By Mark Gold, MD
Alcohol use disorders (AUDs) are one of the most common and least-treated health conditions in the world. Some AUDs decline in severity or even get better without treatment.1 AUDs often accompany depression, anxiety, fears and phobias, sleep disorders, liver problems, and other diseases. They may be caused by shared genes underlying other psychiatric conditions, especially depression.2 And while there’s a strong genetic component in many AUD cases, there are a host of contributing factors, from cultural and regulatory environments to psychological disposition to brain circuitry and anxiety, that can play important roles in the development of the condition—or, at least, that can play anything from a substantial role to a very limited one. It all depends.
As any patient, involved health care practitioner, and/or expert would be quick to point out, AUD is a highly complicated condition, sometimes frustratingly so. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), 6.2 percent of adults over 18 in the U.S. have an AUD, including over 9 million men and 5 million women.3 These numbers can be difficult to gauge in part because of the condition’s complexity—if we had a blood test that a physician could perform or a throat culture that could be sent to the lab, it would establish a diagnosis to everyone’s satisfaction. AUD is the most prevalent substance use disorder in the world, and from a public health perspective, it’s important not to let the complexity of AUD get in the way of sound policies and treatment practices. A comprehensive seminar recently published in The Lancet offered an updated discussion of the state of research on AUD, covering diagnosis, treatment, epidemiology, risk factors, environmental issues, and other considerations, as a guide to what we’ve learned about the condition.
What did this seminar say we’ve learned about AUD?
This comprehensive review concludes that while AUD is certainly complex, there’s a lot of room around the world to improve current treatment approaches by aligning them with the best available research. Drs. Andre Carvalho, Markus Heilig, Augusto Perez, Charlotte Probst, and Jurgen Rehm organize this review on the basis of progress and research results from the past five years. They think of AUD as, “a pattern of compulsive heavy alcohol use and a loss of control over alcohol intake which can, for instance, be seen when use is continued despite adverse consequences and despite the availability of other rewarding activities.” This review prefers this definition in part because of what it identifies as a troubling gap in diagnostic standards in Europe, Canada, and the U.S. The Diagnostic and Statistical Manual of Mental Disorders (DSM-see table) and the International Classification of Disease (ICD) differ in their diagnosis of AUD. To receive a diagnosis under the DSM-5, patients must meet more than one criterion on a list of adverse social, biological, psychological, and behavioral consequences. The severity of a diagnosed AUD depends on how many criteria a patient meets. The ICD-11 classifies patients as either having a less severe “harmful pattern of use of alcohol” or more severe alcohol dependence. Given this diagnostic gap, this seminar wonders, how are health care practitioners around the globe supposed to have a clear and easily applied diagnostic standard? This seminar’s “more informal definition” aligns with actual practice, and with research findings emphasizing heavy drinking as the core problem of the condition across different countries. It is similar to the criteria proposed for addictive behaviors like gambling.
Harm reduction for alcohol and AUD is simple. More consumption of alcohol is associated with more AUDs and related diseases. Less heavy drinking saves lives. This seminar suggests that health care systems are biased toward biomarkers measuring patient drinking. Without a diagnostic test, biomarker changes tend to delay diagnosis and treatment. It finds related problems in other areas. The stigma surrounding other mental health conditions has fallen over time but, interestingly, stigma hasn’t fallen as much for AUD, which makes patients less inclined to ask for help, and health care providers less inclined to offer it. Only about 21-22 percent of individuals with AUD receive treatment. When they do, it’s often at later stages of the condition. And health care professionals who stigmatize AUD often lack appropriate or effective screening standards. When it comes to interventions to combat AUD, this seminar says, medications can be an important piece of the puzzle—disulfiram under supervision, naltrexone, injectable long-acting naltrexone and nalmefene to prevent relapse and possibly in therapy, acamprosate for severe AUDs—but they’re an unfortunately overlooked part of the solution. It’s always important to have innovative work advancing new medications,4 but the larger problem right now is very low prescription rates. About 5-8 percent of patients in specialty treatment receive these medications, and 0-7 percent of patients do overall. We do a much better job of adding medications to the treatment plans for patients with opioid use disorders.
The top ten most successful AUD interventions, research shows, include social skills training, motivational therapy, community reinforcement, behavior contracting, and counseling. Research also indicates that AA and 12 Step is one of the most effective approaches to AUD, for a variety of reasons, including NIAAA findings on 12 Step facilitation. Participating in the program and finding a sponsor is also, importantly, free. Prevention should be prioritized, as promising non-use and delay-of-use data have emerged. Given AUD’s complexity and sometimes fraught disputes about the nature of the condition, it’s important for medical professionals to keep this information in mind—many, especially in the primary health care system, can spot and fight AUDs before they progress in severity. Understanding what works best for whom, and when, can help them do that. This seminar also says that while AUDs are most common in rich countries, they are more common among individuals with lower socioeconomic statuses within them, and more common among men than women. In 2016, for example, estimates indicate that 8.6 percent of men and 1.7 percent of women in the world had AUDs. Studies show that AUD heritability ranges from 40-70 percent irrespective of sex. In the brain, binge drinking can change dopamine function, stress from not drinking can change the amygdala, and cravings can change the prefrontal cortex. Some genes may curb the effects of trauma or stress in sparking compulsive drinking, and dispositional traits associated with AUD, such as impulsivity, may have a genetic underpinning. Genes and alcohol misuse has been associated with smaller subcortical and cortical regional gray matter volumes.5 And other conditions and environmental factors are also linked to AUDs: anxiety management, mood disorders, family stability, and even wanting to enhance sexual performance.
Why is this important?
Individual, familial, communal, and political understandings of addiction can be emotionally charged, and that may be especially true of a complex condition like AUD. But complexity doesn’t mean failing to establish best practices. The NIAAA suggests that it starts with diagnosis.
AUDs are genuinely complicated and a “correct” approach may depend just as much on a well-informed cultural perspective as it does on careful attention to individual patients. This seminar helps to frame AUD’s complexity in a broader literature and points to the potential global benefits of more evidence-based practice. Data from some Nordic countries indicates that AUDs and associated health problems can lower life expectancy by 20 years. Some cultures have norms restricting the social acceptability of alcohol, or at least confining it to certain settings, and others have ritualistically celebratory standards for drinking. Officials have discussed public policies to reduce total alcohol consumption, delay first use, prevent binge use, and detect early alcohol misuse. Some options, like higher alcohol taxes or advertising prohibitions, have some effects mostly by curtailing heavy drinking—and we should want that to happen, the seminar stresses, as heavier drinking increases mortality. We know that patients, families, communities, and even countries need better approaches to alcohol and AUD across the board.
Drug and alcohol problems are often accompanied by major life problems, other medical issues, and psychiatric concerns. But in AUDs, psychiatric disorders are so common that some experts suggest that if you haven’t found one, you are not looking hard enough. Most common are co-occurring problems with anxiety and depression, so individuals with AUD should also be screened for these psychiatric issues. A recent review on the co-occurrence of AUD and depressive disorders includes data on prevalence, course, and treatment outcomes.6 AUD and depression, called “double trouble”, is associated with greater severity and worse prognosis than either disorder alone.7 People with AUD have a heightened risk for suicidal behavior and repeat suicide attempts.8 Treatment for one is complicated by having the other. Vigorous concurrent treatment is required for these two major chronic and relapsing illnesses with significant overlap.
Remember, we do have medication-assisted treatments, motivational interviewing, 12 Step, SBIRT, and other important evidence-based approaches for AUD. This expert-led seminar is convincing on a key point—we have learned a great deal, we can do better, and there’s substantial room for improvement in prevention, early intervention, and treatment.
Walters, G.D. (2000) Spontaneous remission from alcohol, tobacco, and other drug abuse: seeking quantitative answers to qualitative questions. Am J Drug Alcohol Abuse
Fu, Q., Heath, A.C., Bucholz, K.K (2002) Shared Genetic Risk of Major Depression, Alcohol Dependence, and Marijuana Dependence. Contribution of Antisocial Personality Disorder in Men. JAMA Psychiatry
National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorder. Retrieved from https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders
Leggio, L., Falk, D.E., Ryan, M.L., Fertig, J.,, Litten, R.Z. (2019) Medication Development for Alcohol Use Disorder: A Focus on Clinical Studies. Handb Exp Pharmacol
Baranger, D.A.A., Demers, C.H., Elsayed, N.M., Knodt, A.R., Radtke, S.R., Desmarais, A., Few, L.R., Agrawal, A., Heath, A.C., Barch, D.M., Squeglia, L.M., Williamson, D.E., Hariri, A.R., Bogdan, R. (2019) Convergent Evidence for Predispositional Effects of Brain Gray Matter Volume on Alcohol Consumption. Biol Psychiatry
McHugh, K.R., Weiss, R.D. (2019) Alcohol Use Disorder and Depressive Disorders. Alcohol Research: Current Reviews