Heading Off Alcohol Use Disorder

Many people don’t realize they have an alcohol problem. Yet early indicators of alcohol issues show that if attention were paid, excessive drinking might be headed off before alcoholism develops. For example, experts now recognize a pre-addiction stage of alcohol use disorder (AUD). If a person is identified with pre-addiction before alcohol issues become entrenched and then receives treatment, major emotional and physical pain could be averted. This post covers the range of problematic alcohol use from pre-addiction to AUD. It also describes existing and potential treatments.

Identifying Possible Problems: Brief Interventions

The National Institute of Alcohol Abuse and Alcoholism (NIAAA) encourages medical providers to screen patients for alcohol consumption and initiate interventions aimed at harm reduction. Yale’s Joel Gelertner studied heavy drinking and compared it to lower levels of alcohol use, alcohol dependence, and relationships with mental and physical health. Habitual heavy drinking is genetically similar to AUD -an important risk for developing alcohol dependence.

Most heavy drinkers do not have AUD but may benefit from feedback leading to their making healthy changes. All heavy drinkers need counseling from physicians—called a brief intervention—to reduce risks for alcohol-related harm. Sadly, fewer than 10% of individuals needing treatment for AUD receive treatment. In addition, less than 2% receive one of the three FDA-approved and effective medications for AUD. Teresa Rummans, MD, Professor and Chair at Mayo Clinic, says, “We see too many patients whose lives have been changed because of their drinking. We need to intervene and start treatment earlier. We have excellent treatments for AUD, but few patients taking them. More patients take MATs [Medication-assisted treatment] for OUDs [opioid use disorders] than people taking medications for their AUDs, even though more deaths are associated with AUD."

Understanding Pre-Addiction

With pre-addiction, there is a high risk of developing a substance use disorder (SUD), but the person isn’t there yet. The person in the pre-addiction phase is starting to experience social, psychological, or physical impairments due to alcohol, but these outcomes are not yet severely disrupting daily life. Pre-addiction, if untreated, leads to alcohol use disorder.

Nora Volkow, director of the National Institute on Drug Abuse (NIDA), calls for alcohol problems to be identified whenever possible in the pre-addiction phase.

Nora Volkow, MD, Director of NIDA

Source: NIDA

Volkow explains, “Far too often, the expectation is that someone must hit ‘rock bottom’ before treatment can work. But this is a myth that can have dire consequences. By then, the damage is consequential, and the road to recovery is much harder. Factually, the best time to get help is as soon as possible.”

Volkow adds, "A diagnosis of pre-addiction could similarly serve as an alert to the individual about a behavioral pattern with potentially major—but also very preventable—health and life consequences down the road. It could create a different inflection point, one that recruits the patient more actively as an agent in their own health and wellness.”

Alcohol Use Disorder

Addiction to alcohol means a person feels compelled to use alcohol. Alcohol use disorder is a chronic, lifelong, relapsing illness undermining happiness, work, relationships, and free will.

Treatment of Alcohol Use Disorder

Alcoholics Anonymous (AA), with 2.1 million members worldwide, has assisted people to regain control over alcohol use since 1935. There are also medications effective in treating AUD, such as naltrexone and other drugs. In addition, newer or emerging treatments may include GLP-1s and psychedelics as well as neuromodulation (like TMS).

Self-help groups

AA meetings are free and nonjudgmental, and they are available day or night and even multiple times a day in many cities. Successful AA members usually become sponsors once they have been senior members in recovery for at least a year. A sponsor is a confidante with essential lived experiences and can be called 24/7 for help.

Sponsors help new members work on the 12 steps toward sobriety and offer accountability. Studies have shown that sponsorship leads to better treatment outcomes, and those in 12-step programs with sponsors have better attendance and more involvement in the group.

Alcohol-Associated Organ Damage

Source: NIAAA

Medication-assisted treatment (MAT)

The most commonly used and recognized MAT for alcohol use disorders is naltrexone, taken orally or as an injection. Naltrexone helps decrease total drinks consumed per day, cravings, and pleasurable effects of alcohol. Injectable Naltrexone (Vivitrol) injections are given once a month, providing a way to get beneficial effects for 30 days at a time. Patients can and do drink while taking naltrexone, but it is less pleasurable, and they also take Naltrexone to prevent or decrease anticipated likely drinking events.

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Acamprosate (Campral), usually taken three times a day, is another medication for AUD. Extensive evidence proves Naltrexone and acamprosate reduce heavy drinking and promote abstinence. Disulfiram (Antabuse) is another medication FDA-approved to treat alcohol use disorder, but it is used very infrequently.

Since the 1970s, I have researched and written scientific papers on oral naltrexone and injectable naltrexone (Vivitrol). Taking Vivitrol for 3-6 months while going to 90 AA meetings in 90 days is often recommended after residential detox or treatment. Making the commitment to take one Vivitrol shot helps overcome the ambivalence of taking a daily pill. However, it is rarely the approach offered or accepted by patients. Dr. Rummans says, “It is a very good approach, but many who are struggling with addiction either don’t want to take another medication, or they only want to take it for a short period of time, or they prefer to take a reinforcing medicine similar to the substance they were addicted to.”

Many people struggle to achieve lasting recovery from alcohol dependence, highlighting the need to individualize patient treatment based on their life history, genes, coexisting illnesses, and other issues. “Evaluation of the patient for co-existing medical and psychiatric diseases is an important part of the assessment of patients with AUDs, but too often ignored or complicated by detoxification,” said Rummans. For example, AUD patients with major depression have significantly more relapses.

Psilocybin and other new treatment options for AUD

New research has found that psilocybin reduces alcohol consumption in rats by altering the left nucleus accumbens in the brain. While we wait for definitive trials leading to FDA medication approvals in humans, promising studies using neuromodulation of the brain as well as treatment with ketamine and other psychedelics are encouraging. Most recently, real-world human studies have been very positive in reporting decreases in drinking for diabetic patients treated with GLP-1s (think Ozempic and Wegovy). Animal studies also show that GLP-1 receptor agonists suppress the rewarding effects of alcohol and reduce alcohol consumption.

Conclusion

Alcohol misuse is a leading preventable cause of death in the United States. AUD is undertreated and marked by guilt, shame, and stigma, too often ending in despair and suicide. According to the Journal of the American Medical Association, 37% of alcohol abusers have at least one serious mental illness. Among people dying by suicide, AUD is the second-most-common mental disorder, involved in 1 in 4 suicide deaths. Rather than wait for people to “bottom out,” we need to intervene much sooner with regular alcohol screening and identification of pre-addiction. Earlier treatment saves suffering and lives. AUD medications work but are rarely prescribed or taken. Current AUD medications are the same MATs we’ve had for decades. AUD treatment failures are more likely when we do not treat comorbidities. Further research on neuromodulation (TMS), ketamine, psychedelics, and GLP-1 receptor agonists may increase patient and physician interest in AUD treatment.