
“There’s No Point”: Alcohol Use Disorder Relapses
Alcohol use disorder: one of the most prevalent mental health disorders worldwide.
TALES FROM THE CLINIC
In this installment of 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.
Case Study
“Ms Frank” is a young woman with a history of alcohol use disorder (AUD), cocaine use disorder,
After a significant
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
AUD is known to be one of the most prevalent mental health disorders worldwide. As seen in
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 (
Treatment Options and Barriers to Care for AUDs
Despite the increasing prevalence of AUD and the multitude of services available, national surveys consistently demonstrate low utilization of treatments (
Although underutilized, effective and safe treatment for AUD is available through psychosocial and pharmacological interventions.8 The combination of pharmacotherapy and psychotherapy (
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 (
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.10 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.11 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.10 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,
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
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
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.13 Due to the lack of sufficient evidence, psychotherapies for ASPD are limited.13 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.15
Concluding Thoughts
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.
Dr Hanif 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. Dr Aldrich is a psychiatry resident at Baylor College of Medicine. Dr Parks 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.
References
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.
2. Alcohol use basics. Centers for Disease Control and Prevention. Updated December 30, 2019. Accessed January 5, 2022.
3. Neumann T, Neuner B, Gentilello LM, et al.
4. McHugh RK, Votaw VR, Sugarman DE, Greenfield SF.
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.
6. Gilbert PA, Pro G, Zemore SE, et al.
7. Verissimo ADO, Grella CE.
8. Witkiewitz K, Litten RZ, Leggio L.
9. Alcohol facts and statistics. National Institute on Alcohol Abuse and Alcoholism. Updated June 2021. Accessed January 5, 2022.
10. Rombouts SA, Conigrave J, Louie E, et al.
11. Storholm ED, Ober AJ, Hunter SB, et al.
12. Kranzler HR, Rosenthal RN.
13. Helle AC, Watts AL, Trull TJ, Sher KJ.
14. Gianoli MO, Jane JS, O’Brien E, Ralevski E.
15. Khalifa N, Duggan C, Stoffers J, et al.
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