Millions of Americans Have Alcohol Use Disorder, but Few Get Treatment

NIAAA director views drinking as the '5th vital sign' and calls for greater alcohol screening and treatment

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Millions of Americans Have Alcohol Use Disorder, but Few Get Treatment
Dr. George Koob is the director of the National Institute on Alcohol Abuse and Alcoholism.

Many Americans struggle with their relationship to alcohol. As of 2022, the most recent year for which data is available, more than 29 million people in the United States ages 12 and up had alcohol use disorder (AUD), which the National Institute on Alcohol Abuse and Alcoholism (NIAAA) describes as “a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences.”

Evidence-based methods, including therapy and Food and Drug Administration-approved medications, can help people reduce or stop their alcohol intake entirely, but just a fraction of people with AUD access treatment.

This interview with NIAAA director Dr. George Koob has been edited for length and clarity.

What’s the state of alcohol use in the U.S. today?

We’re now losing almost 180,000 people a year to alcohol misuse, which NIAAA defines as drinking in a manner, situation, amount, or frequency that could cause harm to the person who is engaging in drinking or to those around that person. For some individuals, any alcohol use constitutes alcohol misuse.

We’ve seen a huge increase in emergency department visits; alcohol-associated liver disease is responsible for nearly half of liver disease deaths; and the American Cancer Society attributes about 5.6% of cancer occurrences to alcohol. And one of the biggest trends that concerns us is that the percent of women drinking or binge drinking is nearly as much or more than men for the first time ever, despite experiencing more harmful side effects.

How does someone get diagnosed with AUD?

We think about AUD as a spectrum disorder with 11 criteria. These criteria include questions about alcohol tolerance, withdrawal symptoms, how much time you spend drinking, and if your drinking is causing social or occupation impairments. If you meet two criteria, you have mild AUD; four would be considered moderate; and six and up is severe. By addressing AUD as a spectrum disorder, we can adjust treatment to meet specific needs. And if we catch AUD in the early stages, a person can be helped much more quickly.

You mentioned withdrawal symptoms. What are some of them?

Acute withdrawal is like an exaggerated hangover. On top of irritability, sleep disturbances, an upset stomach, or a dry mouth, it’s also characterized by dysphoria, or feelings of unease or dissatisfaction, anxiety, tremors, and sometimes delusions. For some people, it can be life-threatening if not treated. On the other hand, protracted withdrawal—the gray, negative emotional state that persists for weeks after stopping drinking—is more likely to interfere with sustaining abstinence from drinking. It becomes a time of high vulnerability to relapse, and it can go on for months and even years.

If someone wants help with drinking, what treatments work?

There are behavioral treatments that are very effective, including motivational interviewing, cognitive behavioral therapy, mindfulness, and group therapy. Alcoholics Anonymous as well as other 12-step programs can be effective if people go to meetings. And three medications are approved by the FDA for the treatment of AUD: naltrexone, disulfiram, and acamprosate.

Tell us more about these medications.

Naltrexone blunts the pleasurable effects of alcohol. So, even if you have a slip-up and you start drinking, that second drink just doesn't have as much of an effect. Disulfiram makes you sick if you drink. It’s not particularly popular, but it’s a way to establish some abstinence by discouraging drinking. And acamprosate can be used once you’re abstinent to help reduce cravings, irritability, and the low-level, negative emotional state that’s associated with protracted withdrawal.

So are people accessing these treatments?

Not enough. We estimate that less than 10% of people who need treatment for AUD actually get it, and that only 2% access these FDA-approved medications.

Why do you think that is?

Unfortunately, because of the stigma associated with views about overdrinking and treating patients with AUD, in most cases there’s a long lag between when problems start to emerge with alcohol and the actual diagnosis and treatment. Also, we’re not sure that primary care doctors are aware of these medications and how to prescribe them. There’s a lot of evidence now of providers screening for alcohol misuse, but then there’s very little subsequent intervention or referral of patients to treatment.

What can be done to change that?

Clinicians need to view alcohol consumption as the fifth vital sign and screen for alcohol misuse and AUD.

The other four being your temperature, pulse rate, blood pressure, and rate of breathing?

Right. Alcohol misuse offers a window into other medical conditions—everything from liver enzymes to anxiety disorders. Primary care providers don’t always have much time, but screening could be assigned to a nurse practitioner or even done on a tablet as a person enters the office. Many providers use the Alcohol Use Disorders Identification Test C (or the AUDIT-C), which is three questions and highly predictive of AUD. And if screening indicates that a patient may have AUD, providers must take the next steps to perform intervention and referral to treatment.

What resources exist to connect people to care?

With the NIAAA treatment navigator, anyone can put their ZIP code in and find programs, doctors, and therapists in their area. And for health care providers, we developed the Healthcare Professional’s Core Research on Alcohol, which tells them everything they’ve ever wanted to know about alcohol.

Any final thoughts?

Here’s the bottom line: If you stop drinking for a week and you feel better, you sleep better, and you’re interacting better with your loved ones, then listen to your body. It’s trying to tell you something.

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