is a psychiatry resident at Baylor College of Medicine.

Christie Aldrich, MD

Tales From the Clinic: The Art of Psychiatry

Tales From The Clinic: The Art of Psychiatry,

 we follow the story of a young man who turned his life around for the sake of his spouse and child, but nevertheless struggled with the tribulations of normal upheaval. Recovery from 

 does not protect against normal life events, but our patients are more sensitive to stress than their nonsubstance user counterparts, increasing the potential for stigmatization. We visit the moral versus brain disease model of addictive processes through the case, and hope to help readers appreciate their own biases and open themselves to understanding the neurobiology of addiction. The aim of proper diagnosis and treatment is to have an objective conception of addiction rather than a morally framed conversation, when behaviors related to addiction are viewed through a negative prism.

“Mr Wallace” is a young man with opioid use disorder and major depressive disorder. He lost contact with his wife and young child as a consequence of his 

. His wife moved to another country, prompting him to get treatment “like I really mean it this time.” He gained sobriety on medication-assisted treatment (buprenorphine/naloxone) and did well, earning advanced certification in his field and increasing his earnings significantly. He also took up the hobby of synthetic music. His wife returned with their child, with subsequent stabilization of the relationship, the purchase of a house, and other life milestones.

The National Institute on Drug Abuse (NIDA) defines addiction as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain—they change its structure and how it works. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs.”

 Although NIDA adheres to the brain disease model of addiction (

), there continues to be controversy surrounding whether addiction is a disease or a matter of choice. If addiction is viewed as a moral failing, as posited by the moral model of addiction, then there is the belief that the patient is responsible for their substance use and at fault for having a character defect or a weakness of will.

Advancements in neuroscience have made it possible to identify strong genetic, neurodevelopmental, and sociocultural components of addiction. Evidence pointing to the activation of reinforcement circuits (

) by drugs through the neurotransmitter dopamine in brain areas, such as the nucleus accumbens and ventral tegmental area, further supports irreversible changes in the brain’s structure and function resulting from substance use.

 Because of these permanent changes, it is postulated that individuals cannot exercise self-control over their behavior pertaining to addiction.

This biological approach, supported by animal models of addiction,

 has made room for pharmaceutical treatments of 

. This approach also supports liberation from the belief that addiction is a moral lapse in individuals who have deep character flaws. The disease model of addiction has often been assumed to diminish the attribution of free will to those with drug addictions, which could possibly have significant implications in the attribution of responsibility and stigma as well as the acceptance of treatment.

Critics of the purely brain disease model of addiction believe that categorizing substance use as a disease may further stigmatize individuals with addiction and prevent them from developing self-control, all while damaging their self-esteem.

 and simply diseasing addiction will only further stigmatize those who suffer from addictions. While proponents of the brain disease model of addiction believe adherence to this model will encourage treatment-seeking behaviors, critics believe it will erode the confidence of addicted individuals in their ability to overcome addiction if it is inherently viewed as permanent structural and functional changes in the brain. Research on addictions such as smoking finds that attribution of addiction to unchangeable intrinsic factors leads to lower levels of quitting intentions and quitting self-efficacy.

 Naysayers of the brain disease model of addiction also point out that a clear majority of addicted individuals recover naturally without requiring medical interventions.

Opponents of the brain disease model of addiction believe it: is insufficiently supported by animal-model and neuroimaging data; has only a modest impact on public policies toward drugs and addiction; and has not majorly contributed to the development of more effective treatments despite the decades of research.

 Evidence to support environmental approaches to reducing substance use cautions strongly against the possibility of policy makers and government officials being enticed by the allure of 

. There is some concern that an overly biological emphasis on addiction could take attention away from the necessary social and environmental interventions and divert resources to the production of expensive and perhaps risky medical interventions that can realistically only be accessed by a certain population. 

Proponents of the brain disease model of addiction postulate that adherence will encourage seeking of evidence-based medical assistance to overcome a brain disease. They believe this model lends itself to a collaborative approach between patients and physicians against addiction. However, critics believe the brain disease model of addiction lends itself to addicted individuals absolving themselves of personal responsibility. This results in infantilizing individuals with addictions while shifting the responsibility of overcoming addiction to medical professionals.

 This stark difference in how each model contributes to the physician-patient relationship sheds light on the topic of countertransference (

 The Brain Disease Model of Addiction and Countertransference

Mr Wallace later found out—after buying the house, buying a car, and moving back in with his wife and child—that his wife had not been faithful. This led to significant use of Adderall by Mr Wallace and ongoing relationship issues. He continues to have interpersonal issues in the relationship and struggles with maintaining the relationship for the sake of keeping access to his daughter.

, not only does the relationship between the clinician and the patient play a role, but so do the thoughts, beliefs, and experiences of the physician. Besides the brain disease model of addiction, there are several other models that seek to explain the development of substance use. The moral model describes addiction as resulting from a character flaw or moral failing; the choice model sees drug use as a voluntary but harmful behavior; and the psychosocial model regards substance use as related to economic, cultural, and other social factors.

These lead to beliefs about who claims responsibility for beginning and overcoming 

, including the medical model, which regards patients as requiring medical treatment and having low responsibility for the presence and resolution of use; the moral model, which places all responsibility on the patient; the enlightenment model, which states that the individual is responsible for the problem but not the solution; and the compensatory model, which states that the individual is not responsible for the problem but is responsible for the solution.

From studies on treatment providers’ views on the brain disease model of addiction, there seems to be overall support for this concept, although with variations noted among different professions of providers. The strongest support was generally seen in psychiatrists, especially those who were older.

 Interestingly, there was significant evidence of an amalgamation of beliefs, with providers expressing support for multiple models and levels of patient responsibility. These findings extended from treatment providers to treatment settings as well, with examples provided of substance as a “self-induced disease,” bringing together the requirement for medical treatment with responsibility for the initiation and resolution of use belonging to the individual.

 This appears to reflect the complexity of 

 and its treatment, and suggests that the conceptualization of substance use may be tailored to the needs of a particular patient or to the needs of the patient population seeking treatment in a specific setting.

How a physician conceptualizes substance use plays a role in the countertransference experienced. Thinking a patient is willfully making bad choices will obviously decrease positive feelings or wanting to help them, or to go the extra mile in treatment planning. On the other hand, approaching substance use from the brain disease model of addiction helps patients overcome stigma and reduce guilt, as use is not conceptualized as a moral failure of the patient. This may help reduce negative countertransference toward patients with substance use by assisting in understanding frustrating, demanding, or confrontational behavior as not intentional or specifically directed at the provider. Negative countertransference could result in direct consequences, such as avoidance of the patient, difficulty with empathetic responses, and sessions cut short.

This could also increase protective or parental feelings toward patients, especially if they are viewed as helpless against the structural and chemical factors that contribute to their use.

 Such a “positive” countertransference can also lead to difficulty in the therapeutic relationship, as the clinician may take on the role of a parent, becoming overly engaged, protective, and permissive. If the patient then regresses and begins to act out or relapses, the clinician may feel betrayed and subsequently have difficulty in future encounters with the patient. A parental countertransference may also result in the clinician infantilizing the patient and minimizing their strengths and abilities.

 As with all forms of countertransference, the ability to identify and label the ensuing emotion is as critical as the adjustments the clinician must accordingly make.

Although there are many frequently underutilized medications for substance use disorder, a mainstay of treatment relies on naturalistic options such as Alcoholics Anonymous, Narcotics Anonymous, inpatient and outpatient rehabilitation programs, and similar offerings. The Anonymous groups generally involve a 12-step approach that includes concepts of acknowledging addiction as well as the difficulty in overcoming it, recognizing wrongs, making amends for those shortcomings, committing to a life with continued focus on sustained abstinence, and working to help others, especially those experiencing similar struggles with substance use (

Historically, and continuing in the present day, these programs tend to have a strong spiritual component to them, which can be off-putting for some individuals and make it harder to engage. Of the limited data available, there is evidence for the beneficial effect of involvement in 12-step programs for maintaining sobriety, both with and without attending a rehabilitation program. The impact seems to be strongest for those who started attending 12-step groups prior to entering a rehabilitation program and who continued to be involved after completion of rehabilitation. Most of the available evidence is in regard to alcohol use, with less data focused on other substances.

Medicine is far from the conceptualization of addiction as a sin, yet the belief in biological models still lags considerably, as evidenced by suboptimal prescribing of anti-craving medications. In general, evidence-based practices for addiction treatment are still not fully implemented at the scale they could be, and this is likely reflective of how addictive diseases are conceptualized in everyday practice.

is a psychiatry resident at Baylor College of Medicine. 

 is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She plans to pursue a fellowship in forensic psychiatry after graduation.

is an addiction psychiatrist at Baylor College of Medicine and the director of the Consult Liaison Psychiatry service at the Ben Taub General Hospital- Harris Health System in Houston, Texas.

1. National Institute on Drug Abuse; National Institutes of Health. Drugs, brains, and behavior: the science of addiction. 2007. Accessed March 15, 2022. 

https://nida.nih.gov/sites/default/files/soa.pdf

Brain disease or biopsychosocial model in addiction? Remembering the Vietnam Veteran Study.

The science of making drug-addicted animals.

Free will and the brain disease model of addiction: the not so seductive allure of neuroscience and its modest impact on the attribution of free will to people with an addiction.

Addiction and moralization: the role of the underlying model of addiction.

6. Harackiewicz JM, Sansone C, Blair LW, et al. 

Attributional processes in behavior change and maintenance: smoking cessation and continued abstinence.

The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?

Drug and alcohol treatment providers’ views about the disease model of addiction and its impact on clinical practice: a systematic review.

Countertransferential and attitudinal considerations in the treatment of drug abuse and addiction.

11. Thomas S, Monico N. The 12 steps of Alcoholics Anonymous. American Addiction Centers. Updated December 20, 2021. Accessed March 15, 2022. 

https://www.alcohol.org/alcoholics-anonymous/

Articles

Recovery from addiction does not protect against normal life events...

Normal Life Stress, They Say…

Tales From the Clinic: The Art of Psychiatry, 

we discuss alcohol use disorder (AUD) with difficult relapses. AUD is one of the most prevalent mental health disorders worldwide. This discussion examines comorbidities and barriers to treatment.

“Ms Frank” is a young woman with a history of alcohol use disorder (AUD), cocaine use disorder, 

 (PTSD), and bipolar disorder who is receiving psychiatric care at an outpatient program. She has a severe trauma history that has never been fully discussed with a therapist or psychiatrist, despite years of treatment. She has chronic suicidal thoughts after multiple previous attempts by 

. Suicidality is increased in times of intoxication, and suicidal thoughts have never completely gone away even with the switch to lithium. She has failed more than 15 medications and is often sensitive to adverse effects.

 and inpatient rehabilitation for 90 days, Ms Frank achieved and maintained sobriety for almost 2 years before being put into a supervisory role at her sober living facility. Some of her duties included expelling individuals who had relapsed, including those who had become her friends. She felt that “everyone relapses, anyway” and “there’s no point,” and subsequently relapsed herself with successive suicide attempts and psychiatric hospitalizations. She has since regained sobriety and gone through another 30-day rehab program. She continues to have persistent suicidal thoughts and difficulty engaging with therapy. However, she has again achieved and maintained sobriety for more than a month with a medication regimen including naltrexone monthly injectable, which reportedly helped with her cravings. She previously tried and failed 

 by mouth, acamprosate, and disulfiram due to adverse effects. She regularly attends Alcoholics Anonymous meetings and therapy.

Ms Frank’s history is significant for a pervasive pattern of instability in personal relationships; impulsivity; affective instability; difficulty controlling anger; and recurrent suicidal behavior, gestures, and threats that may indicate an underlying cluster B personality disorder. As she deals with these issues, she maintains a close circle of friends and is able to maintain a consistent job.

The Most Prevalent Mental Health Disorder

Alcohol Use Disorder Among Individuals 18 Years or Older, by Gender: 2019

AUD is known to be one of the most prevalent mental health disorders worldwide. As seen in 

 according to the 2019 National Survey on Drug Use and Health (NSDUH), 7.6% of men and 4.1% of women 18 years and older have AUD.

 As the prevalence of AUD cases has continued to rise, various methods of detection have been recommended. The Alcohol Use Disorder Identification Test (AUDIT) is recommended by the World Health Organization as a screening tool to detect 

. Different AUDIT scoring thresholds are required for men and women, as research has shown that AUD in women has distinctive social and biological characteristics.

For the same amount of alcohol, women develop a higher blood alcohol concentration than men. Therefore, the Centers for Disease Control and Prevention (CDC) provides distinctive cutoffs for alcohol use and binge drinking in women vs men (

). Women are more susceptible to the toxic effects of alcohol such as cognitive disorders, 

, and liver cirrhosis. Women also differ in their approach to the health care system, which may influence their performance on self-reported screening tests.

 Women also often display a shorter trajectory from onset of alcohol use to when they receive a diagnosis of AUD. The prevalence of AUD has steadily increased in women, resulting in a narrower 

 These are a few of the many reasons it is imperative to utilize a lower screening threshold when assessing female patients for AUD.

Treatment Options and Barriers to Care for AUDs

 Alcohol Use Treatment in Past Year Among Individuals 18 Years or Older: 2019

Despite the increasing prevalence of AUD and the multitude of services available, national surveys consistently demonstrate low utilization of treatments (

). Gender disparities in the utilization of treatment are long-standing and significant. Women have approximately one-third to one-half the odds of utilizing treatment when compared with men.

 Fears of stigmatization and beliefs that treatment is ineffective seem to play a large role across the board. In a recent study, women were found to be more likely than men to report attitudinal barriers to treatment. These barriers consisted of shame, fear of others finding out, belief that no one can help, and belief that the problem is not serious enough.

 Because women are less likely to seek help, tailored interventions are warranted.

Although underutilized, effective and safe treatment for AUD is available through psychosocial and pharmacological interventions.

 The combination of pharmacotherapy and psychotherapy (

, individual and group drug counseling, motivational enhancement therapy, etc) has been found to enhance outcomes for AUD. Currently, the US Food and Drug Administration (FDA)-approved drugs for AUD include disulfiram, acamprosate, and naltrexone. Disulfiram acts by blocking the metabolism of alcohol leading to an accumulation of acetaldehyde, a toxic substance that results in tachycardia, 

, nausea, and vomiting after an individual consumes alcohol. Acamprosate has been associated with decreased craving and consumption of alcohol through agonist activity at γ-aminobutyric acid receptors and inhibitory activity at N-methyl-d-aspartate receptors. Naltrexone, available in oral formulation as well as long-acting injectable form, has been shown to decrease cravings and help prevent relapse through its action as an opioid antagonist.

Advances in addiction neurobiology have led to the development of the FDA-approved medications previously mentioned. However, substance abuse retail medication sales remain relatively small when considering the size of the population that could benefit. According to the 2019 NSDUH, approximately 7.3% of individuals 18 years and older with AUD received any treatment in the past year, and 0.3% of patients with AUD were prescribed an FDA-approved medication for AUD (

 Treatment Patterns of AUD in Individuals Aged 18 and Older

Individuals with AUD are unlikely to initially seek help from specialty providers. The best chance of identifying AUD usually occurs within the primary care setting; however, the recognition of AUD remains low in such settings.

 Studies have identified reasons such as limited time, limited organizational capacity, fear of losing patients, and feelings of incompetency regarding treatment of AUD as potential barriers regarding identification of AUD in primary care.

 Within primary care settings, there is evidence to support the effectiveness of AUD screening, brief interventions, and referral to specialized treatment. However, the implementation of models for identifying and treating AUD in primary care remain inadequate.

 Effective treatment may be more widely utilized if measures are taken to increase primary care participation, destigmatize AUD, and address inaccurate attitudes about treatment efficacy.

Not only is AUD associated with many physical illnesses, but it also often occurs with other mental health disorders. Significant associations exist with other substance use disorders, 

, generalized anxiety disorder, panic disorder, PTSD, bipolar disorder, specific phobias, and antisocial and borderline personality disorders. 

 in patients with AUD tend to lead to increased risk of suicide, lower rates of treatment retention, shorter period before relapse, greater number of hospital admissions, and overall poorer clinical course.

When formulating treatment plans for patients with cooccurring disorders, it is imperative to determine the chronology of onset of the diseases. The clinical course tends to be determined by the primary diagnosis. Comorbidity has particularly important clinical implications in cases where psychiatric symptoms increase the 

. AUD in patients with depressive disorder is associated with increased suicidality.

 Personality traits that are often associated with increased risk for 

 (impulsivity, negative emotionality, and antagonism) are also characteristics of borderline personality disorder (BPD) and antisocial personality disorder (ASPD).

Although these disorders are highly comorbid and result in poorer prognosis when they occur together, there are limited treatments that target the symptoms of both BPD and AUD. There is promising evidence that some anticonvulsants (eg, topiramate, lamotrigine) and second-generation 

 (eg, aripiprazole, olanzapine) may reduce the anger, impulsivity, and mood lability present in BPD. Similarly, there are also studies suggesting that these same medications may also reduce alcohol craving and consumption.

 It should be noted that these medications are not FDA approved for BPD or AUD.

Modified psychotherapies (eg, dynamic deconstructive therapy, dialectical behavior therapy, dual focus schema therapy) have been developed for the treatment of comorbid AUD and BPD; however, there is limited evidence to support the efficacy of these modalities on treating symptoms of both disorders concurrently. Only dynamic deconstructive psychotherapy has been specifically tested on patients with both AUD and BPD. Evidence shows that although this therapy may be successful in treating symptoms of BPD, its efficacy in reducing alcohol consumption may not be sustained long term.

The efficacy of the other 2 models in the treatment of AUD has not yet been established.

 Due to the lack of sufficient evidence, psychotherapies for ASPD are limited.

 Although there is sparse evidence to support pharmacotherapy for ASPD, medications can be used to treat symptoms of the disease such as aggression and impulsivity.

In order to effectively treat AUD, an awareness and utilization of evidence-based treatment options is imperative. Furthermore, barriers to seeking care in this particular population require special consideration when formulating treatment plans.

is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She plans to pursue a fellowship in forensic psychiatry after graduation. 

is a psychiatry resident at Baylor College of Medicine. 

is an addiction psychiatrist at Baylor College of Medicine and the Director of the Consult Liaison Psychiatry service at the Ben Taub General Hospital- Harris Health System- Houston, Texas.

1. 2019 National Survey on Drug Use and Health. Table 5.4B – Alcohol use disorder in past year among persons aged 12 or older, by age group and demographic characteristics: percentages, 2018 and 2019. Substance Abuse and Mental Health Services Administration. Accessed January 5, 2022. 

https://www.samhsa.gov/data/sites/default/files/reports/rpt29394/NSDUHDetailedTabs2019/NSDUHDetTabsSect5pe2019.htm

2. Alcohol use basics. Centers for Disease Control and Prevention. Updated December 30, 2019. Accessed January 5, 2022. 

https://www.cdc.gov/alcohol/fact-sheets.htm

3. Neumann T, Neuner B, Gentilello LM, et al. 

Gender differences in the performance of a computerized version of the alcohol use disorders identification test in subcritically injured patients who are admitted to the emergency department.

4. McHugh RK, Votaw VR, Sugarman DE, Greenfield SF. 

Sex and gender differences in substance use disorder.

5. 2019 National Survey on Drug Use and Health. Table 5.11B – Received alcohol use treatment in past year among persons aged 12 or older, by age group and demographic characteristics: percentages, 2018 and 2019. Substance Abuse and Mental Health Services Administration. Accessed January 5, 2022. 

Gender differences in use of alcohol treatment services and reasons for nonuse in a national sample.

Influence of gender and race/ethnicity on perceived barriers to help-seeking for alcohol or drug problems.

Advances in the science and treatment of alcohol use disorder. 

9. Alcohol facts and statistics. National Institute on Alcohol Abuse and Alcoholism. Updated June 2021. Accessed January 5, 2022. 

https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics

10. Rombouts SA, Conigrave J, Louie E, et al. 

Evidence-based models of care for the treatment of alcohol use disorder in primary health care settings: protocol for systematic review.

11. Storholm ED, Ober AJ, Hunter SB, et al. 

Barriers to integrating the continuum of care for opioid and alcohol use disorders in primary care: a qualitative longitudinal study.

Dual diagnosis: alcoholism and co-morbid psychiatric disorders.

13. Helle AC, Watts AL, Trull TJ, Sher KJ. 

Alcohol use disorder and antisocial and borderline personality disorders.

14. Gianoli MO, Jane JS, O’Brien E, Ralevski E. 

Treatment for comorbid borderline personality disorder and alcohol use disorders: a review of the evidence and future recommendations.

15. Khalifa N, Duggan C, Stoffers J, et al. 

Pharmacological interventions for antisocial personality disorder. 

Alcohol use disorder: one of the most prevalent mental health disorders worldwide. 

“There’s No Point”: Alcohol Use Disorder Relapses

, we examine the case of alcohol use disorder with difficult relapses. AUDs are known to be 1 of the most prevalent mental health disorders worldwide. This discussion examines comorbidities and barriers to treatment.

“Ms Frank” is a young woman with a history of 

 (PTSD), and bipolar disorder who is currently receiving psychiatric care at an outpatient program. She has a severe trauma history that has never been fully discussed with a therapist or psychiatrist, despite years of treatment. She has chronic suicidal thoughts after multiple previous attempts by overdose. 

 is increased in times of intoxication, and suicidal thoughts have never completely gone away even with the switch to lithium. She has failed over 15 medications and is often sensitive to adverse effects.

After a significant suicide attempt and inpatient rehabilitation for 90 days, Ms Frank achieved and maintained sobriety for almost 2 years prior to being put into a supervisory role at her sober living facility. Some of her duties in this included expelling people who had relapsed, including people she had gotten to know as friends. She felt that “everyone relapses anyway” and “there’s no point,” and subsequently relapsed herself with successive suicide attempts and psychiatric hospitalizations. She has since regained sobriety and gone to another 30-day 

. She continues to struggle with persistent suicidal thoughts and difficulty engaging with therapy; however, she has managed to again achieve and maintain sobriety for over a month with a medication regimen including naltrexone monthly injectable, which has reportedly helped with her cravings. She has previously tried and failed naltrexone by mouth, acamprosate, and disulfiram due to 

. She regularly attends Alcoholics Anonymous meetings and therapy.

Ms Frank’s history is significant for a pervasive pattern of instability in personal relationships; impulsivity; affective instability; difficulty controlling anger; and recurrent suicidal behavior, gestures, and threats concerning for an underlying cluster B personality disorder. While she deals with these issues, she does maintain a close circle of friends and is able to maintain a consistent job.

AUDs are known to be 1 of the most prevalent mental health disorders worldwide. As seen in 

, according to the 2019 National Survey on Drug Use and Health (NSDUH), 7.6% of men and 4.1% of women aged 18 and older suffer from AUD.

 As the prevalence of AUDs has continued to rise, various methods of detection have been recommended. The Alcohol Use Disorder Identification Test (AUDIT) is recommended by the World Health Organization as a screening tool to detect alcohol problems. Different AUDIT scoring thresholds are required for men and women, as research has shown that AUDs in women have distinctive social and biological characteristics.

 Alcohol Use Disorder in the Past Year Among Persons Aged 18 or Older, by Gender: Percentages 2019

Adapted from “SAMHSA, Center for Behavioral Health Statistics and Quality. 2019 National Survey on Drug Use andHealth. Table 5.4B – Alcohol Use Disorder in Past Year among Persons Aged 12 or Older, by Age Group and DemographicCharacteristics: Percentages, 2018 and 2019.” In the public domain.

, women develop a higher blood alcohol concentration than men. Therefore, the Centers for Disease Control and Prevention (CDC) provides distinctive cutoffs for alcohol use and binge drinking in women vs men, as seen in 

. Women are also more susceptible to the toxic effects of alcohol such as cognitive disorders, 

 Women also often display a shorter trajectory from onset of alcohol use to the diagnosis of AUD. The prevalence of AUD in women has steadily increased in women, resulting in a narrower gender gap in AUD diagnoses.

 These are a few of the many reasons it is imperative to utilize a lower screening threshold when assessing female patients for AUDs.

Despite the increasing prevalence of AUDs and the multitude of services available, national surveys consistently demonstrate low utilization of treatments, as seen in 

 Gender disparities in the utilization of treatment are long-standing and significant. Women have about one-third to one-half the odds of utilizing any alcohol use treatment when compared to men.

 and beliefs that treatment is ineffective seem to play a large role across the board. In a recent study, women were found to be more likely than men to report attitudinal barriers to treatment. These barriers consisted of shame, fear of others finding out, belief that no one can help, and the belief that the problem is not serious enough.

 Several gender-specific factors have been identified as reasons women are less likely to seek help, further warranting the need for tailored interventions.

 Received Alcohol Use Treatment in Past Year among Persons Aged 18 or Older, by Gender: Percentages, 2019

Adapted from “SAMHSA, Center for Behavioral Health Statistics and Quality. 2019 National Survey on Drug Use andHealth. Table 5.11B – Received Alcohol Use Treatment in Past Year among Persons Aged 12 or Older, by Age Group andDemographic Characteristics: Percentages, 2018 and 2019.” In public domain. 

, individual and group drug counseling, motivational enhancement therapy, etc) has been found to enhance outcomes for AUD. Currently, the Federal Drug Administration (FDA)-approved drugs for AUD include disulfiram, acamprosate, and naltrexone. Disulfiram, commonly known as Antabuse, acts by blocking the metabolism of alcohol leading to an accumulation of acetaldehyde, a toxic substance that results in tachycardia, 

, nausea, and vomiting after an individual consumes alcohol. Acamprosate has been associated with decreased craving and consumption of alcohol through agonist activity at GABA receptors and inhibitory activity at NMDA receptors. Naltrexone, available in oral formulation as well as long-acting injectable form, has been shown to decrease cravings and help prevent relapse through its action as an opioid antagonist.

Advances in addiction neurobiology have led to the development of the FDA-approved medications previously mentioned; however, 

 retail medication sales remain relatively small when considering the size of the population that could benefit. According to the 2019 NSDUH, only about 7.3% of adults aged 18 and older with AUD received any treatment in the past year. As seen in 

, less than 4% of patients with AUD were prescribed an FDA-approved medication for AUD.

 Treatment Patterns of AUD in Adults Aged 18 and Older

Individuals struggling with AUD are unlikely to initially seek help from specialty providers. The best chance of identifying AUD usually occurs within the primary care setting; however, the recognition of AUD remains low in such settings.

 Studies have identified reasons such as limited time, limited organizational capacity, fear of losing patients, and feelings of incompetency regarding treatment of AUD as 

 regarding identification of AUD in primary care.

 Within primary care settings, there is evidence to support the effectiveness of AUD screening, brief interventions, and referral to specialized treatment (SBIRT). However, the implementation of models for identifying and treating AUD in primary care remain inadequate.

Not only are AUDs associated with many physical illnesses, but they also often cooccur with other mental health disorders. Significant associations exist with other substance use disorders, major depressive disorder, generalized anxiety disorder, panic disorder, PTSD, 

, specific phobias, and antisocial and borderline personality disorders. 

 Personality traits that are often associated with increased risk for alcohol abuse, impulsivity, negative emotionality, and antagonism are also characteristics of 

(BPD) and antisocial personality disorder.

Although these disorders are highly comorbid and result in poorer prognosis when they occur together, there are limited treatments that target the symptoms of both BPD and AUD. There is promising evidence that some anticonvulsants (topiramate, lamotrigine)and second-generation 

 (aripiprazole, olanzapine) may reduce the anger, impulsivity, and mood lability present in BPD. There are also studies suggesting that these same medications may also reduce alcohol craving and consumption.

 It should be noted that these medications are not FDA approved for BPD or AUD. Modified psychotherapies have been developed for the treatment of comorbid AUD and BPD (dynamic deconstructive therapy, dialectical behavior therapy, and dual focus schema therapy); however, there is limited evidence to support the efficacy of these modalities on treating symptoms of both disorders concurrently. Only dynamic deconstructive psychotherapy has been specifically tested on patients with both AUD and BPD. Evidence shows that although this therapy may be successful in treating symptoms of BPD, its efficacy in reducing alcohol consumption may not be sustained long-term.

 Due to the lack of sufficient evidence, psychotherapies for antisocial personality disorder (ASPD) are limited.

 Although there is sparse evidence to support pharmacotherapy for ASPD, medications can be used to treat symptoms of the disease, such as aggression and impulsivity.

Alcohol use disorders are known to be one of the most prevalent mental health disorders in the world. In order to effectively treat these disorders, an awareness and utilization of evidence based treatment options is imperative. Furthermore, barriers to seeking care in this particular population require special consideration when formulating treatment plans.

is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry & Behavioral Sciences at the Baylor College of Medicine. She plans to pursue a fellowship in forensic psychiatry after graduation. 

1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2019 NationalSurvey on Drug Use and Health. Table 5.4B – Alcohol Use Disorder in Past Year amongPersons Aged 12 or Older, by Age Group and Demographic Characteristics: Percentages,2018 and 2019. Accessed January 5, 2022. 

2. Neumann T, Neuner B, Gentilello LM, et al. 

3. McHugh RK, Votaw VR, Sugarman DE, Greenfield SF. 

4. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2019 NationalSurvey on Drug Use and Health. Table 5.11B – Received Alcohol Use Treatment in PastYear among Persons Aged 12 or Older, by Age Group and Demographic Characteristics:Percentages, 2018 and 2019. Accessed January 5, 2022. 

Advances in the science and treatment of alcohol use disorder.

8. National Institute on Alcohol Abuse and Alcoholism. Alcohol facts and statistics. Updated June 2021. Accessed January 5, 2022. 

9. Rombouts SA, Conigrave J, Louie E, et al. 

Evidence-based models of care forthe treatment of alcohol use disorder in primary health care settings: protocol for systematic review.

10. Storholm ED, Ober AJ, Hunter SB, et al. 

12. Helle AC, Watts AL, Trull TJ, Sher KJ. 

13. Gianoli MO, Jane JS, O'Brien E, Ralevski E. 

14. Khalifa N, Duggan C, Stoffers J, et al. 

Pharmacological interventions for antisocial personality disorder.

15. Centers for Disease Control and Prevention. Alcohol Use Basics. Updated December 30, 2019. Accessed January 5, 2022. 

Approximately 7.6% of men and 4.1% of women aged 18 and older suffer from AUD, but national surveys consistently demonstrate low utilization of treatments. 

Christie Aldrich, MD

Articles

Normal Life Stress, They Say…

“There’s No Point”: Alcohol Use Disorder Relapses

Everyone Relapses Anyway. Or Do They?