Closing the Gap on Alcohol Use Disorder One Conversation at a Time

Addiction medicine expert Joseph Volpicelli, M.D., Ph.D., executive director of the Institute of Addiction Medicine, is pushing back against one of the most persistent myths in the field: that people with alcohol use disorder need to hit rock bottom before they can get better. For some people, he notes plainly, rock bottom is death.

The good news is that treatment has changed significantly, and Volpicelli wants more people to know it. The old model, checking into a 28-day rehab program, committing to total abstinence and attending daily meetings for months, is no longer the only path forward. For people who catch the problem early, there are more flexible, less disruptive options that can fit into everyday life.

Chief among them is naltrexone, a U.S. Food and Drug Administration (FDA)-approved medication that has been available for 30 years but remains staggeringly underutilized. Naltrexone works by quieting what Volpicelli describes as the noise in the brain, the persistent pull toward drinking that crowds out other pleasures and makes moderation feel impossible. For some patients, the goal is complete abstinence without the constant mental battle of white-knuckling sobriety. For others, it is moderation, taking a pill before drinking to prevent a session from spiraling out of control. Both are legitimate treatment goals, and naltrexone can support either.

Despite being available for three decades, less than 1% of people in treatment for alcohol use disorder were receiving any FDA-approved medication for the first 20 years after naltrexone's approval. That number has climbed to about 2.5% today, and among people actively in treatment, roughly 25% are now being offered the medication. Progress, Volpicelli says, but still woefully insufficient.

Interestingly, much of that progress has come from patients themselves. A grassroots movement of people who heard about naltrexone through podcasts, TED talks and online communities began bringing it to their doctors directly, driving awareness from the ground up rather than the top down.

Volpicelli's survey of people in treatment found that on average, half of respondents waited between five and 10 years between first recognizing they had a problem and actually seeking help. Closing that gap, he says, starts with a single conversation. Talk to your doctor. If your doctor does not bring it up, bring it up yourself.