July 13, 2021

Alcohol misuse is increasingly common. So why aren’t more doctors treating it?

Daily Briefing

    Alcohol use disorder has become more common in the wake of the Covid-19 pandemic—but research indicates that even when patients disclose their struggles with alcohol use, physicians are often ill equipped to provide treatment. 

    Alcohol use on the rise

    Research has found that alcohol use has risen significantly in the wake of the Covid-19 pandemic.

    For example, data from Nielsen found a 54% increase in national alcohol sales year-to-year in the week ending in March 21, 2020, right at the start of the pandemic. And a 2020 survey found that 75% of Americans drank more alcohol during the pandemic, including drinking at least one more day per month than they did in before the pandemic.

    Women’s alcohol intake went up noticeably. The Nielsen survey found that women increased their alcohol intake by 39% in 2020 compared to 2019. Another study found that women saw a bigger increase in alcohol consumption than men during the pandemic, and one other study found that women’s alcohol intake levels were nearly equal to that of men.

    In addition, a survey from the American Psychological Association conducted this year found that almost 25% of Americans reported drinking more alcohol to combat stress related to the pandemic.

    Why doctors often miss opportunities to address alcohol use

    Despite the large and increasing number of people who report disordered alcohol use, most do not receive treatment—even after they share their issues with alcohol with a primary care provider or other physician, research has found.

    For instance, a study conducted by researchers at the Washington University School of Medicine in St. Louis found that around 80% of people meeting the criteria for alcohol use disorder visited either a doctor, hospital, or medical clinic for various reasons within the past year. About 70% of those patients had been asked about their alcohol consumption, but only around 10% were encouraged to scale back their drinking by a health care provider—and just 6% received treatment for their condition.

    In addition, research indicates that physicians rarely prescribe medications that have been shown to help treat alcohol misuse by curbing cravings, such as naltrexone, acamprosate, and disulfiram. For example, a recent study published in JAMA Psychiatry found that just 1.6% of the "millions of Americans
    with alcohol use disorder had been prescribed a medication as a treatment, the New York Times reports.

    According to the Times, physicians' reluctance to prescribe medications for alcohol use disorder stems partly from a lack of training on how to treat addiction and a lack of education on treatment options. Other providers may simply be uncomfortable prescribing medications for alcohol use disorder, said Carrie Mintz, an assistant professor of psychiatry at Washington University, even though doing so doesn't require special training.

    "These are potentially life-saving medications, and what we found is that even among people with a diagnosable alcohol use disorder the rate at which they are used is extremely low," said Wilson Compton, deputy director of the National Institute on Drug Abuse and an author on the JAMA study.

    And still other providers may believe the stereotype that people with alcohol use disorder are "difficult" and have an "intractable condition," the Times reports. In fact, John Mendelson, a professor of clinical medicine at the University of California-San Francisco and CMO of Ria Health, a telehealth program that helps people with alcohol use disorder, said many people come to Ria after their doctors "fir[e]" them as patients.

    As a result of these physician concerns, patients are often referred to a mental health expert or sent to a rehab center, the Times reports—which imposes an extra step to access care.

    "There's a stigma associated with substance use disorders, and the treatment for them has historically been outside of the health care system," Mintz said. "We think these extra steps of having to refer people out for treatment is a hindrance. We argue that treatment should take place right there at point of care when people are in the hospital or clinic."

    Why patients are reluctant to acknowledge alcohol misuse

    In addition, people with alcohol use disorder are often in denial about their condition, research indicates, making it even harder for doctors to treat them, the Times reports.

    "People are perfectly willing to tell you about their symptoms and the difficulties they face," Compton said. "But then if you say, 'Do you think you need treatment?' they will say they do not. There's a blind spot when it comes to putting those pieces together."

    According to research, some people may be reluctant to seek treatment for alcohol use disorder because they believe abstinence is the only treatment for the condition—a belief driven in large part by abstinence-focused programs like Alcoholics Anonymous.

    But although abstinence may be necessary for people struggling with very severe alcohol use disorder, it is not the "the only way," Katie Witkiewitz, director of the Addictive Behaviors and Quantitative Research Lab at the University of New Mexico, said. "We find robust improvements in health and functioning when people reduce their drinking, even if they're not reducing to abstinence."

    Witkiewitz recommends that those who want to reduce their alcohol consumption track how much alcohol they consume and then set a goal to lower their consumption. For example, if someone consumes 21 drinks a week on average, eliminating 5 to 10 drinks can make a big difference, Witkiewitz said.

    "Even that level of reduction is going to be associated with improvements in cardiovascular functioning, blood pressure, liver function, sleep quality, and mental health generally," she said. (O'Connor, New York Times, 7/12; Walsh, Axios, 7/7).

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