Reframing Alcohol Abuse as Treatable Cuts Stigma

Andrew D. Bowser

May 06, 2020

As alcohol-related death and disease rates rise, framing alcohol use disorder as a treatable disease with neurobiologic underpinnings might help reduce the stigma that many patients endure, according to George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Dr George Koob

"Alcohol misuse and alcohol use disorder (AUD) have not gone away during the opioid crisis, and [they have] not gone away during the current (COVID-19) pandemic," Dr. Koob said in a presentation at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.

There are at least 14 million individuals in the United States with AUD now, compared with 2 million with opioid use disorder, Dr. Koob said.

Clinicians should strive to reduce stigma related to AUD, he said, and reinforce the understanding that these millions of individuals have a treatable chronic condition – just like hypertension or diabetes are treatable chronic conditions.

However, framing AUD as a treatable chronic condition is just one of many issues that need to be addressed, he said, adding that rates of screening and referral for AUD need to be increased among patients with other mental health conditions.

Psychiatrists can play a key role in reducing that screening and treatment gap, though concerningly, data suggest fewer than half of psychiatric patients with substance use disorders (SUDs) are being diagnosed or treated, said Andrew J. Saxon, MD, director of the Center of Excellence in Substance Abuse Treatment and Education (CESATE) VA Puget Sound Health Care System in Seattle.

Only about 9% of psychiatrist office visits from 2012 to 2015 involved a substance use disorder diagnosis or prescribed medication, whereas at least 20% of adults with mental health conditions also have an SUD, according to authors of a recent study in Psychiatric Services (2018 Jan 16. doi: 10.1176/

Better efforts are needed to improve training or somehow better incentivize psychiatrists to screen for alcohol use disorder and make sure patients get treatment for addiction, Dr. Saxon said in an interview.

"What we have is a lack of subspecialists in addiction psychiatry," said Dr. Saxon, former director of the addiction psychiatry residency program at the University of Washington. "That becomes self-perpetuating, because we don't have the knowledge experts to train the residents, and therefore, the residency programs don't provide a rich enough experience."

Changes in Alcohol-Related Deaths

A new report (Alcoholism Clin Exper Res. 2020 Jan;44[1]:178-87) highlights the gravity of the AUD problem, showing that alcohol-related deaths have doubled over the past few decades, Dr. Koob said in his presentation.

Among individuals 16 years of age or older, the number of alcohol-related deaths in the United States rose from 35,914 in 1999 to 72,558 (or about 2.6% of all U.S. deaths) in 2017, according to that report, which was based on U.S. mortality data from the National Center for Health Statistics. The largest increase was seen in non-Hispanic white females, according to the investigators.

Alcohol is playing a more prominent role in "deaths of despair," said Dr. Koob, noting that it contributes to about one-quarter of suicides and up to 20% of drug overdoses. "Probably even more salient is that half of liver disease in the United States is now caused by alcohol," he added.

Misuse of alcohol is correlated with poor mental health, an observation that Dr. Koob said was particularly relevant to the current COVID-19 pandemic, he said, since alcohol is commonly used to cope with stress and symptoms of mental health conditions.

"In the end, it makes the prognosis worse," he said.

Addressing AUD Stigma

A better understanding of the neurobiology of addiction may reduce the stigma associated with AUD, helping reframe the issue as a "health condition, rather than as a moral failing," Dr. Koob said.

Stigma remains a major barrier to AUD treatment, he added, explaining that factors contributing to stigma include shame patients may feel for what they perceive as a personal failure, and lack of knowledge about treatment options.

Separating AUD treatment from primary care exacerbates that problem, perpetuating the sense that AUD is somehow a "different" kind of issue, he said. Health care clinicians in primary care can help alleviate the stigma by engaging in screening and offering referral to treatment, he said, adding that the NIAAA offers a navigator website designed to help individuals negotiate the process of choosing a treatment approach for AUD.

Language matters, according to Dr. Koob, who suggested using nonstigmatizing "person-first" terminology to refer to affected individuals not as alcoholics, but as "persons with AUD."

Challenges Ahead for AUD

There's still a lot of work to be done to understand differences in alcohol pathology between men and women, especially as gaps narrow between the sexes for AUD incidence, early-onset drinking, frequency and intensity of drinking, and self-reported consequences, Dr. Koob said.

Age differences are also important to study. On one hand, older individuals appear to be more sensitive to the effects of alcohol, he said, because of metabolism changes, neurocognitive decline, and "inflamm-aging," or the chronic and low level inflammatory state associated with aging.

Adolescents are also an increased-risk population of research interest, since brain wiring connections are "particularly sensitive" to alcohol in the teen years, potentially setting up changes in vulnerability to AUD that last into adulthood.

Other challenges include the unmet need for better and more individualized AUD treatments, the issue of alcohol tolerance, which Dr. Koob said has been "ignored for many years" by researchers, the contribution of pain to AUD, and the way that dysregulated sleep contributes to AUD, and vice versa.

Research likewise remains "challenging" regarding conditions that are frequently found in conjunction with AUD, such as major depressive episodes, anxiety disorders, and posttraumatic stress disorder: "These are all areas that we're intensely interested in as comorbidities with AUD," Dr. Koob said.

Dr. Koob reported no disclosures.

SOURCE: Koob GF. APA 2020, Abstract.

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