State-of-the-Art Treatment of Alcohol Use Disorder

Introduction

Alcohol use disorder (AUD) is a chronic, relapsing condition, characterized by continued use despite a host of harmful medical, psychological, and social consequences. AUD and its associated consequences remain significant public health problems, as alcohol misuse was deemed the fifth largest risk factor for premature death and disability in 2010. Further, 3.3 million deaths (5.9% of all deaths) and 5.1% of the burden of disease and injury worldwide were attributable to alcohol consumption in 2012. More recently, it has been estimated that alcohol use and misuse contributed to over 200 diseases and injury-related health conditions, including liver cirrhosis, cancers, and injuries.

Recent findings from a major epidemiological study, the National Epidemiological Survey on Alcohol and Related Conditions III (NESARC-III) conducted between 2012 and 2013 by the National Institute on Alcohol Abuse and Alcoholism, indicated that the prevalence of DSM-5 12-month and lifetime AUD in the general population of adults in the United States was 13.9% and 29.1%, respectively. Stratifying by severity, 12-month prevalence of AUD was estimated to be 7.3% for mild AUD, 3.2% for moderate AUD, and 3.4% for severe AUD. Lifetime diagnosis rates broken down by severity revealed a similar pattern, with a prevalence of mild AUD of 8.6%, 6.6% for moderate AUD, and 13.9% for severe AUD. Mean age of AUD onset, of any severity, was found to be 26.2 years. Age of onset seems to decrease with increasing severity, with the age of onset approximating 30.1 years for mild AUD and 23.9 years for severe AUD.

In terms of sociodemographic differences, the incidence of both a 12-month and lifetime AUD, of any severity, were greater among men (17.6% and 36.0%) than women (10.4% and 22.7%). Conversely, rates of lifetime AUD were found to be lower among black (14.4%), Asian or Pacific Islander (15.6%), and Hispanic (22.9%) respondents than Caucasians (32.6%). The prevalence of AUDs also varied by age, such that individuals between the ages of 18 and 29 had the highest rates of DSM-5 AUD with a prevalence estimate of 26.7% for 12-month and 37.0% for lifetime compared to 16.2% 12-month and 34.4% lifetime for individuals between the ages of 30 and 44.

Results from NESARC-III compared to previous epidemiological studies of alcohol use disorders show a marked increase in prevalence of AUD since 2002. Previous NESARC data compared to the latest NESARC results suggest that both the 12-month and lifetime prevalence of DSM-IV AUD substantially increased over the past decade, from 8.5% to 12.7% and from 30.3% to 43.6%, respectively. These observed significant increases may be attributable to significant increases in high-risk drinking from 2002 to 2013. It is important to note that a striking cohort effect has been documented in that the gender gap between the prevalence of AUD between men and women appears to be narrowing. Possible explanations for this effect include the notion that drinking norms may have become more liberal among women, coupled with increased educational and occupational opportunities for women as compared to previous decades, perhaps leading to increased alcohol use in general among women. These factors may explain the marked increase in high-risk drinking among women in more recent cohorts, yet further studies of this recently identified effect are warranted.

Overall, results from the most recent epidemiological study of alcohol use disorder and related conditions [NESARC] show that 13.9% of the adult population in the United States suffer from an alcohol use disorder in a given year, and 29.1% will suffer from an alcohol use disorder in their lifetime, with affected individuals totaling roughly 44.6 million and 93.4 million, respectively. Further, it is estimated that the economic burden of alcohol use disorder treatment is $250 billion nationally. These figures overtly highlight the gravity of alcohol use disorder as an important public health and economic concern and call for an effort for the development and implementation of effective treatments to address alcohol-related problems in the US. The remainder of this chapter addresses the issue of best practices in the treatment of AUD, including both psychosocial and pharmacological interventions with a focus on identifying those receiving the most empirical support.