One night in 2012, back when I was an addiction medicine fellow at Boston Medical Center, I received a life-changing call. My younger brother had died from a self-inflicted gunshot wound. The real cause, however, was depression worsened by his alcohol use disorder (AUD). More than a decade has passed since his death and I have devoted my career to addiction medicine, but I still ask myself, “Why does our country fail so badly when it comes to alcohol use?”
Today, I see my brother’s face reflected in those of my patients at Michigan State University College of Human Medicine in East Lansing. Too often, alcohol has deeply undermined their mental, physical, and emotional health. But I remain committed to providing the best possible care, including medications for AUD — none of which were offered to my brother — and to advocate for those at risk of dying from alcohol use.
Alcohol-related deaths in the United States have surged by 30% in recent years. Excessive drinking is responsible for nearly 500 U.S. deaths every day, whether from car accidents, liver disease, or dozens of other risks. An estimated 1 in 8 deaths among U.S. adults ages 20 to 64 each year is attributable to excessive drinking. In 2022, nearly 3 million U.S. teens and adults self-identified as having AUD. Of these, 753,000 were youths ages 12 to 17.
Yet far too often, Americans fail to recognize the potential dangers of drinking alcohol. Physicians also fall painfully short in discussing alcohol use with patients and providing appropriate treatments to those who need it.
Part of the problem is that alcohol permeates people’s everyday lives, appearing everywhere from joyous celebrations to moments of grief, thus obscuring its possible dangers. Also, AUD carries a terrible stigma, which prevents people from seeking treatment.
As a medical community, and as a nation, we can — and must — do better to prevent the tremendous amount of disease and death that alcohol causes millions of people and the suffering it causes families like mine.
It can be tough to understand what constitutes excessive alcohol consumption. According to the Centers for Disease Control and Prevention, it’s heavy drinking — consuming eight or more drinks per week for women and 15 or more for men. It’s also binge drinking — four or more drinks on one occasion for women and five or more for men — a dangerous behavior that is increasingly normalized, particularly among 18- to 25-year-olds. Finally, it’s any alcohol use by a person who is pregnant or under age 21. It’s important to note, though, that recent research goes even further, suggesting that the healthiest approach is to avoid alcohol entirely.
Alcohol can be highly addictive for some people. Alcohol reduces anxiety quickly and efficiently — but the anxiety can return even more powerfully when the alcohol wears off. So a person drinks again, the effects wear off, and a potentially toxic downward spiral can begin.
For those individuals who develop AUD — defined as an inability to control drinking despite adverse consequences — there are evidenced-based treatments, including medication and psychosocial supports such as therapy. The Food and Drug Administration has approved three AUD medications as safe and effective. Two, naltrexone (Vivitrol) and acamprosate (Campral), work by reducing alcohol cravings. The third, disulfiram (Antabuse), discourages drinking by causing nausea, vomiting, and similar negative effects if a patient ingests alcohol.
So, if we have evidence-based treatments, why are so many people dying of AUD?
Too often, the answer is stigma. Sometimes, that comes from family and friends. Without a strong support system, sustained remission from any substance use disorder is extremely difficult. However, health care providers’ negative attitudes toward patients with AUD also play a major role, including their use of damaging words like “alcoholic.” That stigma often fuels providers’ failure to offer patients medications that can be crucial.
However, there are clear — and essential — ways forward to address stigma, improve understanding of alcohol use, and ensure appropriate treatment of AUD for those who need it.
Physicians can play a huge role in preventing, detecting, and treating excessive alcohol use, but we are not doing nearly enough. A 2021 study found that of people who met the criteria for AUD, 80% had seen a doctor in the past year, but only 12% had been advised to cut down on their drinking, and just 5% were offered treatment information.
Although individual medical schools and teaching hospitals have made progress, we need better AUD training. Why aren’t current and future physicians equipped to treat AUD with the same facility as other chronic illnesses like diabetes, hypertension, and asthma?
Educators need to ensure that AUD education covers prevention, screening, diagnosis, and treatment, and that it includes direct clinical care. The Accreditation Council for Graduate Medical Education should require that residency programs teach about AUD, and it should monitor them to ensure that training includes prescribing medications. Given the pervasiveness of alcohol in the United States, all physicians — not just primary care providers — need to understand and prescribe medications. And they must be able to monitor alcohol withdrawal, which can be fatal if not handled correctly. For existing physicians, continuing medical education such as a module from the American Society of Addiction Medicine is a good option.
In addition, given the limitations of current options, we need increased research into AUD medications. For example, naltrexone can be unsafe for patients with liver damage. Acamprosate must be taken three times a day. As for disulfiram, if a patient wants to drink on a certain day, they may decide to halt the medication for a few days prior to avoid its effects.
Doctors also need to do more to screen patients for excessive drinking and to do so effectively, using validated screening tools. For example, it’s important to avoid leading questions that can stall conversations, such as, “You don’t drink much, do you?” Screening then should be followed by caring conversations that are devoid of judgment. Patients who engage in excessive drinking should be asked if they are open to feedback on their alcohol use along with a reminder of the risks of alcohol consumption. Patients identified as having AUD should be offered medication as well as psychosocial supports.
Finally, medical leaders should advocate for evidenced-based alcohol-related policies, including public education campaigns to reduce both the stigma surrounding AUD and the widespread trivialization of excess alcohol consumption. In addition, raising excise taxes on alcohol purchases can be highly effective. Research points to a significant relationship between increased alcohol prices and reduced alcohol-related morbidity and mortality, including from disease, traffic crashes, and violence. Yet, the United States has not raised the federal alcohol tax since 1991.
When I think of all the patients I’ve seen in my 20 years of doctoring, some still haunt me. There’s a former patient who reminded me deeply of my brother, a man in his 30s determined to stop the drinking that was driving away his wife and children. He managed to achieve remission, but I wonder if he continued to receive the necessary quality care to stay well. And there’s a patient I met during internal medicine residency whose alcohol withdrawal brought him to the hospital seven times in one month. So many questions arose from his care. Did he fill his prescriptions when he went home — and did he even have a stable home? How effective was the follow-up plan if it resulted in so many hospitalizations? Could we have created a better plan by considering how his disease fit in the rest of his life?
I know we can do better — we must do better. We can improve education, reduce stigma, normalize treatment, and advocate for commonsense public policy. We must work together to address the devastation of alcohol use and create a healthier community for all.
Cara Poland, MD, MEd, is an associate professor at Michigan State University College of Human Medicine and the Addiction Medicine fellowship director at Trinity Health West Michigan.
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