Why medications for AUD should be as popular as GLP-1 agonists for obesity

A recent commentary in the Journal of General Internal Medicine compared anti-obesity medications with medications for alcohol use disorder (AUD). Both chronic conditions are “characterized by behavioral patterns that pose risks of adverse health consequences” and “subject to societal stigma including … the idea that they reflect a lack of personal willpower.” While prescriptions for costly glucagon-like-peptide-1 (GLP-1) agonists for obesity such as semaglutide have skyrocketed, use of less expensive drugs for AUD remains low. The authors suggested that public perceptions that the latter are ineffective or unnecessary, implicit biases of clinicians, and delayed health benefits of alcohol cessation compared to weight loss contribute to the differences in use.

Given the magnitude of the problem, which worsened during the pandemic, an American College of Physicians policy brief advocated “training, payment, and delivery system policies to enable physicians and other qualified health professionals to screen, diagnose, and treat excessive alcohol use and AUD.” Recognizing patients with excessive alcohol use remains a challenge despite a U.S. Preventive Task Force recommendation to routinely screen adults, including pregnant patients, for unhealthy alcohol use and provide brief behavioral counseling interventions to persons engaged in risky or hazardous drinking.

A systematic review in JAMA’s Rational Clinical Examination series concluded that the Alcohol Use Disorders Identification Test (AUDIT) is most the useful tool for identifying AUD in adults and postpartum individuals, while the abbreviated AUDIT-Consumption (AUDIT-C) best identifies excessive alcohol use in children aged 9 to 18 years and older adults. Other studies have found that a single question alcohol screen (“How many times in the past year have you had five (men)/four (women) or more drinks in a day?”) is comparable to the AUDIT-C in detecting unhealthy alcohol use and current AUD in primary care.

Articles in the January 2024 and May 2024 issues of American Family Physician discussed FDA-approved and off-label pharmacotherapies for adults with AUD. According to an Agency for Healthcare Research and Quality review, oral naltrexone, acamprosate, and topiramate have the strongest evidence for reducing alcohol consumption, while injectable naltrexone, baclofen, and gabapentin have weaker supporting evidence. Of the two first-line treatments approved by the FDA for AUD, acamprosate is contraindicated in patients with a creatinine clearance of ≤ 30 mL/min, while naltrexone should be avoided in patients who use opioids or have advanced liver disease. Disulfiram is not more effective than placebo in reducing alcohol consumption.

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This post first appeared on the AFP Community Blog.