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Alcohol problems are no joke.
Excessive drinking can have a wide range of consequences,
and it can lead to other diseases, like liver disease, heart disease, and cancer.
It’s also incredibly common and seriously undertreated, affecting millions of people worldwide.
And to make matters more complicated, there are a lot of stereotypes and stigma
surrounding alcohol that prevent both understanding and adequate care.
For one thing, though we usually refer to “alcohol abuse” or “alcoholism,”
psychiatrists and other medical professionals now formally use the term alcohol use disorder, or AUD.
That’s because previous definitions didn’t totally capture the spectrum of symptoms that AUD can include.
But also, the way we think about treatments doesn’t always represent the full story.
Here in the United States, common treatments include rehab
and those anonymized, 12-step group therapy programs.
But those are far from the only treatments for alcohol use disorder,
nor are they necessarily the most effective.
What many people don’t realize is that there are so many ways to treat AUD.
So many, in fact, that doctors and patients have choices when it comes to treatment and recovery.
It’s not all about checking into rehab or starting a 12-step program; there’s tons of stuff.
So here are some of the ways that we can treat AUD.
The term “alcohol use disorder” officially comes from the
Diagnostic and Statistical Manual of Mental Disorders, or DSM,
the manual psychiatrists use to diagnose mental illnesses.
The 5th edition of the DSM lists 11 criteria for AUD, including having cravings for alcohol,
continuing to drink even though you suspect it might be causing problems,
and actually having job or life problems caused by drinking.
But patients don’t have to check all 11 boxes.
If they meet at least 2 criteria, medical professionals may diagnose them with mild AUD.
And if they meet more than 2, doctors may bump up that diagnosis to moderate or severe.
Before we talk about what’s involved with AUD treatments, though,
we should establish what doctors actually want as a result of that treatment,
the outcomes, to use the medical jargon.
Most of the time, the treatment goal is abstinence, for patients to stop drinking entirely.
But that’s not always the case, and in some circumstances,
it may be appropriate to try and shoot for more moderate, controlled drinking habits.
That can come up when patients don’t want to, or don’t think they can, stop drinking completely.
Because ultimately, it’s more important to engage these folks in treatment, even if it means compromising.
Like anything else, it’s something to be figured out between a patient and their doctor.
But regardless of what the goal is, there’s a wide range of
behavioral treatment programs that can be applied to alcohol use disorder.
At least in the U.S., the most well-recognized are probably those 12-step programs.
One example is Alcoholics Anonymous, but there are others,
some based on religious or spiritual beliefs, and others that are more secular.
Either way, doctors refer to such programs as 12-step facilitation.
But despite the number of people who go through these programs,
there’s not actually much evidence about how well they work,
because these things are really hard to study.
Scientists have looked at them, but their research often examines such a range of outcomes
that it’s hard to compare one paper to another.
Also, the programs are anonymous.
And it’s kinda hard to recruit study participants when you don’t know who they are.
One 2006 review sorted through the literature about these programs,
and it actually suggested that none of the studies out there
provided convincing evidence in favor of the 12-step approach.
The most encouraging thing they could offer was one study, which did find
some indication that AA might help get patients into treatment and keep them there.
That doesn’t mean these programs are bad, though, just that the research is a bit fuzzy.
Outside of studies, many patients have reported that the support provided by group therapy is helpful,
so many doctors keep twelve-step programs on the table.
Now, treatments like this aren’t the only kind of behavioral intervention.
Behavioral interventions can cover all kinds of things,
from a brief meeting with a primary care doctor to residential rehab programs.
But unfortunately, the story surrounding them is the same.
It’s really hard to study for various reasons,
so there’s not much clear evidence about whether or not they work.
Groups like the World Health Organization keep recommending them, though,
because they provide psychological and social support, which is definitely something.
So if these programs work for people, they are definitely worth it.
Regardless, there are forms of behavioral treatment
that do have some pretty good evidence that back them up.
Cognitive behavioral therapy, for example, is a form of therapy that focuses on
helping people identify and change unhelpful thoughts and behaviors.
It’s been shown to be effective for substance abuse time and time again in the medical literature,
and patients respond well to it.
Brief interventions are also highly effective for alcohol use, maybe surprisingly.
These are exactly what they sound like: short, one-off meetings with patients for as little as 5 minutes.
Studies have shown that even such a minimal treatment can decrease heavy drinking 20 to 30%,
and have measurable benefits up to 2 years down the line.
They’re targeted at people whose behavior represents a risk of developing alcohol problems,
rather than those who already have some form of dependence,
which might help explain why a short conversation can be so effective.
Because of their one-off nature, brief interventions are a way to reach people
who show up to a hospital or their doctor’s office for whatever reason,
so doctors consider them the first line of treatment.
But while therapy in all its various forms can really help people, it’s also not the only option.
In the US, there are a handful of drugs that are approved to treat alcohol use disorder,
including naltrexone, disulfiram, and acamprosate.
Naltrexone is available in both pill and injectable forms,
and it was originally designed to treat opioid dependence.
But it also helps treat alcohol dependence,
probably by decreasing the amount of dopamine released in the brain in response to alcohol.
Since dopamine is associated with a pleasant, rewarding feeling,
naltrexone makes it feel less rewarding to drink.
Multiple studies have shown that naltrexone reduces both a return to binge drinking
and a return to any drinking in patients who have quit alcohol.
Though the size of the effect isn’t as big as doctors might like.
AUD isn’t just about the cravings, though.
Chronic alcohol use and dependence also produce a host of changes in the brain,
and acamprosate aims to change them back.
For example, alcohol can mess with the signaling done by the neurotransmitter NMDA,
which is involved in learning and memory.
Acamprosate helps modulate that signaling, so it can help patients maintain abstinence from alcohol.
Studies show it helps people avoid taking up drinking again,
although it doesn’t prevent a return to binge drinking in particular,
which is defined as having more than 4 or 5 drinks in a day.
Finally, disulfiram is a bit different.
It’s been approved for decades, ever since the 1940s.
And instead of your brain, it works in your liver.
It blocks aldehyde dehydrogenase, one of the enzymes responsible for breaking down alcohol.
And if that sounds bad, it is! It’s bad on purpose.
When aldehyde dehydrogenase doesn’t work properly,
it leads to a buildup of a chemical called acetaldehyde in the body.
And that leads to flushing, nausea, vomiting, palpitations, and occasionally worse symptoms
like heart problems, though it’s not clear how common those are.
Basically, if you’re taking this medication and you drink alcohol,
you will get sick, and it will not be nice.
The idea is that people will quickly learn to avoid the adverse reaction.
Unfortunately, when study patients aren’t told whether they’re getting disulfiram or a placebo,
it doesn’t seem to make much difference to their alcohol use.
Although there is evidence to suggest it’s more effective when used under a doctor’s supervision than without.
Of course, these are just drugs used in the U.S.
The European Union has also approved a drug called nalmefene
to help people with alcohol dependence drink less.
It works quite a bit like naltrexone,
and it can reduce the number of days that people binge drink compared to a placebo.
And in the US, some drugs for other conditions can also be used to treat AUD,
like gabapentin, which is used for seizures.
But more studies are needed to determine their effectiveness.
All in all, there are a lot of safe, potentially effective drug options out there,
but alarmingly, researchers have estimated that only 9% of people
who could stand to benefit from them are actually getting them.
Plenty of people receive behavioral treatments,
but it seems like a lot more people could be getting these drugs.
There are likely a number of reasons for that, but it’s also worth keeping in mind
that there’s no rule that says you have to pick just one of these things.
Medicine and behavioral intervention together has also been shown to be effective,
like in the 2006 COMBINE study.
This was a randomized controlled study of almost 1,400 patients that explored several questions
about the relationship between drug and behavioral therapy for alcohol use.
The researchers wanted to know things like
whether drugs can be effective independently of treatment by a specialist,
and whether specialist treatment could be improved by adding drugs.
They looked at how many days patients went without drinking,
as well as how long it took patients to have a day where they drank heavily after beginning treatment.
And they tested both naltrexone and acamprosate.
Most groups received what the researchers called medical management:
a basic, 9-session treatment designed to be administered by a primary care doctor.
But some also received more specialized counseling referred to as combined behavioral intervention.
People in all treatment conditions showed improvement, which is great!
You don’t want to see your study population get worse if you can help it.
Patients taking naltrexone, receiving a behavioral intervention, or both
all fared better than patients receiving a placebo or medical management alone.
However, the combination of naltrexone and therapy didn’t fare any better than either treatment by itself.
The authors suggest this could actually be beneficial for some patients.
If they didn’t have access to therapy,
seeing a primary care doctor and receiving naltrexone could still help them.
And this really drives home the idea that doctors want to see people get better.
The goal isn’t to promote one treatment over another; it’s to get people into any treatment at all.
In fact, some researchers have suggested that informing patients of all of the options
could give them more independence and control over their own treatments.
And that could help tear down the stigma against seeking help in the first place.
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