What Clinicians Need to Know About Alcohol Use Disorder

There are drugs that have more potential for developing problematic use, and there are drugs that can do more damage to one’s health.  

But without a doubt, no drug is more common, expected even, than alcohol.  

Be it fine dining, a 21^st birthday, or cooking outside in the summer, alcohol is a part of America’s social fabric and, as such, alcohol use disorder (AUD) is a common diagnosis that affects people from all walks of life.  

Because of this, all health care providers should have an understanding of AUD, warning signs, the dangers of untreated withdrawal, and what medical treatments are available.  

Those topics will all be covered in an upcoming SNJMATCOE lecture on March 13. Titled “Alcohol Use Disorder: Modern Pharmacotherapy and Implementation Challenges,” this lecture will be presented by Caroline Kaigh, MD, and Jessica C. Moore, MD, addiction medicine physicians in the Cooper Center for Healing.  

Dr. Kaigh answered the following questions about AUD, alcohol withdrawal, treatment, and common misconceptions about alcohol addiction.  

What should people interested in your upcoming lecture on AUD expect? 

We will cover treatment options for both alcohol withdrawal and alcohol use disorder.  

For AUD, we’ll look at the FDA-approved medications, how they work, different formulations, and how they can be integrated into different care spaces. We’ll also explore the medications that aren’t currently FDA-approved for treating AUD, but that we often use off-label, and look at the evidence for the efficacy of those drugs.  

For treatment of alcohol withdrawal, we’ll discuss different treatment protocols using benzodiazepines, as well as phenobarbital, and we’ll talk about adjunct medications and other options that have been studied, like dexmedetomidine.  

It’ll be a comprehensive review of current practices, with an eye toward where we see this heading in the near future. 

Tell me about the use of medications in treating AUD. How do they work? 

The medications that we use to treat AUD are safe, effective, and based in science and neurobiology.  

Chronic exposure to alcohol disrupts the normal balance of GABA and glutamate in the brain, and it affects dopamine pathways in the brain’s reward system.  

Medications for AUD differ in some ways, but all of them work to control cravings and/or make alcohol use less biochemically rewarding.  

Although psychosocial treatments like abstinence, Twelve Step programs, and counseling can and often do play an important role in the treatment of addiction, AUD is a medical disease, and medications that intervene on the pathophysiological basis of the disease are essential to its treatment. 

What about withdrawal from alcohol? What are the risks there and how are they managed?  

Alcohol withdrawal tends to follow a stepwise progression.  

Typically, we first see abnormalities with heart rate and blood pressure, as well as nausea, sweating, and anxiety, then confusion and hallucinations. If we don’t intervene, patients can progress to having seizures.  

The most severe stage of alcohol withdrawal is a syndrome called delirium tremens, or DTs. When patients have DTs, they become confused, and they have significant abnormalities in heart rate, blood pressure, temperature regulation, and respiration. These abnormalities can lead to electrolyte problems, metabolic abnormalities, and decreased blood flow to vital organs like the brain, heart, and kidneys, which can lead to seizures, arrhythmias, renal failure, and other complications. DTs can be life-threatening.  

Luckily, because we tend to see less severe manifestations first, we can intervene before things get worse. The most typical treatment is to use benzodiazepines, which act on the same pathways as alcohol, but there are other treatment modalities too, which we’ll explore in the talk.  

We also have different strategies for how we dose these medications, which we’ll also cover in the March lecture. 

What is the long-term prognosis for someone with AUD who is in treatment or in recovery?  

It can look different for everyone, but, in general, substance use disorder is a relapsing and remitting disease. With treatment, many people get into recovery and experience sustained remission.  

Some patients stabilize and then stay on medication for a long time, months or even years. Some folks find the medications to be more effective early in recovery, then find that they don’t need them as their brain chemistry begins to recover. In general, periods of recovery give the brain time to rebuild healthier pathways, so patients feel more stable in recovery as they get further out from active use.  

With all substance use disorders, it’s pretty common for patients to have multiple attempts at recovery followed by return to use before they get into remission for a more sustained period, so many patients try medications more than once before finding something that works for them. 

What misconceptions about AUD would you like to clear up? 

The biggest misconception I see about AUD is the idea that the most effective treatments are behavioral.  

Behavioral and psychosocial interventions are great and can be helpful, but we also have great, effective medications available to support recovery. Alcohol is everywhere in our society, and AUD is common.  

More people should know that medical treatments are available, safe, and effective.