Cornel N Stanciu, Thomas M Penders, Karl L Wuensch, Joshua Davis and Khalid Elnagar
Introduction: Alcohol is the third leading cause of preventable death worldwide. There is substantial risk for development of alcohol use disorder among those with psychiatric disorders, complicating their care. Despite extensive evidence in support from controlled trials and from expert opinion, medication-assisted treatment has had low levels of penetration in practice. Only 3% of sufferers receive FDA-approved treatment.
The goal of this survey is to explore potential causes of underutilization of evidence-based pharmacotherapeutical agents in the treatment of alcohol use. Secondary, we analyze differences in practice patterns between different academic institutions, facilities specializing in chemical dependence treatment, and general community practitioners. We are aware of no prior study that has attempted to evaluate these factors.
Methods: An online questionnaire was designed in Qualtrics and distributed through the use of an anonymous link. Target participants were members of the Psychiatry departments of four academic institutions in NC, community mental health providers, prescribers from chemical dependence treatment facilities, and Veteran Affairs psychiatrists. A total of 170 participated, an 85% response rate. Data was analyzed using Qualtrics software as well as by a statistician.
Results: A significant portion of psychiatric patients have comorbid alcohol use, and despite patient interest, medications are rarely utilized in both academic as well as chemical dependence facilities-20% of respondents never prescribed any. Reasons mainly include lack of provider knowledge of available medications (r=-0.277, n=136, p=0.001), prescribing guidelines (r=-0.265, n=136, p=0.002) and dosing (r=-0.245, n=136, p=0.004). Provider’s attitude towards substance use treatment also affects prescribing (r=-0.21, n=136, p=0.014). Those who do prescribe seem to favor off-label medications and avoid Naltrexone IM formulation. Providers acknowledge that the majority of those with alcohol use disorders have medical conditions caused or affected by the ongoing use. Instituting medications leads to positive experiences: patients maintain sobriety longer, have less legal problems and are better able to engage in their care.
Conclusion: In the treatment of alcohol use, guidelines recommend FDA approved medications in conjunction with bio psychosocial interventions. Global assessment indicates prescribers mainly avoid pharmacotherapy due to lack of comfort and knowledge. There may also be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Although it is recommended to start with FDA approved medications, off-label use is high. Despite positive implications noted when medications are instituted, providers’ ambivalence continues. As part of our daily practices, general psychiatrists should gain confidence in using evidence-based, FDA approved, medications in treatment of alcohol use disorders.