With Dry January firmly behind us, many adults are prompted to reassess their relationship with alcohol. Alcohol Change, the UK charity behind the popular Dry January initiative, found that 30% of men and 26% of women in the UK wished to reduce the amount of alcohol they drank in 2024.
In 2023, the World Health Organization (WHO) published a statement in Lancet Public Health that “when it comes to alcohol consumption, there is no safe amount that does not affect health”. More recently, the US surgeon general advised that alcohol bottles should feature cancer warnings on their labels, akin to tobacco products, as a way to “increase awareness of alcohol’s cancer risk and minimise harm”.
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Research by Gallup suggests sociocultural change is afoot, with young adults in the US becoming progressively less likely to use alcohol over the past two decades. However, while the realities of alcohol’s effect on health may be prompting younger individuals to take note, research by the US National Institute of Alcohol Abuse & Alcoholism (NIAAA) indicates there are almost 29 million adults in the US with alcohol use disorder (AUD).
Three US Food and Drug Administration (FDA)-approved medications for AUD currently exist, and glucagon-like peptide 1 receptor agonists (GLP 1RAs), popularly known for their use in obesity and diabetes, are now being studied as potential medications. Yet research by US non-profit the Federation of American Scientists (FAS) indicates they are only prescribed to around 2% of persons with AUD in the US.
The treatment ideal for alcohol use disorder
The FDA approved the first AUD medication, Antabuse (disulfiram), in 1951 and the second approval came after a gap of more than 40 years, for naltrexone sold as Revia/Vivitrol, now commonly known as a treatment for opioid use disorder. This was followed by the Campral (acamprosate) approval in 2004.
Dr Akhil Anand, a psychiatrist at the Cleveland Clinic, says the available AUD medications are efficacious, but mainly as preventatives towards harmful drinking and binge drinking.
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By GlobalData“These medications may not completely solve abstinence, but they definitely will help a patient in some capacity,” he says.
“Ideally, treatment would be a combination of an intensive outpatient or residential programme and also pharmacotherapy.”
Increased awareness of the broad spectrum of treatment options for AUD could enhance their utilisation, but Dr Lorenzo Leggio, clinical director of the National Institute on Drug Abuse (NIDA), emphasises that treatment should not be viewed as rehab versus medication.
He adds that both approaches are important, but the most appropriate treatment option(s) depends on factors including the severity of AUD, and the presence of medical and mental health comorbidities.
“In general, it’s important to keep in mind that AUD is a chronic relapsing but treatable condition and as such, it’s important to establish long-term patient care plans,” Leggio concludes.
The roots of treatment underutilisation
Despite the apparent efficacy of AUD medications, various factors have influenced their underutilisation.
Firstly, a historic lack of addiction-related education among healthcare providers has presented a significant primary hurdle towards their prescription.
“[This] is now improved drastically, but with a lot of medical school training, addiction isn’t the core topic, and if you don’t prescribe AUD medications during your residency, it’s very unlikely you’re going to prescribe them in clinical practice,” says Anand.
This issue is further exacerbated by the fact that those who may benefit from treatment often don’t come asking for it, and some family doctors may feel some hesitation in prescribing these medications, due to a lack of training.
Secondly, some providers may worry about alcohol withdrawal syndrome (AWS). “That complicates the picture…. and makes these medications a bit more difficult to just pick up and start using,” says Dr Niranjan Karnik, professor of psychiatry and co-director of the Institute for Research on Addictions at the University of Illinois, Chicago.
Characterised by symptoms such as anxiety, shakiness, and vomiting, AWS may occur when an individual stops drinking alcohol. More severe symptoms can include seizures and delirium tremens, which can prove fatal.
GLP-1 agonists could play a role
A recent report published in JAMA Psychiatry concluded that GLP-1s may be effective in the treatment of AUD and that randomised clinical trials are “urgently needed” to confirm whether GLP-1 agonists could be used to treat AUD and substance use disorders (SUDs).
Since primary care providers are now comfortable working with these weight loss medications, trying to use them for alcohol reduction and weight loss would be appealing to them, says Karnik. The use of such drugs may also change the dynamic around patient interaction.
Karnik adds: “With alcohol use…..patients usually have to be at that hard tipping point where they have had some particularly negative consequences before they’re going to come in and ask for a treatment.”
Multi-disciplinary approach that targets stigma
“Stigma can impact a person’s willingness to seek treatment, as can bias among treatment providers,” says Leggio.
To remove this stigma, Anand states that societal changes are needed when thinking about substance use disorders.
He adds: “Society looks down on people that have substance use disorders, so folks that have substance use disorders isolate. They’re ambivalent. They try to avoid addressing it.”
Treatment approaches to AUD may be flawed since they largely reside in the domain of addiction specialists.
Anand explains: “A liver doctor will not care about the addiction until the person develops alcohol cirrhosis. I think we need to be more interdisciplinary and multi-disciplinary when it comes to substance use disorders.”
With a more multi-disciplinary approach, he states it may help to give patients more offramps before their AUD becomes severe: “In the US, we’re not a preventative society; our hospital systems are to treat disease states, but we’re not really designed to address prevention, and that’s a big problem.”
How the Trump administration may approach AUD
With Trump back in the White House, many are adopting a “wait and see approach” to gauge potential change in the healthcare sector. Kyle Faget, partner at law firm Foley & Lardner concedes that it is hard to say what the new administration will mean for addiction treatment, but the new administration is expected to take a tougher stance and more punitive approach to drugs and drug trafficking.
Still, Anand is optimistic, noting there has generally been a mutual interest from Democrats and Republicans in tackling addiction.
“Last time he [Trump] was president, he did a lot of good things for suboxone in relation to the opioid epidemic,” he notes.
In addition, Faget observes that neither Trump nor Robert F Kennedy Jr., the likely secretary of the Department of Health and Human Services, drink alcohol. Still, warning labels on alcohol containers “seems unlikely” because the Trump administration will favour “less and not more regulation”.
Conversely, Karnik states the new administration’s approach to AUD may come from more of a prohibitionist standpoint: “They aren’t [Trump and RFK Jr] very sympathetic to harm reduction practices, which, for alcohol, are proven right.
“Even though the surgeon general said that there is no lower threshold of safety, clearly drinking one opposed to two drinks a day is a marked change in terms of an individual’s health risk over time.
“But those approaches are not going to be supported by this administration, is my guess.”
