Three medicines treat alcohol use disorder, and almost nobody is offered them

Most people picture one treatment for a drinking problem: a room, a circle of
chairs, and a commitment to stop. Support groups such as Alcoholics Anonymous
genuinely help, and people in treatment are encouraged to attend. But they are
one part of a treatment plan, and the part most often left out is
pharmacological — three medicines are approved for alcohol use disorder,
and each attacks a different link in the chain.

First, what the condition is. An alcohol use disorder is drinking that causes
distress and harm: drinking compulsively, being unable to control how much,
and feeling anxious, irritable or stressed when not drinking. It ranges from
mild to severe depending on how many of those symptoms are present. Severe AUD
is what older language called alcoholism or alcohol dependence.

The three medicines, and what each one does

Two points that stop people taking them. They are not addictive, so there
is no question of trading one dependence for another. And they are not a cure:
they manage a chronic condition, in the same way that medicines manage asthma
or diabetes. Neither of those framings is a lowering of ambition — it is how
most long-term conditions are treated.

The therapies, and how they differ

Behavioural therapy — "alcohol counselling" — means working with a
professional to identify and change the behaviours that lead to heavy
drinking. The four main forms are not interchangeable:

• Cognitive behavioural therapy identifies the feelings and situations
  that precede heavy drinking and teaches coping skills: managing stress, and
  changing the thoughts that produce the want. One-to-one or in small groups.
• Motivational enhancement therapy is short — about four sessions. It
  starts by listing the pros and cons of seeking treatment at all, then builds
  a plan, then builds the confidence and skills to hold to it.
• Marital and family counselling brings in spouses and family. Studies
  show strong family support through family therapy helps people stay away
  from drinking, so repairing those relationships is treatment rather than an
  adjunct to it.
• Brief interventions are one to four short sessions: information about
  your own drinking pattern and its risks, then goals set with a counsellor.

For many people the best results come from using medicine and therapy,
not choosing between them. Where the disorder is severe, a residential
rehabilitation centre provides a highly structured version of the same
things, plus medical treatment for withdrawal.

Relapse is part of the process

Overcoming an alcohol use disorder is ongoing, and many people try to cut back
or quit, have a setback, and try again. A relapse does not mean recovery is
impossible. What it means is: return to treatment straight away, so that the
triggers behind it get identified and the coping skills improve. People who
treat a relapse as a failure tend to stop; people who treat it as information
tend to succeed the next time.

If a mental illness is present alongside the AUD, both need treating. Treating
only one leaves the other driving.

Source: National Institute on Alcohol Abuse and Alcoholism, via MedlinePlus.