Why Aren’t More People Taking Medication for Alcohol Use Disorder?

The Food and Drug Administration (FDA) has approved four medications for treating alcohol use disorder (AUD) since 1949, but they are rarely prescribed or used.

A new study examining data from a 2019 national survey on drug and alcohol use found that 6% of U.S. adults had AUD. Of those, fewer than 10% reported receiving any treatment for their condition and only about 1.6% said they used AUD medications.

Why are both treatment and medication rates so low for AUD? Emily Einstein, PhD, chief of the National Institute on Drug Abuse’s Science Policy Branch and one of the authors of the study, tells Verywell that cultural stigma surrounding alcoholism in the U.S. hinders treatment.

"Stigma is a huge factor that plays a role across that hopeful cascade of care," Einstein says. "The person who has the addiction to alcohol might not want to admit that they have it because it's so stigmatizing. And then healthcare providers interact with patients in a way that's different than other diseases."

Medications for AUD

In 2017, the American Psychiatric Association released guidelines for pharmacological treatments of patients with AUD. However, Einstein and her colleagues say that, prior to their study, little was known about the prevalence of medication prescribed among U.S. adults with AUD.

There are three active ingredients—disulfiram, naltrexone, and acamprosate—used in medications approved to treat AUD.

Disulfiram, sold under the trade name Antabuse, is the longest-known one. Its anti-alcohol properties were discovered by accident between the '40s and '50s, Einstein says. "People came in contact with disulfiram, and then they consumed alcohol and got horribly sick," she says. "It creates a physical reaction in your body that just makes the consumption of alcohol really aversive."

Naltrexone, sold under brand names including Vivitrol, is used in treating opioid use disorder in addition to AUD. Naltrexone blocks the brain's new opioid receptors—the very receptors that make opioid drugs, and likely alcohol, rewarding. "The thought behind naltrexone is that it makes consuming alcohol a less pleasurable experience," Einstein says. Rather than making someone physically sick like disulfiram, naltrexone blocks the the alcohol-related highs and pleasures.

Acamprosate, formerly sold under the brand name Campral, can help remove the discomfort experienced during withdrawal. It normalizes the transmission of the neurotransmitter glutamate in the brain, which can become dysregulated when a long-time drinker stops drinking. "If they have been drinking alcohol problematically for a long time, then that discomfort can be a reason to relapse," Einstein says.

These medications are in no way a cure-all, Einstein says. For example, disulfiram may require supervised dosing, because someone can just not take the pill the day they decide to drink. Still, AUD medications can help, and should be prescribed in conjunction with other treatments such as counseling.

Spreading more awareness, Einstein says, can help in assisting treatments and reducing stigma. Remember: Addiction is not someone's fault.

"Reasons that someone's circuitry causes them to develop alcoholism might vary from person to person," Einstein says. "It's better to have more medications that are possible for conditions like this."

Einstein emphasizes that taking these medications is not a cop-out. "Lingering and outdated ideas that taking a medication is similar to taking a substance, or that you're replacing one addiction with another, is not the case," she says. "That really strong negative attitude around taking medication for addiction can impede people from seeking care."

Highlighting the Need to Address Alcohol Use Disorder

Around 5-6% of the U.S. population meets the criteria for AUD. To put concrete figures to the statistic:

• About 14.5 million Americans are experiencing AUD at any given time.
• Alcohol misuse is the primary reason for more than 1.7 million emergency department visits and 95,000 deaths in the U.S. annually.
• Alcohol is the third-leading preventable cause of death in the country.

On average, alcohol abuse and alcoholism are more likely to afflict men (6.8%) than women (3.9%). Alcohol abuse can also lead to other health issues and risks, such as liver disease, heart disease, depression, stroke, and various cancers. It may increase likelihood of unsafe sexual behavior, drowning, injuries from violence, falls, and motor vehicle crashes, harmful medication interactions, and Fetal Alcohol Spectrum Disorders (FASD) in the offspring of women who consume alcohol during pregnancy. 

How to Fill the Gap  

Treatment patterns also reveal health care disparities. Researchers of the study found that those who received medication tend to live in large metropolitan areas, visit the hospital more frequently, and receive mental health care. This suggests that only those with the most severe cases, or with access to certain resources, are getting treatment more often than others.

Despite the availability and efficacy of AUD medications, distributing them to people in need is the biggest challenge. In order to implement the treatments more effectively, at least three systemic changes must be made: more screening, basic training for healthcare providers, and changing cultural perception.

More pervasive screening for AUD

It's recommended that clinicians, whether they are primary care doctors or gynecologists, screen patients for their alcohol use during their visits. Asking about how often they drink, for example, is a simple question that is so often neglected. Screening and assessment tools are accessible and open to both patients and healthcare providers online.

A recent paper also found that screening for AUD at any medical visit, as opposed to just once a year, increased the screening rate significantly. "The diagnostic criteria for alcohol use disorder are very defined," Einstein says. "It's fairly easy to diagnose someone screening for problematic drinking."

Basic training on AUD and medications in medical school and for all mental health professionals

Much is lost through the cracks of uncoordinated care, Einstein says. "If [patients] don't even know these medications exist, and then their doctors aren't even asking them about their alcohol use, then even engaging with care can be really difficult," she says.

Changing the cultural perception of AUD

As seen in the data, a smaller percentage of people receive medications for AUD than for other addiction-related disease such as opioid use disorder. Einstein says this is likely influenced by the fact that alcohol is legal and common in social gatherings.

"It's a substance that is very culturally pervasive, and there are situations in which alcohol use can be positive and people use it responsibly," she says. However, this can lead to AUD progressing farther before people even seek out help. So changing our general perception of AUD as a real disease, and furthering knowledge about treatment options, is essential.

"People don't know that these medications are there to help, and are also very reluctant to seek help for alcohol use disorder," Einstein says. "We have these things that work, and how on earth can we actually push them out into the world?"