Addressing Disparities in Alcohol Use Disorder Treatment: A Call to Action

The article by Le et al. in this issue of the Journal (1) examines factors associated with the receipt of treatment for an alcohol use disorder (AUD) among more than 400,000 participants in the All of Us Research Program, which is sponsored by the National Institutes of Health. They found that, among the nearly 19,000 All of Us participants with a lifetime AUD diagnosis, nearly three-quarters (69.5%) reported having never received alcohol treatment. Among the people with AUD in the sample who received alcohol treatment, 24.0% received psychotherapy, 11.4% received an FDA-approved medication for treating AUD, and 4.9% received both psychotherapy and pharmacotherapy. Thus, the 30.5% of individuals with AUD in the All of Us sample that received alcohol treatment is twice the proportion of individuals with AUD in a large population sample (14.6%) (2). One possible explanation for this difference is that the availability of treatment has increased over the 20 years between the two studies. However, it should be noted that the two samples differ in another major way: the All of Us sample comprised volunteer participants, while the population study used a probability sample (3). Thus, the All of Us sample, with a lifetime prevalence of AUD of only 5%, differed fundamentally from the general population sample, with a lifetime AUD prevalence greater than 29% (4).

To put access to alcohol treatment in context, it is useful to compare it with treatment for a common psychiatric condition such as depression. Whereas only about 7.6% of individuals with past-year AUD in a large population sample reported receiving AUD-specific treatment, 38.2% of individuals with past-year major depressive disorder received depression treatment (5). Similar findings were obtained in another population sample (6), where 61.5% of adults with a past-year major depressive episode (MDE) received mental health treatment, and 47.4% took prescription medication for the disorder. Thus, the likelihood that an individual with past-year depression will receive disorder-specific treatment is up to six times that of an individual with past-year AUD receiving alcohol treatment. Furthermore, the likelihood of an individual with an AUD ever receiving an FDA-approved medication for the disorder is one-quarter that of an individual with MDE receiving antidepressant therapy in the past year. The obvious disparities in treatment availability that confront individuals with AUD who seek disorder-specific care underscore the need to make treatment for AUD more widely available to the U.S. population.

The large All of Us sample, with its detailed phenotypic data, enabled Le et al. to evaluate the impact of race/ethnicity, insurance coverage, income, and other measures of socioeconomic status on the likelihood of receiving AUD treatment while controlling for potential confounders. Notably, they found that Black and Hispanic individuals with AUD are about 25% less likely to receive an FDA-approved medication for AUD than non-Hispanic White individuals. It is of interest that they found no racial/ethnic differences in the likelihood of receiving psychotherapy (alone or in combination with medication). Individuals with lower income and greater socioeconomic deprivation were less likely to receive any form of AUD treatment. In contrast, respondents eligible for Veterans Health Administration (VHA) care were the most likely to receive AUD treatment, surpassing those with private insurance, while individuals with Medicare or Medicaid or no insurance were least likely to receive AUD treatment. These findings of disparities in AUD treatment availability replicate those from a study of nearly 300,000 veterans with AUD, in which Black veterans were more than 30% less likely to receive pharmacotherapy for AUD than White veterans (7). Despite providing valuable insights into the individual effects of race/ethnicity and socioeconomic status on AUD treatment access, the analysis by Le et al. does not fully consider whether these factors interact to compound the barriers to AUD treatment experienced by minoritized individuals.

Studies have shown that multilevel racism—particularly that comprising systemic and institutional elements—contributes significantly to health disparities both independently and in conjunction with socioeconomic status (8, 9). Racism can reduce the health benefits that typically accrue to socioeconomic advancement among minoritized individuals, attenuating potential improvements in health outcomes (10). Additionally, the compound effects of racism and socioeconomic disadvantage may worsen health outcomes more than either factor alone (10), which may help to explain why Black and Hispanic individuals are less likely to receive AUD treatment even after accounting for socioeconomic factors, as Le et al. report. Given the nonequivalent effects of socioeconomic measures across racial and ethnic groups (10), stratified analyses by race/ethnicity that adjust for socioeconomic variables may better reveal these complex interactions. Further research on the joint effects of race/ethnicity and socioeconomic status is critical for developing comprehensive interventions that ensure equitable treatment for all individuals with AUD.

Also noteworthy among the findings of Le et al. is the relative success of the VHA, the largest U.S. health care system and a single-payer system, in caring for individuals with AUD. This success reflects the VHA’s systematic approach to identifying and managing AUD across its more than 1,300 inpatient and outpatient treatment facilities across the country. Annual screening for alcohol misuse, well-defined guidelines for alcohol treatment, and abundant treatment services available ensure a consistent standard of care for veterans with AUD. This contrasts with greater disparities seen elsewhere in U.S. health care, which are magnified by the fragmented nature of the system and evident even among individuals covered by private and public third-party payers.

The immense cost to the country of caring for the complications of untreated AUD includes lost earnings and adverse effects on the quality of life of both affected individuals and their families. Efforts to ensure good quality care for all Americans with AUD—independent of race, ethnicity, income, or socioeconomic status—may be best served by advancing the implementation of a single-payer health care system, where incentives for preventing the complications of a chronic disorder such as AUD are given appropriate attention and resources. However, even in the VHA, disparities persist: Black veterans are more likely than White veterans to be identified as needing an intervention (11) and to receive psychosocial interventions (11, 12) but are less likely to receive pharmacotherapy for AUD (7). Ensuring effective and equitable care for all individuals with AUD will require continued and concerted efforts in both the public and private health care sectors.