Alcohol overuse causes 140,000 American deaths annually. Why is it so undertreated?

Vartika Sharma for Vox

Medications can help the 1 in 12 people who suffer from alcohol use disorder. But most will never be treated.

There is something that kills more Americans every year than drug overdoses, than guns, than car accidents. It’s legal, doesn’t require a background check to buy, is widely advertised, and if you’re 21, you can probably buy it at your corner store. It’s called alcohol.

While cold beers, glasses of wine, and hard liquor cocktails are often treated as end-of-the-workday or weekend indulgences, alcohol is technically a psychoactive, addictive drug, one linked to over 50 fatal conditions, including heart disease; breast, pancreatic, and stomach cancers; liver disease; hypertension; and stroke. It contributes to the death of 140,000 people in the US annually, making it one of the leading causes of preventable death in the country.

More and more research supports the conclusion that even light drinking — that is, less than 15 drinks a week for men or eight drinks a week for women — can contribute to an increased risk for heart disease and cancers. More recent medical recommendations in countries like Canada have increasingly tightened, moving toward the idea that there is no truly safe level of alcohol consumption.

But the dose is the poison, and those who are at the greatest risk are those who consistently binge drink. This group suffers from alcohol use disorder, a condition where someone consumes excessive amounts of alcohol to the point that it impairs their ability to stop or control their use despite negative social, occupational, or health consequences. And that group is larger than you might think: more than 1 in 12 people in the US have AUD, and it’s likely that figure underestimates the real breadth of the problem.

In the 20th century, binge drinking coupled with its negative repercussions was called alcohol abuse, alcohol dependence, alcohol addiction, or alcoholism. However, such diagnoses carry a shameful stigma and make unhealthy alcohol use seem like purely a bad choice, rather than the result of a brain-altering disease. By not indicating a range in how alcohol overuse can affect a person, these names also fell short of describing the condition of all people who drink in unhealthy ways. In 2013, the American Psychiatric Association began defining all forms of excessive alcohol use as alcohol use disorder, or AUD.

“Decades ago alcohol use, and really all substance use disorders in general, were sort of viewed as personality flaws or moral failings,” Carrie Mintz, an assistant professor of psychiatry at Washington University in St. Louis, told Vox. “We really know now — especially from the past 50 years of increasing amounts of research and data — that these are really brain diseases. There are clear neurologic changes that occur with repeated pathologic use of a potentially addictive substance like alcohol.”

But while America treats other dangerous substances, such as opioids, as a public health problem, alcohol use is not treated similarly as a crisis — legally, medically, or culturally. Rather, access to alcohol is only growing. The alcoholic beverage industry generated $250 billion in revenue in 2021, while the category of hard alcohol spirits has now surpassed beer in total sales, even as the number of breweries in the US grew from 3,305 in 2017 to 4,493 in 2020. Alcohol is generally taxed higher than other goods in part to limit its consumption, but since 2000, these taxes have lost much of their value — and with it, their ability to curb consumption — because they haven’t kept up with inflation rates and beverage costs.

“It’s a real blind spot in drug policy, that a huge number of people are not willing to see alcohol as a drug for which we have a pretty serious problem,” said Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford University. What this all means is that nearly a century since the founding of Alcoholics Anonymous — a program that studies show is the most effective at helping people achieve and maintain abstinence — the problem is only getting worse.

But that may be changing. As researchers continue to delve into how alcohol use can hurt one’s overall health and lead to addiction, more people are looking for solutions — especially for the group of heavy drinkers who need it most. Beyond the therapeutic and social groups like AA that have long existed to support AUD sufferers, there is a trio of FDA-approved drugs that have a history of curbing alcohol abuse. Rumblings of Ozempic’s apparent off-label ability to curb alcohol cravings, as well as overeating, have put the spotlight back on the power of medical intervention with the help of a prescription. In the same way that we view medications like Prozac as tools for treating depression, these medications could be a key element in AUD treatment plans.

But they remain vastly underused; while 14.1 million adults experienced AUD in the US in 2019, only 223,000 will ever be prescribed existing medications. The reasons for this vary; some patients don’t want to take a drug to treat their addiction, health care professionals lack awareness and training in treating AUD, and the ongoing stigma surrounding the disease makes it difficult for sufferers to seek help.

What’s clear is that the cost of failing to effectively treat alcohol abuse is astronomical, adding up to tens of thousands of deaths a year. AUD breaks apart families and disrupts the workplace, causing 232 million missed work days annually. New treatments and even laws are emerging daily, but it’s important for health care professionals and those with AUD to remember that effective treatment options are already available.

“I think it’s great that we have medications,” said Humphreys. “They all can be used much more than they are. None of them is at the level of antibiotics for infections. But they have a role, and it’s too bad we don’t use them more.”

What is AUD?

Americans can purchase alcohol at restaurants, bars, liquor shops, grocery stores, gas stations, and in some states, even drive-throughs. Alcohol is everywhere. “At the end of the day, it is so baked into our society to use alcohol. Some people are going to drink it and never develop a problem, and other people are going to develop a problem,” said Mark Disselkoen, the senior project manager at the Center for the Application of Substance Abuse Technologies (CASAT) at the University of Nevada Reno.

While AUD and its effects are widespread, those suffering the most from the disease are the most frequent and heaviest drinkers. Data from the late 2000s showed that the top 10 percent of American drinkers (approximately 24 million people) consumed an average of 74 alcoholic drinks a week, which means those with the most severe form of AUD purchase over half the alcohol bought in the country.

The research since then only further proves the pervasive influence of alcohol in the US. Americans spend billions on alcohol every year, with approximately 65 percent of adults of legal drinking age in the US reporting they drink alcohol (the average American consumes 2.51 gallons of the substance annually).

And the numbers only got worse when Covid-19 swept across the country. In 2020, the first year of the pandemic, studies show that overall a quarter of Americans drank more than they usually did due to the stress of the pandemic.

AUD remains most common in men, but the rate of alcohol-related deaths is growing faster for women, partially due to a general uptick in alcohol consumption by the group. This is an unfortunate shift, explained in part by women’s greater susceptibility to alcohol-related liver and heart disease, and cancers.

Historically, repeated binge drinking episodes — periods where men drink five or more alcoholic beverages in two hours, or for women, four or more beverages in two hours — were called alcohol abuse or alcohol dependence. The DSM-IV (a widely used manual published by the American Psychiatric Association to help diagnose mental disorders) categorized alcohol use as either abuse — continued alcohol use despite negative consequences — or dependence, an increasing need for consumption to become intoxicated and avoid withdrawal symptoms, George Koob, director of the National Institute on Alcohol Abuse and Alcoholism, told Vox.

But these outdated terms perpetuate negative connotations and stereotypes about people who drink, the experts Vox spoke to agreed. “The terms ‘alcohol abuse’ or ‘substance abuse’ are terms that we try to avoid,” said Kenneth Leonard, the director of the Clinical and Research Institute on Addictions at the University at Buffalo and the former president of the Division of Addictions of the American Psychological Association. “They have the impact of stigmatizing individuals who have an alcohol use or substance use disorder.” Additionally, because the word “abuse” is associated with violence, it leads to people seeking to punish those with AUD, rather than treat them, said Humphreys.

In 2013, the APA replaced the DSM-IV with the DSM-5, which recategorized all forms of abuse as AUD, with cases ranging from mild to moderate or severe. The DSM-5 criteria include a series of yes-or-no questions about a patient’s drinking habits and the repercussions of those habits from the last year.

Answering yes to two or three of the DSM-5 questions indicates mild AUD; answering yes to four or five of the questions indicates moderate AUD; and answering yes to six or more indicates severe AUD.

The amount and type of alcohol someone consumes also affects where they fall on the spectrum for this disorder, said Disselkoen. When primary care physicians ask about alcohol consumption — which they should do at annual visits — they shouldn’t just ask how many alcoholic drinks are consumed per week or month, but also about the alcohol by volume (ABV) consumed. (Two glasses of wine with an ABV of 11 to 13 percent a night is very different from two cocktails with an average ABV of 25 percent a night.)

Nonetheless, some experts believe that not everyone who meets this criteria in the last 12 months should receive an AUD diagnosis. Older teens and college students who use alcohol more heavily while in a college party setting may not go on to develop lifelong AUD, for instance, said Sara Jo Nixon, a distinguished professor in psychiatry, neuroscience, and psychology and director of the University of Florida’s Center for Addiction Research and Education.

“Yes, there is this period of heavy partying, and it’s not without negative consequences, and so certainly, in that time span, you might think of [older teens and college students] as having met the criteria. But it doesn’t mean that they’re going to carry that throughout their lifetime,” she said.

Still, sometimes preconceived notions of who suffers from AUD prevent people from identifying the disease. “Although we often think of individuals with an alcohol use disorder as being in their 40s or 50s, the disorder often began when they were in their 20s and may have progressed slowly from then on or progressed rapidly when a major life challenge occurred,” Leonard said.

And sometimes other factors, such as socioeconomic status or race, affect whether or not someone’s AUD is discovered, said Humphreys.

For example, Humphreys said, if someone like himself, a white Stanford professor, gets pulled over after drinking at a work holiday party, he may speak with the police officer and then continue on his way. But, if the police pulled over someone poor, Black, or driving a beat-up car, they may take them to jail and they would incur a documented case of harm from drinking. Latino and Hispanic men are up to 66 percent more likely to be convicted of a DUI than white men, a 2021 University of California, Davis study found from alcohol-related crash data in California.

About 18.7 million white people ages 12 and up experience AUD each year, accounting for the greatest number of AUD sufferers, the 2021 National Survey on Drug Use and Health found. However, those who identify as two or more races; American Indian or Alaska Native adults; and Native Hawaiian or other Pacific Islander adults report higher rates of AUD relative to their population sizes.

How to treat the disorder

In the last decade, the medical community has come to recognize AUD as a disease that (like all others) needs medical treatment through a range of interventions. With new treatments coming out every day, hope exists that in the years to come more and more people will receive the care they need.

For those with the most severe forms of AUD, treatment aims at stopping the individual’s alcohol consumption entirely (while recognizing that having a drink or breaking abstinence isn’t a failure, but an almost inevitable part of the recovery cycle).

“What’s happened in the last probably 50 years or so is there’s a more medicalized understanding,” said Humphreys. “So there’s been the rise of neuroscience that looks at things like how the brain changes with repeated administration of alcohol, how that limits things like self-control, how that increases phenomena like craving.”

And as with any other mental health diagnosis, successful treatment for AUD often boils down to a combination of therapy and medication, the experts Vox spoke to said. Just as depression is treated with medication to balance chemicals in the brain, and therapy to help patients unlearn harmful behaviors, AUD often needs the same combination of treatments, said Disselkoen.

The Federal Drug Administration approved the first medication to treat AUD, disulfiram, in 1951. Disulfiram, whose brand name is Antabuse, is a daily pill that causes someone to fall ill — face redness, headache, nausea, sweating, and more — if they drink even a small amount of alcohol. Disulfiram is safe and effective, but the same characteristic that makes it successful (the way it induces illness) also makes it unpopular among patients, said Nixon.

Disulfiram is now a second-line option, with the two other FDA-approved medications, naltrexone and acamprosate, serving as first-line options. Naltrexone and acamprosate were approved in the 1990s and early 2000s respectively.

Naltrexone, which comes in a pill and injectable form, blocks the buzz of opioids or alcohol, essentially preventing intoxication and therefore the desired effect of drinking or drug use. One flaw with naltrexone and disulfiram is that they stay in the body for relatively short periods of time, with the daily pills only treating AUD the day they are taken. If someone chooses not to take the pill one day — as studies have shown, patients don’t take it approximately 20 to 30 percent of the days — then their body will quickly begin to respond to drugs the way they did prior to taking the pill. (In contrast, the once-a-month injectable version consistently prevents someone from experiencing intoxication.) Another side effect is that in rare cases, the drug can damage the liver, which could compound damage from past alcohol consumption.

In contrast, acamprosate, a pill taken three times a day and usually prescribed for up to 6 months at a time, is not metabolized in the liver. Rather than reducing craving or inducing illness, acamprosate merely restores the chemical balance of the brain. In time that helps the brain unlearn the cravings that consistent and intense alcohol use creates, ideally reducing addiction.

Disulfiram, naltrexone, and acamprosate are the only three medications approved by the FDA to treat AUD, but other off-label drugs can be prescribed. For example, the epilepsy medicine topiramate and even the diabetes medication Ozempic may reduce cravings and encourage sobriety. In a dozen experiments, the drugs reduced mice and rats’ consumption of alcohol. But given how the existing medicines aren’t sufficiently used, these new approaches may not reach the patients in need of them.

In 2021, an estimated 61 percent of adults with a major depressive episode received treatment in the US, and globally, about 25 percent of those with anxiety disorders receive treatment. In contrast to these other mental health disorders, AUD is vastly undertreated. In 2021, less than 5 percent of people ages 12 and up with AUD received any kind of treatment, and even less, only 2 percent, were prescribed medication.

This makes sense when you consider that of the approximately 940,000 physicians in the US, around 38,000 of them specialize in psychiatry, and approximately 3,000 specialize in addiction medicine. And today, patients don’t have the same longstanding relationships they once had with primary care physicians, with nearly half of adults under 30 saying in 2018 that they didn’t have a primary care doctor, Vox’s Dylan Scott previously reported. Instead, patients are turning to emergency rooms and urgent clinics that are not designed to treat underlying diseases, but rather the symptoms or repercussions of those illnesses.

“A lot of doctors don’t want to treat alcohol problems,” said Humphreys. “I have a friend who used to say what’s strange about being a doctor is we’re the only profession that you can look a stranger in the eye, and say, ‘Go into that room and take off your clothes,’ and the person will do it. Yet those same people would say, ‘I could never ask somebody about their drinking, that’s too inappropriate.’ ... that says a lot about just the deep discomfort a lot of doctors feel about them getting involved in someone’s drinking.”

There’s no question disulfiram, naltrexone, and acamprosate are underprescribed, but Disselkoen warns these drugs are not a “silver bullet” against AUD, just like antidepressants alone can’t always treat depression.

“There is no one-size-fits-all approach to the treatment of AUD,” said Koob. “The important thing is that individuals continue trying until they find an approach, or combination of approaches, that works for them.”

For those with a concurrent diagnosis of AUD and another mental health diagnosis, some form of therapy is often needed to treat both conditions. Mild AUD can be treated with a short mental health screening and intervention in a primary care doctor’s office. Meanwhile, for those with more severe cases of AUD, further treatment — cognitive behavior or motivational enhancement therapy — could help.

And it’s important not to underestimate the importance of social groups. Alcoholics Anonymous (AA) is often successful in promoting abstinence, even sometimes more so than therapy. Reviews of the program have found that the practical advice, emotional support, and non-judgmental space AA provides truly help those with AUD refrain from drinking.

However, sobriety or abstinence from alcohol may no longer be the only form of recovery from AUD. Unlike in the past, today we understand that just like with most diseases, remission is possible, or rather that someone who suffers from AUD at one point in their life may recover and go on to not have AUD later in life.

“Until relatively recently, the idea was a person with AUD had that disorder forever. That was sort of the mantra and the only way to recover was to not use at all,” said Nixon. “Individuals who did use were seen to relapse. Well, over time that’s evolved. And we now understand that a person might have a drink, that might be a slip, it might not mean they’re going to go into drinking at the same levels that they did before.”