A small portion of Americans who have alcohol use disorder (AUD) get potentially lifesaving and effective treatment.
Patients and providers alike overlook medication-assisted treatment (MAT) for AUD due to rather potent market forces. Unlike most substances for which people seek treatment, huge sectors of American society and the economy encourage the consumption of alcohol. Spirits suppliers alone generated $38 billion in sales in the U.S.
“A huge aspect of American social culture is using substances like alcohol,” Brian Dawson, chief medical officer of Ideal Option, told Addiction Treatment News. “It’s much harder for patients to avoid the triggers and pervasive availability of alcohol in our society, especially if they’re trying to integrate socially back into communities … In a lot of social situations, alcohol is the primary driver for the social occasion itself.”
Kennewick, Washington-based Ideal Option is an outpatient addiction treatment provider that operates 82 locations in nine states, several of which are based in rural areas.
The U.S. certainly isn’t alone when it comes to the ubiquity of alcohol. New data from the World Health Organization (WHO) found that 7% of the world’s population 15 years of age and older (about 400 million people) have AUD.
The prevalence and social acceptance of alcohol make getting care for those who could benefit so tricky. It also makes it difficult for patients to recognize the opportunity for treatment.
In some ways, the ubiquity of alcohol and the widespread acceptance of MAT as a primary mode of treating opioid use disorder (OUD) cast a very wide combined shadow on the use of MAT to treat AUD. Still, the small prevalence of MAT for AUD across the addiction treatment landscape is growing.
What the data show
Within the U.S., about 2.1%, or 634,000 people, who could be considered as having AUD received MAT within the past year, according to the 2022 National Survey on Drug Use and Health (NSDUH) report.
The number of people who received treatment pales compared to the number of people with an AUD: 29.5 million people, or about 10.5%. The NSDUH surveys those ages 12 and older. Those with an AUD represented 61% of those with any use disorder, while 44% had alcohol-only use disorder.
Nationally, about 11% of all Ideal Option patients in 2023 had AUD as a primary concern at the first visit, according to the organization’s latest outcomes report. Dawson said that, at the state level, the figure is closer to 10% to 15%.
For Spero Health, a Nashville, Tennessee-based outpatient addiction treatment provider, the number of patients that seek care for AUD exclusively is about 4%; 10% seek care as part of polysubstance use, David Hayden, the company’s senior vice president of clinical services, told ATB.
“I think we have a far greater number that are not diagnosed with AUD,” Hayden said. “[Our providers] focus on a lot of things that are more evident and more brought to their attention by the patient, what they’re wanting help for. … It’s just so common that it’s often overlooked.”
That may provide some context for the relatively low rate of those diagnosed with AUD and another substance use disorder: 16.5% of those with any SUD, about 8 million, report both, according to the NSDUH report.
Dr. Brian O’Connor, medical director of Middlesex Recovery, a part of the addiction treatment provider BayMark Health Services, told ATB he rarely sees people with both AUD and another SUD.
“They may do opioids and cocaine and meth or abuse benzos and Adderall, they can do all that, but they just don’t drink,” O’Connor said. “Over 90% of the patients in Middlesex Recovery seek care for an OUD, while 7% to 8% seek care for an AUD exclusively. “Many more people have an AUD compared to an OUD; proportionally, those numbers should be reversed.”
About 6.1 million (2.2%) people surveyed could be considered to have an opioid use disorder. About 4.8 times as many people in the U.S. have an AUD.
Retention challenges
Unlike with treating OUD, addiction treatment providers don’t always have the assistance of other segments of the health care system in detecting AUD. Opioid prescriptions are now tracked by state registries, and more primary care providers are aware of prescription seeking behavior. By comparison, there isn’t the same tracking or oversight when it comes to the acquisition of alcohol.
Often, patients seek care after “some negative event,” O’Connor said. This includes things such as run-ins with law enforcement, the loss of a job, deterioration of relationships and the like. These patients tend to be at earlier stages than with other SUDs.
“Most people that come in are not in end-stage alcohol use disorder,” O’Connor said. “It’s starting to interfere with their lives, and so they access care.”
He also notes that, by comparison to OUD, the risk of relapse in treating AUD is not as “devastating.”
Dawson notes that AUD patients tend to be “much harder to retain” in long-term treatment.
“Often, once they get through the acute withdrawal phase, they feel stable for a while, but they try some of these other medications, and they just don’t seem to help,” Dawson said. “That’s unlike patients with opioid OUD who use buprenorphine; you have much higher long-term retention because the buprenorphine is seen as really helping.”
Part of the issue is low public awareness of the treatment of AUD with medications. Another issue is the feeling of taking one of the three medications approved by federal regulators for treating AUD — disulfiram, acamprosate and naltrexone — compared to MAT for OUD.
“It’s not like treating opioid use disorder with methadone or buprenorphine, where you’re taking someone who’s addicted to opioids and you’re giving them an opioid to make them feel normal,” Dawson said.
Disulfiram is meant to make people feel unwell if they drink. Naltrexone is supposed to block the euphoric effects of drugs. Acamprosate reduces the desire to drink by normalizing, but the mechanism of action is not clear.
Key trends
While stigma may prevent the use of certain addictive substances, it has a negative effect on those with AUD and want to seek treatment. Often, society paints AUD treatment outcomes as dichotomous: drinking or sober. But no source describes the goal of MAT for AUD in that way. Rather, every source, to varying degrees, said that improvements in life circumstances and reduced usage should be the goal of treatment. Some specified that patients need to zero in on what that specifically means for them.
“It will vary based on where they’re beginning, what their relationship to alcohol is, and what the desired end point is,” Dr. Mimi Winsberg, chief medical officer and cofounder of Brightside Health, told ATB.”That’s sobriety for many patients. For others, it may be just detox and stabilization and finding some kind of maintenance plan that will work for them.”
Brightside Health provides digital behavioral health services on an in-network basis and focuses on more severe patients. It recently expanded it services to include Medicare patients and landed a $33 million funding round.
MAT, Winsberg added, is especially important when there is a heightened risk of relapse.
Dawson said most patients that Ideal Option treats want to get back to a more normal, stable life. While hard to define universally, Ideal Option leans on using toxicology testing to get some objective sense of treatment progress.
“You can use the objective data of whether or not patients are continuing to use it as a precursor to the improvement in the life functions that you want to see,” Dawson said.
Brightside Health recently beefed up its virtual addiction treatment with the acquisition of Lionrock Recovery, a virtual intensive outpatient (IOP) provider. Winsberg said that Brightside previously supported some MAT for AUD. The acquisition allows the company to provide more and more intensive treatment; Lionrock previously lacked psychiatric services to support MAT within its programming.
The virtual addiction treatment space has seen significant venture capital investment in previous years. But that interest has slackened, in part, because of looming federal regulations related to prescribing controlled substances and telehealth.
Spero Health started as a company that was solely focused on OUD treatment. However, the addiction treatment landscape has evolved over the years to require Spero providers to be ready to treat nearly anything and to focus on recovery support, some address social determinants of health, and provide more intensive levels of care.
At some level, nascent social trends such as the “sober curious” and the increased interest in non-alcoholic drinks suggest a generational shift in perceptions of alcohol among younger people. But for others, harm reduction and increasing while reaching the desired endpoint of treatment is key.
However, the long-standing and well-embedded sobriety movements — such as Alcoholics Anonymous — in the U.S. may deter people from MAT for AUD and limit their likelihood of success.
“I’ve had multiple patients come to me after AA meetings or being in a sober community, and they were told that they’re not really sober because they’re on MAT,” O’Connor said. “One of the first things I tell patients is that if they are, say, on Vivitrol (a long-acting injectable naltrexone), that’s your business. I wouldn’t share that with people in the community, because you’re going to get that kind of response — that somehow your sobriety isn’t as good as theirs.”
There is an accelerating acceptance and use of harm reduction in addiction treatment; abstinence-only programming is falling out of favor. MAT be a form of harm reduction for the “spectrum” of desired patient outcomes. But the use of harm reduction techniques in the absence of MAT is unlikely to lead to a desired outcome, Dawson said.
