platforms like Rethinking Drinking offer tools to raise awareness among healthcare professionals and the general public.

Finally, the three-stage model of AUD highlights intervention targets at each stage, with assessments covering executive function, incentive salience, and negative emotionality, allowing for more personalized treatments. Research to identify new targets for medications and overcome challenges in the pharmaceutical industry is crucial to driving the development of new treatment options. This approach proposes a more comprehensive neuroscientific understanding, aiming to offer individualized and effective treatments.

References:

1. Divya Ayyala-Somayajula, Jennifer L. Dodge, Adam M. Leventhal, et al. Trends in Alcohol Use After the COVID-19 Pandemic: A National Cross-Sectional Study. Ann Intern Med. [Epub 12 November 2024]. doi:10.7326/ANNALS-24-02157