What We Get Wrong About “Alcoholism”

What We Get Wrong About “Alcoholism”


[♪ INTRO] Alcohol problems are no joke. Excessive drinking can have a wide range of
consequences, and it can lead to other diseases, like liver
disease, heart disease, and cancer. It’s also incredibly common and seriously undertreated,
affecting millions of people worldwide. And to make matters more complicated, there
are a lot of stereotypes and stigma surrounding alcohol that prevent both understanding
and adequate care. For one thing, though we usually refer to
“alcohol abuse” or “alcoholism,” psychiatrists and other medical professionals now
formally use the term alcohol use disorder, or AUD. That’s because previous definitions didn’t totally capture
the spectrum of symptoms that AUD can include. But also, the way we think about treatments
doesn’t always represent the full story. Here in the United States,
common treatments include rehab and those anonymized,
12-step group therapy programs. But those are far from the only treatments
for alcohol use disorder, nor are they necessarily the most effective. What many people don’t realize is that there
are so many ways to treat AUD. So many, in fact, that doctors and patients have
choices when it comes to treatment and recovery. It’s not all about checking into rehab or
starting a 12-step program; there’s tons of stuff. So here are some of the ways that we can treat AUD. The term “alcohol use disorder” officially
comes from the Diagnostic and Statistical Manual of Mental
Disorders, or DSM, the manual psychiatrists use to diagnose mental
illnesses. The 5th edition of the DSM lists 11 criteria
for AUD, including having cravings for alcohol, continuing to drink even though you suspect
it might be causing problems, and actually having job or life problems caused
by drinking. But patients don’t have to check all 11
boxes. If they meet at least 2 criteria, medical
professionals may diagnose them with mild AUD. And if they meet more than 2, doctors may
bump up that diagnosis to moderate or severe. Before we talk about what’s involved with
AUD treatments, though, we should establish what doctors actually
want as a result of that treatment, the outcomes, to use the medical jargon. Most of the time, the treatment goal is abstinence,
for patients to stop drinking entirely. But that’s not always the case, and in some
circumstances, it may be appropriate to try and shoot for
more moderate, controlled drinking habits. That can come up when patients don’t want
to, or don’t think they can, stop drinking completely. Because ultimately, it’s more important to engage these
folks in treatment, even if it means compromising. Like anything else, it’s something to be
figured out between a patient and their doctor. But regardless of what the goal is, there’s
a wide range of behavioral treatment programs that can be
applied to alcohol use disorder. At least in the U.S., the most well-recognized
are probably those 12-step programs. One example is Alcoholics Anonymous, but there
are others, some based on religious or spiritual beliefs,
and others that are more secular. Either way, doctors refer to such programs
as 12-step facilitation. But despite the number of people who go through
these programs, there’s not actually much evidence about
how well they work, because these things are really hard to study. Scientists have looked at them, but their
research often examines such a range of outcomes that it’s hard to compare one paper to another. Also, the programs are anonymous. And it’s kinda hard to recruit study participants
when you don’t know who they are. One 2006 review sorted through the literature
about these programs, and it actually suggested that none of the
studies out there provided convincing evidence in favor of the
12-step approach. The most encouraging thing they could offer
was one study, which did find some indication that AA might help get patients
into treatment and keep them there. That doesn’t mean these programs are bad,
though, just that the research is a bit fuzzy. Outside of studies, many patients have reported
that the support provided by group therapy is helpful, so many doctors keep twelve-step programs
on the table. Now, treatments like this aren’t the only
kind of behavioral intervention. Behavioral interventions can cover all kinds
of things, from a brief meeting with a primary care doctor
to residential rehab programs. But unfortunately, the story surrounding them
is the same. It’s really hard to study for various reasons, so there’s not much clear evidence about
whether or not they work. Groups like the World Health Organization
keep recommending them, though, because they provide psychological and social
support, which is definitely something. So if these programs work for people, they
are definitely worth it. Regardless, there are forms of behavioral
treatment that do have some pretty good
evidence that back them up. Cognitive behavioral therapy, for example,
is a form of therapy that focuses on helping people identify and change unhelpful
thoughts and behaviors. It’s been shown to be effective for substance
abuse time and time again in the medical literature, and patients respond well to it. Brief interventions are also highly effective
for alcohol use, maybe surprisingly. These are exactly what they sound like: short, one-off
meetings with patients for as little as 5 minutes. Studies have shown that even such a minimal
treatment can decrease heavy drinking 20 to 30%, and have measurable benefits up to 2 years
down the line. They’re targeted at people whose behavior
represents a risk of developing alcohol problems, rather than those who already have some form
of dependence, which might help explain why a short conversation
can be so effective. Because of their one-off nature, brief interventions
are a way to reach people who show up to a hospital or their doctor’s
office for whatever reason, so doctors consider them the first line of
treatment. But while therapy in all its various forms can
really help people, it’s also not the only option. In the US, there are a handful of drugs that
are approved to treat alcohol use disorder, including naltrexone, disulfiram, and acamprosate. Naltrexone is available in both pill and injectable
forms, and it was originally designed to treat opioid
dependence. But it also helps treat alcohol dependence, probably by decreasing the amount of dopamine
released in the brain in response to alcohol. Since dopamine is associated with a pleasant,
rewarding feeling, naltrexone makes it feel less rewarding to
drink. Multiple studies have shown that naltrexone
reduces both a return to binge drinking and a return to any drinking in patients who
have quit alcohol. Though the size of the effect isn’t as big
as doctors might like. AUD isn’t just about the cravings, though. Chronic alcohol use and dependence also produce
a host of changes in the brain, and acamprosate aims to change them back. For example, alcohol can mess with the signaling
done by the neurotransmitter NMDA, which is involved in learning and memory. Acamprosate helps modulate that signaling, so it can
help patients maintain abstinence from alcohol. Studies show it helps people avoid taking
up drinking again, although it doesn’t prevent a return to
binge drinking in particular, which is defined as having more than 4 or
5 drinks in a day. Finally, disulfiram is a bit different. It’s been approved for decades, ever since
the 1940s. And instead of your brain, it works in your liver. It blocks aldehyde dehydrogenase, one of the
enzymes responsible for breaking down alcohol. And if that sounds bad, it is! It’s bad on purpose. When aldehyde dehydrogenase doesn’t work properly, it leads to a buildup of a chemical called
acetaldehyde in the body. And that leads to flushing, nausea, vomiting,
palpitations, and occasionally worse symptoms like heart problems, though it’s not clear
how common those are. Basically, if you’re taking this medication
and you drink alcohol, you will get sick, and it will not be nice. The idea is that people will quickly learn
to avoid the adverse reaction. Unfortunately, when study patients aren’t
told whether they’re getting disulfiram or a placebo, it doesn’t seem to make much difference
to their alcohol use. Although there is evidence to suggest it’s more effective
when used under a doctor’s supervision than without. Of course, these are just drugs used in the U.S. The European Union has also approved a drug
called nalmefene to help people with alcohol dependence drink less. It works quite a bit like naltrexone, and it can reduce the number of days that
people binge drink compared to a placebo. And in the US, some drugs for other conditions
can also be used to treat AUD, like gabapentin, which is used for seizures. But more studies are needed to determine their
effectiveness. All in all, there are a lot of safe, potentially
effective drug options out there, but alarmingly, researchers have estimated
that only 9% of people who could stand to benefit from them are actually
getting them. Plenty of people receive behavioral treatments, but it seems like a lot more people could
be getting these drugs. There are likely a number of reasons for that,
but it’s also worth keeping in mind that there’s no rule that says you have
to pick just one of these things. Medicine and behavioral intervention together
has also been shown to be effective, like in the 2006 COMBINE study. This was a randomized controlled study of
almost 1,400 patients that explored several questions about the relationship between drug and behavioral
therapy for alcohol use. The researchers wanted to know things like whether drugs can be effective independently
of treatment by a specialist, and whether specialist treatment could be
improved by adding drugs. They looked at how many days patients went
without drinking, as well as how long it took patients to have a day
where they drank heavily after beginning treatment. And they tested both naltrexone and acamprosate. Most groups received what the researchers
called medical management: a basic, 9-session treatment designed to be
administered by a primary care doctor. But some also received more specialized counseling
referred to as combined behavioral intervention. People in all treatment conditions showed
improvement, which is great! You don’t want to see your study population
get worse if you can help it. Patients taking naltrexone, receiving a behavioral
intervention, or both all fared better than patients receiving a
placebo or medical management alone. However, the combination of naltrexone and therapy
didn’t fare any better than either treatment by itself. The authors suggest this could actually be
beneficial for some patients. If they didn’t have access to therapy, seeing a primary care doctor and receiving
naltrexone could still help them. And this really drives home the idea that
doctors want to see people get better. The goal isn’t to promote one treatment over
another; it’s to get people into any treatment at all. In fact, some researchers have suggested that
informing patients of all of the options could give them more independence and control
over their own treatments. And that could help tear down the stigma against
seeking help in the first place. This episode of SciShow is brought to you
by our patrons on Patreon. Having people support this show means that
we can tackle complicated topics like this. We really appreciate everybody who’s able
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been doing it for years. If you wanna see some of
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on the internet, check out patreon.com/scishow. [♪ OUTRO]

  1. I usually overdrink but I have three easy solutions to stop drinking
    1) Be really busy so you don´t have time to drink
    2) weed
    3) Be so poor you literally don´t have enough cash to buy a can of beer

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