Despite increased discussion surrounding alcohol's health impacts and moderation strategies, conversations regarding medical treatments for alcohol addiction remain limited. Physicians may also have limited knowledge of these treatments.
While research on GLP-1s (e.g., Ozempic, Zepbound) for reducing alcohol consumption is ongoing, existing FDA-approved medications for Alcohol Use Disorder (AUD) are notably underutilized. These three medications—naltrexone, acamprosate, and disulfiram—have existed for decades. Addiction physicians state that they are effective for some individuals in reducing or stopping drinking and have few drawbacks.
The Stark Reality: Underutilization of AUD Medications
Only 2% of Americans with an AUD diagnosis receive approved medications for treatment, according to Dr. Lorenzo Leggio of the National Institutes of Health. This significantly contrasts with 85% of people diagnosed with diabetes who receive approved treatments.
Leggio emphasized the need to treat addiction similarly to other chronic conditions such as diabetes, hypertension, cancer, Parkinson's, and depression.
Understanding the Medications: How They Work
These medications primarily function by making drinking less appealing:
- Naltrexone: Originally for opioid use disorder, it blocks the euphoric effects of alcohol. It can be used proactively before drinking (the "Sinclair Method") to diminish alcohol's reward, potentially reducing cravings and leading to decreased consumption or abstinence. It is also available as a one-month extended-release injection.
- Acamprosate: This medication helps restore brain balance disrupted by heavy alcohol use and can reduce cravings. It does not alter alcohol's immediate effects and is more commonly prescribed in Europe.
- Disulfiram: This drug inhibits the body's ability to break down alcohol, causing sickness if alcohol is consumed. It is the least prescribed due to high rates of patient noncompliance.
Research indicates that naltrexone can help reduce heavy drinking and cravings, while acamprosate can promote abstinence and prevent relapse.
Key Benefits and Accessibility
Katie Witkiewitz, a psychologist specializing in substance use disorders, noted that medications are "tremendously helpful in turning the volume down on craving, on withdrawal symptoms, on some of the other reasons that people struggle."
Effectiveness can vary among patients, and side effects like headache or nausea (naltrexone) or lack of appetite/irritability (acamprosate) can occur but are generally well-tolerated.
Sarah Wakeman, senior medical director for substance use disorder at Mass General Brigham, highlighted that these medications are "incredibly safe" and require minimal lab monitoring. Naltrexone, acamprosate, and disulfiram are generic and typically covered by insurance, with the exception of the brand-name Vivitrol injection.
Why Are These Medications Underutilized?
Several factors contribute to the low prescription rates:
- Stigma: Alcoholism is often perceived as a moral failing or lack of willpower rather than a chronic medical condition.
- Patient Knowledge: Many individuals are unaware of these treatment options or may not identify their drinking as problematic.
- Medical Establishment: Treatment for AUD has historically been siloed from mainstream healthcare, often limited to specialty programs, behavioral therapies, or support groups that may not integrate medication.
- Physician Training: Many physicians lack adequate training in addiction medicine, are unaware of available medications, or hold misperceptions about the need for specialization to prescribe them. Keith Humphreys, a Stanford professor of psychiatry, noted that many doctors avoid these conversations.
- Lack of Marketing: As generic drugs, there is no significant marketing or financial incentive for pharmaceutical companies to promote them, limiting patient and physician awareness.
This creates a self-fulfilling prophecy where a small market stifles potential innovations for alcohol addiction, as noted by Humphreys:
"If doctors don't want to prescribe it and patients have never heard of it, then a company is not going to develop the next drug for drinking because they're like, 'It's a waste of money.'"
Some online telehealth providers, such as Oar Health and Ria Health, are emerging to offer medication-assisted alcohol treatment, providing alternatives for patients whose doctors are resistant.
Looking Ahead: GLP-1s and a Shifting Paradigm
Researchers are investigating whether GLP-1s could reduce alcohol consumption. While early evidence is promising, their ultimate effectiveness is still being determined. GLP-1s benefit from existing cultural familiarity and significant investment, which could accelerate their adoption if proven effective for AUD.
Recently, the FDA formally recognized a reduction in drinking as a valid endpoint in alcohol-related clinical trials.
This "paradigm shift," as described by Witkiewitz, allows for medications under development to target moderation rather than just total abstinence, potentially leading to more treatment options and increased awareness of health benefits from cutting back.
Treating alcohol addiction as a disease rather than a character flaw is a significant challenge, similar to the historical shift in public perception of depression. Depression is now widely understood as a treatable condition with various medication options. Humphreys drew a parallel to how depression was once dismissed before medications like Prozac became commonplace, suggesting AUD may be at a similar inflection point.