Did you know that you could buy the deadliest drug in America from your local grocery store any day of the week?
April is Alcohol Awareness Month, and according to the National Institute on Drug Abuse, alcohol addiction is the most common substance use disorder (SUD) in the United States and the second-most prevalent SUD globally (tobacco is first). From celebrities such as Billie Holiday and Amy Winehouse to people at your workplace, alcohol accounts for over 178,000 deaths each year in the U.S. More Americans die in one year from alcohol than total U.S. casualties from World War I and the Vietnam War combined. Careers, marriages and friendships have been destroyed by this simple but powerful liquid chemical.
Despite the heavy toll on individuals and society, alcohol use disorder (AUD) remains poorly understood, and people with AUD rarely receive evidence-based treatment and care. Less than 10% of people with AUD received treatment in the past year. Stigma and lack of education remain major barriers to people getting the therapeutic attention they need and deserve.
As an addiction medicine physician, I’ve cared for scores of patients experiencing SUDs including addictions to alcohol, opioids, tobacco and stimulants (cocaine, amphetamines), as well as behavioral addictions like gambling and eating. As with most chronic conditions such as heart failure and kidney disease, most people with addiction—including alcohol—get better once connected to treatment and care.
“One of the reasons that people still struggle is that alcohol is legal and socially acceptable so it can be hard to avoid at social gatherings, sporting events, office parties and fancy dinners,” explains Michael Weaver, MD, DFASAM, professor in the Department of Psychiatry, University of Texas Health Science Center.
It’s A Disease, Not A Moral Failing
The prevailing myth in society is that “problem drinkers” have a moral weakness. ‘They’re not tough enough’ or ‘they don’t want to get better’ are commonly held misperceptions among family members, cops and doctors—myself included, until I learned about alcohol’s effects on the brain. In low to moderate amounts, wine or beer for instance can help people feel happier, relaxed and social. This is because alcohol activates the brain’s reward system by increasing the release of the “pleasure” neurotransmitter, dopamine.
Over time, however, dopamine’s effect declines, causing a person to drink more in order to achieve the same initial level of euphoria. Chronic alcohol consumption can lead to multiple changes in the brain including cognitive impairment (e.g. poor memory and judgement), dysregulated emotions and behavioral changes. Alcohol is also associated with brain atrophy and neuronal loss. In other words, too much whiskey or rum can kill brain cells and shrink gray and white matter.
Women And Alcohol
In a case of unwanted gender equity, over the past several decades, women have been closing the gender gap in alcohol consumption. Alcohol use and misuse are rising among women. While men are still 2.88 times more likely to die from alcohol-related causes than women, studies reveal an increase in alcohol consumption, alcohol use disorder and alcohol-related deaths among women. In addition, for the first time in history, women are binge drinking more than men. Alcohol-induced complications such as liver disease and gastric bleeding rose 33 to 56% among women aged 40 to 64 during Covid-19 compared to pre-pandemic life.
So, why are more women drinking? The reasons aren’t exactly clear, but experts believe that women are using alcohol to cope with increased stress. The pandemic disproportionately impacted women who were forced to quit their jobs, care for children and elderly relatives, and experienced an increase in domestic violence.
“Isolation and depression from the Covid-19 pandemic resulted in increases in alcohol consumption and alcohol-related harms requiring medical treatment,” reflects Dr. Weaver.
Beverage companies are also specifically targeting women. Branding strategies include making alcohol pink; advertising “low-calorie,” “organic” and “clean” options; and using messages of empowerment like “Believe in Yourself” in ads or earning your “mommy juice” after a hard day’s work. Holly Whitaker, author of the bestseller Quit Like a Woman: The Radical Choice to Not Drink in a Culture Obsessed with Alcohol, debunks the notion of healthy alcohol and calls out these ads as predatory.
First-Line Treatment Is Medications
Most people falsely believe that alcohol addiction is treated through detox or Alcoholics Anonymous (AA). While detoxification using medications like benzodiazepines and phenobarbital reduces the risk of potentially fatal seizures (i.e. delirium tremens), it is considered acute management, not chronic treatment for what is clearly a chronic condition. While mutual support groups like AA can provide a valuable layer of support as adjunct therapy, first-line treatment for AUD remains three FDA-approved medications: naltrexone, disulfiram and acamprosate; as well as behavioral therapies led by health professionals. Several other medicines are currently off-label but can be very effective.
But too few individuals are receiving science-driven treatment. Among the nearly 30 million Americans with an AUD, only 8% received treatment and among them, only 2% got medications.
“AUD is treatable with both medications and behavioral therapy, and they’re generally covered by health insurance,” describes addiction medicine expert, Dr. Weaver. “The biggest barrier to treatment is that someone may not recognize that they have AUD so may not seek treatment until they are in a difficult situation with family or face work or legal troubles.”
We also need to reframe “failure” and “success.” Return to drinking (a.k.a. “relapse”) is not considered failure. In fact, return to use rates in addiction are similar to relapse rates in other chronic conditions. A shift in the addiction community helped us recognize that successful recovery does not necessarily mean abstinence. There is no ‘one-size-fits-all’ model for treatment. SAMHSA’s four dimensions of their updated definition of recovery include health, home, purpose and community. Many of my patients view recovery as having a sense of purpose: returning to school, caring for their kids, going to work or spending time with supportive friends and family. Recovery is 100% possible. Just look at the long list of sober celebrities including Samuel L. Jackson, Bradley Cooper, Drew Barrymore, Brad Pitt, Sir Anthony Hopkins and many more who are leading healthy, productive lives.
Harm Reduction Strategies
‘Just say no’ is an ineffective approach for people who use addictive substances. What if, instead, we applied methods that kept people safe and alive? That’s the premise of harm reduction which is a set of practical strategies and ideas aimed at reducing negative consequences associated with substance use. It’s a spectrum of methods that include safer use, managed use and abstinence. The goal is to meet people where they’re at—not where you want them to be. Examples of harm reduction include clean syringes, naloxone, fentanyl test strips, condoms, overdose prevention sites, job services and clothes.
Similar strategies can and should be applied to reduce harm among people with AUD. Examples include setting goals or limits such as eating and hydrating before consuming alcohol on days you plan on drinking; setting timers to evenly distribute consumption; socializing with non-drinking friends; and increasing stress-relieving activities such as exercise, meditation and music. Medications, as listed previously, can reduce cravings for alcohol. Vitamin supplements (e.g. thiamine, vitamins B12 and folate) can be helpful for those at high risk for developing alcohol-induced vitamin deficiencies.
Seek Help
“Treatment for AUD works and can improve quality of life,” reinforces Dr. Weaver. “Help is available. Talk to a school counselor or nurse, primary care physician or minister/priest/rabbi to get connected to treatment resources for AUD.”
If you or someone you know is struggling with alcohol, please get help from a health professional. Think of it this way: if you had lupus, Strep throat or lung cancer, you would see a doctor, right? AUD needs to be viewed the same way. Remember the good news: most people with addiction—once connected to the appropriate treatment and recovery services—GET BETTER!
