Bringing Alcohol Treatment Into the Mainstream

Nearly 15 million people in the United States have alcohol use disorder (AUD), but in any given year, less than 10 percent of them receive treatment. And even those who receive treatment may not receive the type of care that best fits their needs and improves their chances of a successful recovery. Research shows that about one-third of people treated for alcohol problems have attained abstinence a year later. Many others substantially reduce their drinking and report fewer alcohol-related problems. So, why do so many people who could benefit from treatment not receive it?

“Finding quality AUD care can often be complicated,” says George F. Koob, Ph.D., Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), “and many people aren’t aware of the full range of available treatment options. It can also be difficult to tell if a provider is offering evidence-based care that is grounded in clinical and health services research and has been demonstrated to produce positive treatment outcomes.”

NIAAA has been instrumental in the development and validation of much of today’s evidence-based treatments for AUD and continues to take the lead in the search for new and better treatments. An important aspect of NIAAA’s leadership in this area is communicating—to the public and caregivers—what quality AUD treatment looks like and where people can find it.

In 2017, NIAAA launched the Alcohol Treatment Navigator, a comprehensive online resource to help people search for professionally led, evidence-based AUD treatment. The Navigator educates consumers about AUD and treatment options, recommends 10 questions to ask a potential provider, and suggests 5 signs of higher quality treatment to recognize. It also provides help with searching for licensed professional therapists, specialty AUD treatment programs, and board-certified addiction doctors.

“The Navigator consolidates what health services research has learned over the past 20 years about the treatment system and indicators of good quality treatment,” says Lori Ducharme, Ph.D., NIAAA Program Director for treatment services research and lead developer of the Navigator. “I think its most important feature is that it brings together everything you need to know about alcohol treatment in one place and lays out actionable steps that the general public can understand and follow. The addiction treatment system is confusing even if you know it inside out—we really tried to use the Navigator to help make sense of it all.”

Looking ahead, NIAAA will continue to help bring AUD treatment into the mainstream and make it a well-integrated component of the healthcare system. To that end, NIAAA is developing a complementary Clinician’s Navigator—a resource that leverages the Navigator to help physicians and other healthcare providers talk to their patients about treatment and assist with patient referrals. NIAAA is also developing a core clinician’s resource to supply healthcare providers with essential information they need to know about alcohol to recognize its effects across all domains of health and to help patients assess their risk and make better decisions.

What Treatment Options Are Available?

A common misconception is that there are only two places to get help for alcohol problems—a 12-step program, such as Alcoholics Anonymous, or a long-term residential rehabilitation program. The reality is that evidence-based treatment comes in many forms.

AUD treatment settings include:

  • Outpatient—visits to a physician’s or therapist’s office, or an outpatient treatment program
  • Inpatient—overnight stays in a hospital for a specific period of time, with care provided by physicians and nurses who address psychological and physical health needs
  • Residential—overnight stays at a treatment program for several weeks, with a full daily schedule of counseling, education, and wellness activities

The content of AUD treatment varies across these settings and depends on the patient’s specific needs and goals. Many patients benefit from counseling approaches, such as cognitive behavioral therapy or family therapy. Some patients benefit from medications that help address craving and prevent relapse. Combining counseling and AUD medications can also be a very effective treatment approach.

Expanding Medication Options

NIAAA supports a robust research program on the development of effective AUD pharmacotherapies. Currently, the U.S. Food and Drug Administration has approved three medications for treating AUD:

  1. Naltrexone works by blocking the receptors in the brain involved in the rewarding effects of drinking and thus helps with craving. It comes as either a pill that is taken daily or an injection that can be given once per month.
  2. Acamprosate is prescribed to help people with AUD maintain abstinence from alcohol by alleviating some negative symptoms of prolonged abstinence. It is a pill that is taken three times per day.
  3. Disulfiram is a pill that causes unpleasant symptoms such as nausea and flushing of the skin when a person drinks alcohol. Wanting to avoid those unpleasant effects helps some people refrain from drinking.

“Not all people will respond to medications, but for some individuals, they can be an important part of overcoming AUD,” says Raye Litten, Ph.D., Acting Director of NIAAA’s Division of Treatment and Recovery Research and the Division of Medications Development. “NIAAA scientists are working to develop a larger menu of AUD pharmacotherapies. Future research will include studies to advance personalized medicine to match an individual to a specific medication for a more favorable outcome.”

To encourage the development of medications to treat AUD, NIAAA established a Human Laboratory Program to bridge the gap between preclinical studies and early Phase II clinical trials of candidate compounds. NIAAA also founded the Clinical Investigations Group, a network of clinical sites, to test the safety and effectiveness of promising medications in early Phase II clinical trials. This program helps bridge the gap between preclinical studies and Phase III clinical trials involving larger groups of participants.

Recovery and Relapse: What Does Successful Treatment Look Like?

Although definitions vary, one conceptualization of recovery from AUD is the disappearance of AUD symptoms accompanied by a state of well-being that builds resilience to relapse. Recovery is associated with neuropsychological and neurobiological changes; however, the process is not the same for everyone.

Some people with AUD need longer or more intense treatments, whereas others recover more quickly and with minimal intervention. Relapse is often a part of the process; it may take several attempts before someone can stop or reduce drinking over the longer term. A return to drinking after a period of abstinence is especially likely during times of stress and/or when individuals are exposed to people or places they associate with drinking. Currently, little is known about the factors that facilitate or inhibit long-term recovery, including why some people can recover without some form of treatment. A better understanding of the recovery process, including the factors that enable people to maintain changes in their drinking behavior and promote resilience to relapse, will inform the development of additional effective treatment interventions and strategies to sustain recovery.

Because stress frequently triggers relapse, NIAAA is evaluating compounds that target brain stress systems and that could be used as potential medications for people susceptible to stress-related drinking. Researchers are also investigating whether patterns of brain activation can be used to identify people likely to relapse when exposed to certain stimuli, as well as whether particular AUD treatments are more effective in people with certain gene variants. Finally, NIAAA also supports research on recovery support services and on technology that helps patients sustain the benefits of treatment.

“The challenges for improving AUD care may often seem insurmountable,” says Dr. Koob, “but recent advances and ongoing investigations reveal that opportunities for improving treatment options in all therapeutic domains for people with AUD are plentiful, and we will follow every opportunity to expand the effectiveness and delivery of AUD treatments.”

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