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Defining and treating alcohol use disorder

Matthias Ripp

Addiction to alcohol is costly both on a personal level and as a public health issue. But while neither new nor rare, it’s a disease that is misunderstood by many.

This week on “Take Care,” Dr. Patrick O'Connor, professor of general medicine at Yale School of Medicine, discusses alcohol abuse and its treatments. O’Connor has written extensively on alcoholism and opioid addiction and is the chief of general internal medicine at the Primary Care Center, Yale-New Haven Hospital.

First, many of us have always called it “alcoholism.” But O’Connor says that over time the term has been misconstrued and misused.

“Alcoholism is an old term that is very imprecise,” O’Connor said.

It also has a stigma, or negative connotation associated with it.

The more accurate term is “alcohol use disorder,” says O’Connor. That’s the officially recognized term in the “Diagnostic and Statistical Manual of Mental Disorders” more commonly known as the DSM.

O’Connor says alcohol use disorder has a specific set of 11 criteria. Depending on how many criteria a person has, they would be considered to have mild, moderate or severe alcohol use disorder.

But the amount of alcohol people consume in their daily lives varies widely. So how do you know when it’s crossed the line from social drinking to a problem?

O’Connor says most Americans use some alcohol, though there is a substantial minority that don’t drink at all.

At-risk drinking is defined as consumption of an amount of alcohol that puts individuals at risk for the health problems related to alcohol use disorder. The National Institute on Alcohol Abuse and Alcoholism (NIAAA), which is a branch of that National Institutes of Health, defines at-risk drinking in men as greater than 14 drinks in a week or 4 drinks in one day. For women, it’s 7 drinks in week or 3 per day.

It’s important to note, says O’Connor, that at-risk drinking doesn’t mean that if a person drinks that much, they automatically will have the health problems associated with alcohol, it’s just putting the person at risk for them. O’Connor compares it to when a patient’s cholesterol level is elevated, their risk for heart disease is elevated, but that doesn’t mean they have heart disease.

When a patient’s drinking is above these thresholds, O’Connor says it’s time for their primary care physician to talk to them about the issue and about what the health effects could be.

When there are actual harms from at-risk drinking, that’s when the 11 criteria for alcohol use disorder are considered, says O’Connor. Those criteria include things like using alcohol in larger amounts than intended and trying to cut back but no being able to.

There is a genetic predisposition to alcohol use disorder. Having a family member who has the disease puts you at a higher risk for it. But like other diseases, the genetic signal might be non-existent, weak or strong.

If you are concerned that you or a loved one has alcohol use disorder, O’Connor says the first place patients should be able to go to for information and help is their primary care physician. There is also lots of information on the internet, of course, but O’Connor recommends the NIAAA website.

Treatment always involves some form of counseling. This component of treatment for alcohol use disorder has been well researched and very structured counseling approaches have been developed, O’Connor says. Motivational enhancement therapy, cognitive behavioral therapy or 12-step facilitation are all used.

Generally, these techniques are found in specific treatment programs and used by a psychologist, psychiatrist or counselor who has been trained to treat alcohol addiction. O’Connor says there is great evidence and research that shows those approaches can help people cut back on drinking and stop drinking.

Alcohol treatment programs can be in-patient or out-patient, depending on the severity of the problem.

There are also three FDA-approved medications for treating alcohol use disorder that have been demonstrated to help people both cut down and stop using alcohol. Often the medications are used in combination with counseling.

While these treatments have been proven to be effective, how well they work of course varies by individual.

“Are these medications silver bullets? No. There’s no such thing for addiction,” O’Connor said.