Alcohol Use Disorder (AUD): What it is, and Solutions
According to the USA’s National Institute on Alcohol Use and Alcoholism, Alcohol Use Disorder is a chronic relapsing brain disease characterized by compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using. AUD affects many Canadians and contributes significantly to disability in Canada. Legally, addictions are included under the umbrella term of mental health diseases/ disorders, and are now recognized as a disability, although clearly they are often managed as legal issues. AUD comprises a wide spectrum, so the focus on this article is on moderate to severe AUD.
For a person with AUD or any Substance Use Disorder (SUD), there is often much shame and guilt. There will often be times where a person is asking themselves, “Why can’t I just quit / cut down?” Both the person as well as their loved ones may assume that a failure to get drug or alcohol use under control reflects a lack of willpower, or that the person is “choosing” to drink. The reality is much more complicated. AUD is a disease of the brain. Thankfully, there are different ways of managing AUD, so that a person can get back to enjoying life more without wrestling with the disease.
There are two main philosophies regarding AUD, and neither one is better than the other: it depends on what the person wants. One philosophy is that a person with AUD should aspire to lifelong sobriety. The other philosophy is that a person with AUD can learn to drink differently and to drink in a less harmful way. Again, neither philosophy is “superior” to the other.
Regardless of a person’s decision to quit alcohol entirely or not, psychotherapy is recommended, including Cognitive Behavioural Therapy (CBT). Many people with an AUD will have another, or co-morbid, mental health diagnosis, including anxiety and/or depression. CBT and other psychotherapies will help treat any co-morbid diagnoses, and will also help a person understand why they have an AUD, as well as other ways to cope successfully.
Alcoholics Anonymous (AA) is the most well-known support group available for those who want to quit drinking entirely. There are also other groups that have been designed similarly to AA, and many people find that these are beneficial. There have not been many studies done on the success of AA in people with AUD, but one estimate is between 3-6% success rate. Information about AA is readily available online, and meetings include in-person and online.
Disulfiram is the medication best-known for helping a person who wants to be abstinent. Disulfiram is an oral medication that blocks normal metabolism of alcohol. If a person who is taking disulfiram chooses to have an alcoholic drink, their ability to metabolize the alcohol is compromised, and as a result they will suffer severe side effects. These side effects may include headache, nausea, increased heart rate, vomiting, etc. The main issue with disulfiram is low adherence: a person who is tempted to drink may just stop taking the disulfiram, so that they can drink alcohol without becoming violently ill.
There are some medications that may also be helpful for people with moderate to severe AUD. Baclofen, acamprosate, gabapentin, and naltrexone are medications that are recognized as being useful in AUD. Baclofen and acamprosate may have more limited success rates. Gabapentin can be abused and therefore some physicians will avoid using it. This article will discuss naltrexone briefly, because it is a medication that is very promising.
Naltrexone is an opioid antagonist. What this means is that the medication will block receptors in the brain which normally bind opioids or opioid-like chemicals (including alcohol). So, the first important thing to know is that if a person has AUD but is also prescribed or using opioids (narcotics), then naltrexone is not an option until opioids have been discontinued for at least two weeks.
By blocking the opioid receptors in the brain, naltrexone diminishes the reaction that alcohol will have on a person’s brain. Naltrexone can be taken in two different ways: either a tablet is taken once a day every day, or it is only taken on days when the person will be drinking, at least one hour before the first drink is consumed. This second method, referred to as the Sinclair method, boasts success rates as high as ~75%, and has been published in peer-reviewed medical journals.
Either way, the way that naltrexone works is through behavioural extinction. Basically, with naltrexone in their body, when a person has a drink of alcohol, they consistently fail to experience the normal feelings of relaxation or euphoria that the person used to experience with alcohol use. Over time, as long as the person continues to take naltrexone at least one hour prior to their first drink, the person’s brain begins to recognize alcohol just for the taste, but it no longer represents feelings of relaxation or euphoria, because its ability to cause these sensations is blocked. Now that alcohol’s only effect is on taste, a person will normally consume one or two drinks and then lose interest. This is usually quite surprising for a person who possibly could never leave a drink on the table unfinished.
It is recommended that a person do psychotherapy in conjunction with starting the naltrexone, because as stated above, there are normally underlying reasons, or co-morbid mental health disorders, that help explain why a person has an AUD. There is evidence that online CBT (available for free) is just as effective as in-person CBT. Also, CBT manuals are often available from local libraries or for purchase online. An excellent resource for CBT for depression or anxiety is Mind Over Mood, by Drs. Greenberger and Padesky. While not ideal, if a person either declines to do psychotherapy and/or CBT, or is unable to do it, but would still like to attempt naltrexone to decrease their alcohol intake, then they should still speak with their care provider. From a harm reduction perspective, a trial of naltrexone may still prove helpful and assist the person in improving their health, while reducing the harms due to excessive alcohol intake.
AUDs rarely “disappear” entirely, so normally, a person who is taking naltrexone will continue taking it for the rest of their life. There will always be a risk that if they have a drink of alcohol without first taking the naltrexone, that the receptors in their brain will react positively to the alcohol with feelings of euphoria/ relaxation, the previously unlearned (through extinction) association between the alcohol and the feelings of euphoria will be re-learned, and the person will again feel the “tug” of addiction. However, the good news is that using the Sinclair method, most people will find over time that the days when they have a drink reduce significantly, so that most days they are not taking naltrexone. It is recommended on days where naltrexone is not taken, that a person undertake activities that are pleasurable to them, such as going for a walk, getting outside in their the sun, enjoying some quiet time, etc. By doing so, this apparently helps reset the opioid receptors as the person can begin to feel pleasure doing “normal” activities that do not involve alcohol.
This has been a quick overview of AUD, and the author recognizes that there has been some focus on treatment using naltrexone. Much information is available online regarding other therapies for moderate to severe AUD, however there is a dearth of information on this medication and just how helpful it may be for people with AUD.
Centre for Addiction and Mental Health (CAMH): https://www.porticonetwork.ca/documents/203745/0/Naltrexone+factsheet/fbbdd175-2c99-4361-8434-cfe46980429f?intcid=search-results
The C Three Foundation: https://www.cthreefoundation.org