Alcohol use disorder (AUD) is a relatively common condition characterized by a pattern of problematic alcohol consumption. According to the 2016 National Survey on Drug Use and Health (NSDUH) approximately 14.6 million Americans aged > 18 years had a diagnosis of AUD.1 This same survey also found that 26.2% of individuals over the age of 18 years reported engaging in binge drinking, which is ≥ 5 drinks in males or ≥ 4 drinks in females on the same occasion in the past month. Of those surveyed, 6.6% reported engaging in heavy drinking (binge drinking on 5 or more days in the past month).1
Military and veteran populations have a higher prevalence of alcohol misuse compared with that of the general population.2 Two out of 5 US veterans screen positive for lifetime AUD, which is higher than the prevalence of AUD in the general population.3 A number of studies have found that excessive alcohol use is common among military personnel.2,4,5 One study suggested that the average active-duty military member engages in approximately 30 binge drinking episodes per person per year.4 Military veterans may continue with a similar drinking pattern when transitioning to civilian life, explaining the high prevalence of AUD in the veteran population.6 Furthermore, since alcohol use provides temporary relief of posttraumatic stress disorder(PTSD) symptoms, a diagnosis of PTSD may also contribute to hazardous drinking in this population.7
Excessive alcohol consumption is associated with a number of negative outcomes, including increased motor-vehicle accidents, decreased medication adherence, and therefore, decreased efficacy, increased health care costs, and increased morbidity and mortality.8-13 Additionally, alcohol use is associated with a number of medical and psychiatric comorbidities.14,15 Compared with veterans without AUD, those with a diagnosis of AUD were 2.6 times more likely to have current depression and 2.8 times more likely to have generalized anxiety.3 Veterans with AUD also are 2.1 times more likely to have current suicidal ideation and 4.1 times more likely to have had a suicide attempt compared with veterans without AUD.3
Given the high prevalence and the associated risks, alcohol misuse should be properly addressed and treated. Pharmacotherapy for AUD has demonstrated efficacy in decreasing heavy drinking and prolonging periods of abstinence.16 Despite the proven benefits of available pharmacotherapy, these medications still are drastically underutilized in both the nonveteran and veteran populations. In fiscal year 2012, there were 444,000 veterans with a documented diagnosis of AUD; however, only 5.8% received evidence-based pharmacotherapy.17 The potential barriers for the utilization of AUD pharmacotherapy includes perceived low patient demand, lack of skill or knowledge about addiction, and lack of health care provider (HCP) confidence in efficacy.18 This article will provide a thorough overview of the pharmacotherapy options for the treatment of AUD and the evidence that supports the use of pharmacotherapy. We will then conclude with the recommended treatment approach for specialized patient populations.
Naltrexone was the second FDA-approved medication for the treatment of AUD and is considered a first-line agent by the Department of Veterans Affairs (VA).19,20 Unlike its predecessor, disulfiram, naltrexone significantly reduces cravings.21 During alcohol consumption endogenous opioid activity is greatly enhanced, leading to the rewarding effects of alcohol. By antagonizing the µ-opioid receptor, naltrexone mediates endorphin release during alcohol consumption, explaining the efficacy of naltrexone in AUD.21-28 Since cravings are reduced, patients are able to abstain from drinking for longer periods of time, and since pleasure is reduced, heavy drinking is also reduced.21,25