Treatment of alcohol problems: current status and future directions

Scaling up the treatment of alcohol problems will lead to considerable health benefit across the nation

Alcohol is Australia’s most widely used drug, consumed by nearly 80% of the adult population.1 We lack recent prevalence data for alcohol use disorder in Australia but previous estimates vary from about 800 0002 to over a million.3 With such large numbers, it is quite a paradox that we are not better equipped to manage those who develop problems related to its use.

It is also a paradox that while population level use of alcohol has been declining,1 measures of alcohol‐related harm such as hospitalisation appear to have been stubbornly resisting this trend.4 Indeed, unhealthy use of alcohol is one of our most common health problems and is linked to about 150 000 hospital admissions and 6000 deaths per annum,4,5 and remains the most common substance use problem seen in specialist treatment services. Therefore, identifying and effectively managing alcohol problems remains critical. The recently updated Australian guidelines for the treatment of alcohol problems, published online6 and summarised in the supplement accompanying this issue of the MJA,7 aim to describe the best evidence for treatment. In this editorial, we overview some of the major points and challenges for treating alcohol problems.

Alcohol problems are not distributed equally through the population, being more common among those with a family history, in men, among those living outside the metropolitan areas, and among individuals and populations exposed to high levels of trauma and stress, especially adverse childhood experiences.1,7,8 Ideally, those at higher risk should be easily detected, offered intervention, and encouraged to control problematic consumption. However, identification of people with unhealthy use of alcohol is straightforward in principle but surprisingly difficult in practice. The Alcohol Use Disorder Identification Test (AUDIT) questionnaire, for example, is designed for use in primary care, with ten questions on consumption and its consequences, while the short version (AUDIT‐C) has just three consumption questions, but neither are frequently used in practice.7,8 Routine clinical assessment typically detects severe cases but misses out on the less severely affected. It is the treatment of less severe cases that has the greatest potential to prevent life‐threatening complications. Treatment of alcohol use disorders can be undertaken in primary care settings. Brief interventions are easily offered in primary care or other health care settings and can be effectively delivered online.7,8 Furthermore, a number of culturally specific strategies for engagement have evolved to assist members of specific communities with alcohol problems.7 Thus, the full guidelines include sections on screening, brief interventions, and eight chapters dedicated to the treatment of specific populations.6

Successful treatment of alcohol problems can yield striking improvements across multiple domains of health and social function. The guidelines also include up‐to‐date evidence based recommendations for a range of management options such as pharmacotherapies, psychosocial interventions, and peer support programs. Alcohol use disorder is also associated with many mental, physical and social complications that can make management more challenging.6,8 In addition, the guidelines include three chapters that focus on the management of specific comorbidities associated with alcohol problems (polydrug use, mental comorbidities, and physical comorbidities).

Despite the major contribution to our burden of disease and the growing range of evidence‐based treatment options, there is a reluctance to implement alcohol treatment programs to the populations at risk and in the places where they are needed. The median delay between onset of alcohol problems and treatment in Australia is around 18 years,9 and pharmacotherapies are prescribed in fewer than 5% of cases.10 Guideline concordant care appears to be the exception rather than the rule. Alcohol use disorder is heavily stigmatised and this may impact treatment seeking and care; for this reason, the guidelines include a new chapter addressing the role of stigma. Moreover, public understanding of treatment options other than residential withdrawal and rehabilitation is low. Increasing awareness of available evidence‐based treatment options may have a key impact on treatment seeking. Ambulatory withdrawal management is effective for low risk patients and can be offered by general practitioners and specialist services alike. Treatment should be continued long term and should offer integrated care for the common comorbidities that include mental disorders.6 Notwithstanding, treatment services are often poorly resourced and often not available where they are needed.7

Improving the efficacy and implementation of comprehensive and effective treatment is a priority and has the potential to save lives and return value to the community. This will require expansion of discovery and translational research, clinical training and advocacy. Clinicians, services and government now face the challenge to implement the treatment recommended in the guidelines. With almost 5% of the national burden of disease and injury attributable to alcohol,11 investing in scaling up treatment of alcohol problems will undoubtedly be associated with considerable health benefit across the nation.