It’s a brain disease

Since AUDs are a chronic illness and fewer than 20-30% of patients succeed in avoiding relapse, efforts to cut drinking down – rather than aiming at zero forever – are appropriate in many cases.

In the case of AUDs we’re trying to treat a complicated set of neurobiological phenomena including craving and systems involving reward, affect and impulsivity. Frequently there are associated psychiatric comorbidities. There is likely to be concomitant abuse of other drugs, and, in the United States in particular, marijuana in particular is a growing concern following its effective decriminalisation in many states. Unlike the situation with cannabinoids, there is no single receptor. Alcohol affects multiple neurotransmitter systems.  And the effects of its withdrawal can persist for months.

Of all the disorders psychiatrists have to deal with, this is one of the most complicated.

So there is not going to be a magic bullet. And medication alone is not going to be effective. Multiple therapies need to be employed: counselling, group therapy, self-help groups, vocational rehabilitation. Often the family has to be involved as well as the patient.  And we have to manage the comorbidities. 

There are a lot of people who are non-dependent but still problem drinkers. And their problem may not be obvious. 

A starting point is to determine how much a patient is drinking, and the amount drunk can range widely between different patients with AUDs. Helpful biomarkers such as ethyl glucuronide (EtG), an alcohol metabolite, and phosphatidylethanol, a phospholipid formed on the red cell membrane, are becoming available to confirm the presence of heavy alcohol use.

While DSM-IV described the two distinct disorders of alcohol abuse and alcohol dependence, DSM-5 now has just the one diagnosis – alcohol use disorder – with subclassifications of mild, moderate and severe. To have severe AUD, a patient must meet at least six of the eleven criteria listed in the manual. And being in this category would certainly justify use of drugs, Dr Fleming argued. But any  prior history of hospitalisation for withdrawal or suicidality adds levels of complexity to that approach.