Excessive alcohol use is one of the most pressing public health issues in the United States. Some 88,000 Americans died of alcohol-related causes every year between 2006 and 2010, according to estimates from the Centers for Disease Control and Prevention. That's far higher than the latest numbers of annual deaths from drug overdoses (64,000), breast cancer (42,000) or prostate cancer (28,000). Surveys suggest that more than 15 million American adults suffer from alcohol dependence or abuse within a given year.
Numerous treatment options exist for people who drink to an unhealthy degree, including 12-step programs and inpatient rehabilitation centers. Many patients and health-care providers are less likely to be aware that medications can also help treat alcohol use disorder. (That’s the term now used by medical professionals for people with recurrent problems related to drinking.) Three such medications have been approved by the Food and Drug Administration.
Naltrexone has become well known over the past few years as an option for people with opioid addiction; it also seems to blunt alcohol cravings and the pleasurable effects of drinking in some people. Dozens of randomized-controlled trials suggest naltrexone can help reduce drinking, with the risk of heavy drinking nearly 20 percent lower for patients taking naltrexone vs. a placebo.
Acamprosate also may help decrease alcohol consumption, although the mechanisms by which it achieves this remain unclear. Clinical trials have found patients taking acamprosate are about 15 percent less likely to drink any alcohol compared with people taking a placebo, with significantly more cumulative periods of abstinence.
Disulfiram, also known as Antabuse, can be used to disrupt the metabolism of alcohol, making patients feel ill if they drink and therefore discouraging alcohol consumption. (Because of these effects, many patients stop taking the medication or need constant encouragement to continue.) Some studies suggest disulfiram can help patients limit drinking in the short term, but other trials have shown mixed results in terms of efficacy.
All three of these drugs have been around for years. (Disulfiram received FDA approval for treating alcoholism in 1951.) And organizations such as the American Psychiatric Association and the National Institute on Alcohol Abuse and Alcoholism support using these medications to help certain patients. Yet these treatments remain widely underutilized, according to a variety of studies.
For example, a study published in 2009 estimated that fewer than 1 in 10 Americans in need of treatment for alcoholism received prescription medication for the illness. A 2012 study of more than 330,000 patients with alcohol use disorder at the Veterans Health Administration found that just 3.4 percent of them received drugs for the condition. Another study looked at substance abuse treatment programs across the country and found that fewer than 20 percent sustained their use of medications including naltrexone or disulfiram.
If these medications work for some people, why aren’t we using them?
Part of the problem is that people with alcohol use disorder often don't get treated at all. According to one nationwide survey, fewer than 8 percent of people with alcohol use disorder in the year prior sought treatment for the condition. If people aren't going to health-care providers for treatment, medications can't enter the equation.
Stigma also remains an important barrier to treatment. Although growing numbers in the medical community and the public accept the idea of alcoholism as a neurobiological disease caused by genetics, environmental triggers and chemical imbalances, many remain unconvinced. In fact, a 2010 study found that 65 percent of the U.S. public attributed alcohol dependence to "bad character" in 2006, up from 49 percent in 1996.Research has shown that people who perceive greater levels of stigma toward those with alcoholism are less likely to get medical care for the condition.
Among those who pursue treatment, many seek out non-pharmacologic options, such as cognitive behavioral therapy — a form of talk therapy that has been found to be helpful for those with substance abuse problems — or programs such as Alcoholics Anonymous, which promote meetings and support networks. The availability of free meetings and informal settings can be attractive, although the effectiveness of such programs continues to be debated.
Some may have difficulty with costs or administrative hurdles; according to a 2016 study, many insurance plans require prior authorization for medications such as injectable naltrexone and may place them in expensive tiers that require greater co-payments or cost-sharing from patients.
Lack of training among medical professionals may also contribute to the underuse of these medications. In a recent national study, 67 percent of psychiatrists and 88 percent of family physicians said they would be more likely to prescribe medications for alcohol use disorder if they received additional training. A survey published in 2009 of more than 1,100 addiction treatment counselors found that most of them did not know whether naltrexone or acamprosate were effective treatments for alcohol dependence.
The picture may be changing, though.
Some medical institutions have begun ramping up outreach about these medications to both patients and providers. The Veterans Health Administration is providing additional training to clinicians about these drugs and distributing information to veterans. More medical centers are training physicians in addiction medicine. Last year, the Surgeon General's Report on Alcohol, Drugs and Health included a review of medications for alcohol use disorder and advised that they can play an important role along with counseling.
And new medications may be on the way, according to a recent article in JAMA. Research suggests that some drugs long used by physicians to treat seizures and other ailments — among them gabapentin and topiramate — may be effective for treating alcohol use disorder as well.
Millions of Americans suffer as a result of alcohol use disorder, too often not getting the care they need. Meanwhile, evidence-based treatments that might change these patients’ lives for the better are not being used enough.
It’s past time that changed.
Morris is a resident physician in psychiatry at the Stanford University School of Medicine.