Physicians are the only professionalso who can tell a stranger, “Go in that room, put on a gown, and take off all your clothes,” and the patient will unquestioningly comply. However, many doctors do not identify, refer, or treat drug or alcohol problems in their patients. This post covers key reasons why few doctors prescribe, and even fewer patients take, FDA-approved medications for alcohol or opioid disorders. Some blame the lack of traction of addiction medications on the fact they are very old and don’t work as well as MDs and patients expect.
Less than 2% of patients with alcohol use disorder (AUD) use approved treatment medications. Yet the CDC says 29.5 million met AUD criteria in the past year. It is generally assumed that this shockingly low medication treatment rate is due to stigma, physician fears of treating AUD or opioid use disorder (OUD), and ignorance about the disorders. The recent successes of GLP-1 medications, though, argue that something else may be responsible. Obesity was stigmatized for decades, and physicians did not treat this disorder—other than telling patients to lose weight—until GLP-1s arrived on the scene.
George Koob, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), is correct that the healthcare system has failed to integrate AUD treatment into primary care settings. He suggested doctors may be afraid to prescribe addiction treatment medications, citing inadequate treatment benefits or concern about medication adherence. I would ask, do patients always comply with other drug regimens? Many people fail/forget to take daily meds, but physicians still order medicines for hypertension, high cholesterol, and other chronic conditions. However, I don’t think prescribers who don’t prescribe, or patients who don’t take addiction medications, are to blame. It’s more complicated.
Using AUD as an example, patients who lose control over drinking and have problems may come to treatment to stop. Taking a pill every day, to drink less (vs. abstinence) is no easy sell to patients or their loved ones. Others may seek treatment later, when their addiction is so strong they can’t conceive of detox or stopping. Naltrexone, injectable naltrexone, or acamprosate may be just what they need to step away from alcohol onto the road to recovery.
First adopters like me prescribed naltrexone long ago. Herb Kleber and I gave it to patients in clinical trials in the 1970s while at Yale. Still, doctors may prescribe medication, but patients may never pick up the prescription or take the drug. If they do, most eventually stop taking addiction medications, putting themselves at risk for overdoses and relapse. Oral naltrexone requires daily dosing, making adherence challenging for many. In 2006, the introduction of long-acting injected naltrexone (Vivitrol), which lasts a month, improved compliance. But first, adopter prescribers had a hard time getting patients to take more than one or two shots. Acamprosate was approved for AUD in 2004 but has seen extremely low adoption compared to naltrexone. Also, analyses and experiences showed acamprosate’s benefits were primarily limited to patients who had already achieved abstinence.
Naltrexone reduces craving, allowing patients to receive help from Alcoholocs Anonymous and/or mental health and addiction treatment experts. Those experts making it a binary choice of medication vs. AA or therapy have increased the doubts about medications. When given without support, AUD medication treatments often are not taken. Neither Naltrexone nor Acamposate is addicting. Patients can and do, stop taking the drug anytime they wish.
Alcohol and Opioid Use Disorders Are Chronic Relapsing Brain Disorders
Koob says AUD is a chronic, relapsing brain disorder that benefits from treatment medication, similar to other chronic conditions like diabetes or hypertension. While it is a brain disease, the healthcare system in general, and physicians in particular, may not believe this model proves we should encourage patients to take medicines to use less, or drink less. MDs have seen and heard of many people with addictions stopping substance use on their own, as well as others ending drinking through AA. Most patients have multiple drug and alcohol problems, and we don’t have addiction medicines for cannabis, cocaine, or amphetamine addictions. The best outcomes for the medication-alone approach are with OUDs when patients are given the long-acting and safe replacement opioid: Methadone, itself a narcotic.
Factors Affecting Doctors’ Prescribing of New Medications
Everett Rogers’ Diffusion of Innovations theory provides a framework for understanding early adopters, or pioneer physicians willing to try a medication they haven’t used before. It emphasizes their role as innovators and opinion leaders, influencing “early majority” prescribers to follow suit. This is where the breakdown occurred for addiction medications.
The likelihood of MDs trying and integrating a new treatment for obesity or AUD (or for OUD) depends on five factors. First is the perceived benefit of doing something different from the usual, whether the usual is doing nothing or telling patients to go to AA or NA. Next, what is the specific advantage to prescribing this addiction med, from the physician’s perspective? Next is how prescribing this new treatment is compatible and aligns with the doctor’s values, experiences, and needs. Next, how hard is it for MDs to understand how to prescribe this medication to these patients? Another key factor is how easy it is to prescribe, try it on patients, and see the benefits firsthand. Lastly, are the new med’s positive results observable to others?
Why Aren’t Addiction Meds Big Hits?
A key issue in answering why medications for people with AUDs continue to be a very tough sell is all the finger-pointing-blaming the patients and doctors. These are old medicines, with a long history of disappointing physician early adopters. Medicines for OUD aside, I’d blame the AUD medicines themselves. Even the positive outcomes described for AUD medicines seem tone-deaf. The idea of paying out-of-pocket and taking a pill every day to drink less may also not align with the patient, employer, or family and has failed to convince patients or doctors for the last 20 or more years.
I asked our nation’s first Drug Czar and the Founding Director of the National Institute of Drug Abuse (NIDA), Bob Dupont, for his opinion. He said, “It does not make sense to me to think drinking less is an acceptable outcome for alcoholics when everyone else is trying not to drink alcohol. Nor does it make any sense in drug addiction treatment for people with SUDs.”
Adds DuPont, “There are some people who can stop using drugs, including alcohol, on their own when their use causes them and others problems.” In contrast, addiction is a problem that persists, along with an unwillingness or inability to stop drug or alcohol use. “It’s the hijacked brain,” explains Dupont, defining the underlying problem.
Summary
The recent success of GLP-1 drugs in treating obesity is a reminder that even when a disease itself is perceived as a failure of control or “willpower,” and patients are stigmatized and only treated by a few physicians—as with obesity—a new effective treatment changes the paradigm. The first adopters were obesity medicine specialists and researchers in academia. All of a sudden, every doctor seems to be excited to evaluate and treat patients with obesity and Type 2 diabetes. Everett Rogers’ theory of adoption helped explain how Ozempic, the first GLP-1, was 396th among prescribed medications in 2018 but in the top 50 by 2022.
These GLP-1 drugs are potential treatments for AUD and other issues that have flummoxed experts for years, like gambling and other behavioral addictions. So, we may find that we are entering a new era of medication therapy adoption of safe and effective AUD treatments that are both prescribed and actually taken by patients.
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