An Underutilized, Evidence-Based Treatment for Alcohol Use Disorder

It was 1 a.m. on a Tuesday morning, and I was covering psychiatric consults when I got paged to see Mr. W., a 38-year-old man well known to our department for multiple ED visits while intoxicated. This time, he had a blood alcohol level of .496 endorsing suicidality. A feeling of extreme frustration and agony rushed through me. Why can’t this man maintain abstinence despite numerous therapy sessions and seven-day detox admissions, and what do we even have to offer him at this point?

As psychiatrists, we encounter many patients with alcohol use disorder (AUD) either as a primary or comorbid diagnosis. With 80 percent of our American adolescents having reported using alcohol in the past year and with the emergence of new, more dangerous formulations such as Palcohol, this problem will only continue to grow. A greater prevalence of AUD is noted among psychiatric patients, and ongoing use complicates the course of medical and psychiatric disorders, carrying significant social and financial costs.

Despite the difficulty of treating AUD, diverse pharmacological treatment options are available and can be pursued with minimal disruption to home and work life. To date, medication-assisted treatment (MAT) is vastly underutilized, with only 3 percent of sufferers receiving FDA-approved treatment. Many trainees may have never prescribed or even considered such medications. Despite modest effect sizes in randomized, controlled trials to date, efficacy has been demonstrated with regard to reducing relapse rates and the overall severity of drinking days. Regardless of the severity of alcohol use, these individuals suffer from a potentially fatal chronic disease characterized by frequent relapses. Evidence indicates that recovery rates are highest when addiction treatment includes continuous abstinence monitoring, yet management today remains largely limited to short, episodic inpatient detoxifications and psychosocial therapies.

After six hours in the ED, Mr. W. had become clinically sober. Similar to prior presentations, he then denied suicidal thoughts and expressed disappointment at his relapse, stating he planned to never drink again. With his therapy appointment in two days, discharge planning began. On his way out, he asked, “Is there a magic pill I can take to help me stop drinking?” The physician was vaguely aware of medications for alcohol use disorder, but due to lack of familiarity, he told the patient that attending substance abuse group therapy and discussing stressors with the counselor would be more beneficial.

This case left me wondering: Why are both patients and providers ambivalent about using medication to achieve lasting recovery? Medication initiation certainly requires both parties to be in agreement. Prescribers also fail to offer medications due to lack of familiarity with medications, the guidelines for their use, or even a lack of belief in their effectiveness. Given that treatment is often based on 12-step models such as Alcoholics Anonymous (AA), providers may hesitate to prescribe medication for an illness thought to be managed through psychosocial interventions like group therapy, AA, and motivational therapy. Patients may decline medications due to a fear of dependence on them or patients’ overestimating their ability to achieve remission on their own.

The choice of medication depends on the comfort level of the prescriber, reputation of the medication, side-effect profile, and affordability. However, the most important consideration should be the overall goal and expectation of the patient. It is advised to start with FDA-approved meds such as disulfiram for the motivated patient who has a collaborator and is desiring complete sobriety, naltrexone for those desiring to cut down (a long-acting formulation can be used for noncompliant patients), and acamprosate for patients with at least some established sobriety who need help with postwithdrawal sleep problems. With regard to off-label medications, topiramate has the highest evidence for efficacy. Gabapentin can augment naltrexone and also helps with sleep, anxiety, withdrawal, and cravings.

Use of FDA-approved medications in conjunction with psychosocial interventions should be considered an integral part of our training and, ultimately, a part of our daily practice for the treatment of alcohol use disorder. ■