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Review of Alcohol Use Disorder

Use and misuse of alcohol are reviewed with a focus on pharmacotherapeutic management. “Alcohol is regularly consumed throughout most of the world, including by nearly half the U.S. population age 12 or older,” the authors write. “Heavy drinking, which is also common, contributes to multiple adverse medical, psychiatric, and social outcomes and more than 140,000 deaths annually in the United States. It is the major risk factor for alcohol use disorder (AUD), whose current U.S. prevalence is 11%. However, AUD is undertreated, with less than 15% of individuals with a lifetime diagnosis receiving any treatment. Risk of AUD is nearly equally genetic and environmental.”

The article continues: “AUD is responsive to psychosocial treatments, including cognitive-behavioral therapy and motivational enhancement therapy. Alcohol affects multiple neurotransmitter systems, and thus pharmacotherapy for AUD is also effective. The three medications approved in the United States to treat AUD—disulfiram, naltrexone (oral and long-acting injectable formulations), and acamprosate—are underprescribed, despite being considered first-line treatments in clinical practice guidelines.…

“Two medications not approved for treating AUD, topiramate and gabapentin, have shown efficacy in treating the disorder and are used off-label. Recent studies of novel drug candidates, including psychedelics and phosphodiesterase-4 inhibitors, are promising additions for the treatment of AUD, although they require further evaluation before being used clinically. Despite the growing availability of efficacious psychosocial and pharmacological treatments for AUD, it remains a highly stigmatized condition. Research aimed at enhancing the identification and treatment of AUD, including precision therapeutics, could broaden the acceptability of AUD treatment, benefiting affected individuals and their families and reducing the stigma associated with the disorder.”

Editorial: “As with all behavior and neuropsychiatric studies, [with AUD] we are at the mercy of phenotype definitions that boil into a single scale [Alcohol Use Disorder Identification Test–Consumption (AUDIT-C) scores] or code (diagnoses) a lifetime of intersecting factors: genetic, social, environmental, and institutional,” editorialists write. “This heterogeneity of individual experience means that we simply cannot make the mistake of assuming that individuals who share a diagnosis are homogeneous in trait presentation or genetics. This may seem a pessimistic view, but on the contrary, the underlying variation is ripe for interesting studies in which geneticists, epidemiologists, and medical professionals can work together. By using refined phenotype definitions and careful studies, we can find meaningful associations to translate into clinical knowledge and therapeutics. For example, are there methods to mitigate bias in diagnoses of AUD, especially in individuals with moderate to high AUDIT-C scores? Or are there social and genetic factors distinctive to individuals with similarly moderate consumption but disparate AUD diagnoses? As we work to answer these questions, we posit that, in the effort to understand the genetic etiology of alcohol consumption and alcohol use disorder, there is more in common than there is different. We look forward to other creative work from this group and others to move the field further along the path to understanding alcohol consumption and treating problematic alcohol use and alcohol use disorder.”

Source: American Journal of Psychiatry