Stigma, Unfamiliarity Identified as Patient Barriers to Medications for AUD

Patients cite stigma, lack of knowledge, and concerns over side effects as the biggest barriers to taking medications for alcohol use disorder (AUD), according a study issued this week in Alcohol: Clinical and Experimental Research.

Although medications for AUD have been approved by the U.S. Food and Drug Administration (FDA) for decades and are effective, they remain underutilized. “In 2022, among adults with past-year AUD, only 2.2% received [medications for AUD],” wrote Devin Tomlinson, Ph.D., of the University of Michigan, and colleagues. “To place this in context, although there are important differences, about 22.3% of people with opioid use disorder receive medication treatment.”

Tomlinson and colleagues conducted a scoping review of 14 studies that examined the perspectives of adult patients with AUD on naltrexone, disulfiram, and acamprosate, all of which are FDA-approved for AUD. The authors identified several common themes:

• Many patients reported a lack of awareness of existing treatments for AUD, including medications.
• Patients who had no experience with medications for AUD reported a lack of understanding of their therapeutic effects. These patients also cited side effects as a reason why they were unwilling to try medications in the future.
• The studies identified substantial stigma around medications for AUD. Patients referred to medications as a “last resort,” and some shared feelings of shame, failure, and negative judgments associated with AUD treatment in general and medications specifically.
• For some patients, medications did not align with their treatment goals because they wanted to reduce their alcohol use rather than eliminate it completely.
• However, patients were willing to try medications for AUD when they were adequately informed.

The authors emphasized the importance of educating patients to help alleviate the gap in understanding about medications for AUD: “These recommendations are consistent with results indicating that increasing a patient’s knowledge of [medications on AUD], the intended therapeutic effects, and the potential for unfavorable side effects (including those related to drug interactions) would facilitate the adoption of MAUD.”

For related information, see the Psychiatric News article “Special Report: Psychiatrists Critical in Screening, Treatment of Alcohol Use Disorder.”

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Rural Adults With OUD and AUD Are Under-Prescribed Approved Medications

Fewer than one in 10 people in rural areas who have opioid use disorder (OUD) and alcohol use disorder (AUD) are prescribed medications for both of their disorders, a study in the Journal of Substance Use and Addiction Treatment.

“The present study reinforces the gaps in treatment for patients with OUD and/or AUD who live in rural areas and calls for a better understanding of these gaps as well as additional support for rural clinicians in providing pharmacological treatment,” wrote Emily Kan, Ph.D., of the University of California, Los Angeles, and colleagues.

The researchers analyzed data from 1,874 adult patients who visited one of six rural primary care sites in the Northeastern and Northwestern United States at least once from October 2019 to January 2021. The patients all had a diagnosis code for OUD and/or AUD. The researchers also reviewed medications prescribed for OUD or AUD from the clinics' electronic health records. Medications were grouped into five categories: buprenorphine, oral naltrexone, injectable naltrexone, AUD medications like acamprosate or disulfiram, and combination treatment (buprenorphine plus acamprosate or disulfiram).

Overall, 54.2 % of the adults in the sample were diagnosed with OUD only, 37.9 % with AUD only, and 7.9 % with OUD and AUD.

The researchers found that 85.3% of patients with OUD and AUD were prescribed at least one type of medication, compared with 63.7% of patients with OUD and just 10.3% of patients with AUD. Furthermore, patients with both OUD and AUD spent an average of 264.7 days on medication, compared with 220.5 days for those with OUD and 62.5 days for those with AUD. However, only 8.8 % of patients with OUD and AUD were prescribed combination treatment or some form of naltrexone (which is approved for both disorders).

“The low rates of naltrexone prescription are concerning given current evidence of the effectiveness of extended release-naltrexone in treating both disorders,” Kan and colleagues wrote. They added that greater support for rural primary care clinics, such as integrating specialty expertise in OUD and AUD in assessing and treating these disorders and implementing telemedicine to remotely deliver treatment for OUD and AUD, could be practical next steps for addressing the low rates of pharmacological treatment of these disorders in rural communities.

For related information, see the Psychiatric News article “Medications, Open Communication Vital to Treating Substance Use Disorders.”

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APA Releases New Practice Guideline on AUD Pharmacotherapy

APA today released a new practice guideline for the pharmacological treatment of alcohol use disorder (AUD). Despite the high prevalence of AUD and its significant public health consequences, patients with this disorder remain undertreated.

“This new guideline is an important step in bringing effective, evidence-based treatments for alcohol use disorder to many more people and in helping address the public health burden of alcohol use,” APA President Anita Everett, M.D., said in a press release.

The guideline aims to increase physician and public knowledge on the effectiveness and risks of the five medications that may be used for the treatment of AUD: acamprosate, disulfiram, gabapentin, naltrexone, and topiramate.

• Of these five, naltrexone and acamprosate have the best available evidence related to their benefits, and both have minimal side effects. As such, they should be considered the preferred pharmacological options for patients with moderate to severe AUD who want to reduce drinking or achieve abstinence. However, acamprosate should be avoided in patients with significant renal impairment, and naltrexone should be avoided in patients with acute hepatitis or liver failure, or in patients currently taking opioids or who may be expected to take opioids.
• Disulfiram, gabapentin and topiramate are also options for treatment of AUD but should typically be considered after trying naltrexone and acamprosate, unless the patient has a strong preference for one of these medications. Disulfiram is a special case as it does cause a series of adverse reactions if alcohol is consumed within 12 to 24 hours of taking the medication; the reactions include elevated heart rate, flushed skin, headache, nausea, and vomiting. Therefore, disulfiram is suggested only to patients who wish to achieve abstinence from drinking. Patients taking topiramate are at an increased risk of cognitive dysfunction, dizziness, and loss of appetite, whereas patients taking gabapentin may experience fatigue, insomnia, and headache.

While the guideline focuses specifically on evidence-based pharmacological treatments for AUD, it also includes recommendations and suggestions related to psychiatric evaluation of patients with AUD and developing a person-centered treatment plan. Evidence-based psychotherapeutic treatments for alcohol use disorder also play a major role in treatment and peer support groups such as Alcoholics Anonymous, and other 12-step programs can be helpful for many patients. However, specific recommendations related to these treatments are outside the scope of this guideline.

The full guideline, executive summary, and related materials are available here.

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SAMHSA, NIAAA Develop New Guidance on Pharmacotherapy for Alcohol Use Disorders

In recognition of April as Alcohol Awareness Month, the Substance Abuse and Mental Health Services Administration (SAMHSA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) have released a new guidance on the use of medications to assist in the treatment of alcohol disorders.

Despite the high prevalence of alcohol use problems in the United States and the growing recognition that these problems are a legitimate medical condition, only a fraction of people participating in counseling or a specialized treatment program receive medication to supplement their therapy.

This new guide, developed by a panel of experts in alcohol research, clinical care, medical education, and public policy, was designed for use by primary care and specialty providers, though patients and their families may find it informative as well.

The SAMHSA/NIAAA guide provides detailed information on the four medications approved by the Food and Drug Administration to treat alcohol use disorder, prevent relapse, or both: disulfiram, oral naltrexone, extended-release injectable naltrexone, and acamprosate. It includes recommendations on screening and assessing patients for potential medication use, selecting the appropriate medication based on needs and circumstances, developing a treatment plan, and monitoring patient progress.

To learn more about the topics--including medication therapy--that NIAAA will be discussing at the APA's 2015 annual meeting next month, see the Psychiatric News article “NIAAA Track Focuses on Pharmacotherapy, Alcohol Disorder Guidelines.”

Also, check out The American Psychiatric Publishing Textbook of Substance Abuse Treatment, Fifth Edition from American Psychiatric Publishing. The editors of the book are Marc Galanter, M.D., Herbert D. Kleber, M.D., and Kathleen T. Brady, M.D., Ph.D.