Opinion | Here’s How to Start Treating Alcohol Use Disorder

Addiction is highly prevalent. In whatever medical setting you treat patients, you will see patients with substance use disorder (SUD). To improve their health and well-being, you as their physician must recognize, embrace, and treat all your patients’ diagnoses. This includes alcohol use disorder (AUD).

Despite alcohol use being ranked as a leading risk factor for death and disease globally, AUD remains highly treatable, with the landscape of mental health interventions and treatment pharmacotherapies for AUD comparable to the landscape of treatment for many chronic medical diseases. Familiarizing yourself with evidence-based care practices for AUD treatment is an effective way to combat the rise of this disease.

Here are four ways to enhance the treatment of AUD in your practice today:

Foster Rapport-Building in a Stigma-Free Environment

Stigma is one of the most significant barriers to patients receiving evidence-based treatment for substance use, including alcohol use, in the primary care setting. To counter the stigma and encourage conversation about substance use, primary care physicians need to provide a welcoming, judgment-free space for patients to talk about their use of alcohol and other substances. When our patients share their experiences with us, we need to listen with concern, empathy, and understanding. Patients will be more willing to express their concerns if we foster an inviting environment and a relationship based on trust. Reassure patients that it is always okay to discuss cravings and slip-ups with you.

One way to encourage the conversation is to normalize discussion about alcohol use with your patients. Discussing alcohol consumption should be no different from talking about blood pressure. Keep in mind the neurobiology of addiction, which compromises executive function. Questions like “Why can’t you just stop drinking?” add stigma and judgment to the interaction. When patients succumb to their cravings and drink alcohol, there’s a tendency for their physician to react moralistically. Instead, we need to remind them of the importance of interventions and emphasize that taking action now is going to help to reduce complications down the road.

Another way to build rapport with your patient is to shift how you view your role as your patient’s physician. Think of yourself as a facilitator working together with your patient towards helping them achieve their goal, be it abstinence or simply a reduction in heavy drinking. Motivational interviewing is an effective strategy that can help patients advance these goals, while also building strong, impactful relationships with your patients.

Educate Patients About Medication for AUD

Make sure your patients know about their options, and that medications for AUD are effective and safe. Many medications have been used to treat AUD for decades. It is recommended that patients take medications for a minimum of 3 months, and often for a year or longer, to reduce cravings and the risk of returning to alcohol use.

There is no magical quick fix for AUD. Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. Whatever the factors were that put your patient at risk for heavy drinking, those “complex interactions” usually don’t repair themselves in a matter of weeks. It is always best to think of these medications as a long-term risk reduction strategy for a chronic, relapsing-remitting, medical condition.

Acknowledge the Mental Health Aspects of Addiction

Many people with addiction are self-medicating with alcohol and have untreated mental health issues, such as depression, anxiety, post-traumatic stress disorder, or bipolar disorder. While medications can reduce cravings for alcohol, additional treatments should be considered to address underlying mental health challenges. Most importantly, research indicates that clinicians should screen for and treat co-occurring mental health diagnoses early on, while simultaneously initiating treatments for the accompanying SUD. Simply stated, it is challenging to treat addiction in isolation if you are not also improving the patient’s mental well-being.

Consider Mutual Self-Help Groups as Part of Treatment

It has been said that the opposite of addiction is not just abstinence or sobriety, it is making new connections with people. Patients need to build relationships with people and things that are positive and make them feel good. Oftentimes, that’s with other people who also have lived experience with addiction. Traditionally, this has been limited to Alcoholics Anonymous, which has been around since the 1930s. Recently, however, there has been an explosion of other options in the mutual self-help group landscape that cater to patients of diverse spiritual backgrounds and interests. There are purely secular groups, those that explicitly endorse the use of medications in maintaining sobriety, those that welcome non-abstinence goals, and groups that may be physical activity-oriented, like 12-step yoga or hiking groups. It is a good idea to familiarize yourself with all the options available to your patients so you can help them find a community that aligns with their interests.

Ultimately, AUD is highly prevalent, highly stigmatized, and highly treatable. Helping patients with AUD to feel valued, respected, and trusted by their clinician is an important first step in fostering a therapeutic relationship that can be both highly rewarding for the clinician, and potentially lifesaving for the patient.

Stephen Holt, MD, MS, is an associate professor of medicine at Yale School of Medicine in the Section of General Internal Medicine, associate program director for Yale’s Primary Care Internal Medicine Residency, and director of Yale’s Addiction Recovery Clinic. He is board certified in Addiction Medicine and Internal Medicine, and is a fellow of the American Society of Addiction Medicine.