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Brian Lehrer: It's the Brian Lehrer Show on WNYC. Good morning again, everyone. Alcohol overuse causes 140,000 American deaths annually, according to the National Institutes of Health. That's more than drug overdoses, guns, or car accidents. While other substance use disorders are considered public health problems, the alcohol industry is only growing. It generated $260 billion in revenue in 2022, the last year for which stats are available. That's according to Park Street, an alcohol industry consulting service.

For decades, alcohol use disorder has been seen as a type of moral failing, but new scientific consensus is forming around it being a brain disease. As a brain disease, medical professionals have started to see a range in alcohol overuse treatments. Viewing it that way can be helpful in treating it, especially with medication. Doctors rarely prescribe these medications. However, only 2% of people with alcohol use disorder get medication for it, according to the stats that I've read.

Joining us now to discuss her recent reporting on alcohol use disorder and how it can be treated with medication, including, yes, Ozempic, is Rachel DuRose, Editorial Production Coordinator at the Harvard Business Review. She's a former Vox Future Perfect Fellow, where she wrote an article titled Alcohol Overuse Causes 140,000 American Deaths Annually. Why Is It So Undertreated? Rachel, welcome to WNYC.

Rachel DuRose: Thank you. Thank you for having me today to speak about this topic.

Brian Lehrer: You write that alcohol is "a psychoactive, addictive drug", one linked to over 50 fatal conditions and contributing to the death of 140,000 people in the US annually. What has the research shown is linked to alcohol overuse?

Rachel DuRose: Alcohol overuse, as you just said, is linked to many, many conditions, primarily liver disease, cancers of the stomach and mouth, hypertension, stroke, heart disease, and even breast cancer. Women are actually at an increased risk for heart damage and breast cancer even from lower levels of drinking. Unfortunately, in recent years, the rate of alcohol-related deaths among women specifically is rising at a faster rate compared to men in the US.

Brian Lehrer: The National Institutes of Health defines light drinking as less than 15 drinks a week for men or 8 drinks a week for women, and even that has been linked to certain types of diseases, right?

Rachel DuRose: Yes, absolutely. As I just mentioned, women are more susceptible to certain diseases even at lower consumption levels over longer periods of time. Specifically, the risk of breast cancer goes up, some studies say, by 30% to 50% for women who moderately drink. Also, outside of diseases, even light drinking impairs someone's judgment and perception. Incidents like falling or a car accident, if you choose to get behind the wheel, can also lead to harm from even light levels of drinking.

Brian Lehrer: You write that while America treats other dangerous substances, such as opioids, as a public health problem, alcohol use is not treated similarly as a crisis legally, medically, or culturally. I imagine you don't want to go back to prohibition. How do you think we should be looking at and regulating alcohol?

Rachel DuRose: Absolutely, we're not going back to prohibition. We know that doesn't work, but something that we do know works is taxes. Alcohol taxes are a very effective public health intervention when it comes to reducing the harm from alcohol. German Lopez, a former reporter with Vox, who's now at The New York Times, wrote an article for Vox in 2018, arguing for increasing the tax of alcohol. At the time, Congress had effectively cut the tax by 16%. Over the last two decades, the alcohol tax has reduced in value because of things like inflation.

At the end of last year, even the World Health Organization came out and called on countries to increase their taxes on alcoholic beverages. They cited a 2017 study that showed that taxes that increased alcohol prices by 50% could avert 21 million deaths over 50 years and generate $17 trillion in revenue. It's taxes as well as just increasing awareness around AUD, awareness of what treatment options are out there so that people are comfortable disclosing if they have AUD, comfortable disclosing to their doctors and their community and getting that necessary treatment.

Brian Lehrer: Right. What about cultural attitudes toward alcohol? How do you view them and how do you think they need to change, if at all?

Rachel DuRose: Culturally, alcohol is pretty ingrained in our society. Obviously, the laws vary a bit state by state, but you can find alcohol in gas stations and even in some places, drive-thrus. While we've normalized alcohol, if we're going to normalize alcohol in the way we have, we also, as I hinted at earlier, we need to normalize talking about when it becomes a problem, when someone is experiencing AUD.

One of the biggest issues we're facing when it comes to treatment is, well, it's normal now to go into an annual physical and be asked, how many drinks do you have per week? You're not being asked what type of alcohol you're consuming, and you're not really being asked the questions that are used as the criteria for diagnosing AUD because not many physicians are trained in addiction medicine. It's really about promoting and getting more awareness out there among the community but also within the healthcare community as well so that AUD is more easily diagnosable and more readily talked about and treated.

Brian Lehrer: Listeners, if you're just joining us, we're talking about AUD, alcohol use disorder, with Rachel DuRose, editorial production coordinator at the Harvard Business Review. She wrote an article as a former Vox Future Perfect Fellow called Alcohol Overuse Causes 140,000 American Deaths Annually. Why Is It So Undertreated? Moving now into the part of the conversation where we're going to talk about some of these medications that you say are being underused, we're actually going to take a phone call from Francis in Mount Vernon, who says they are an addiction psychiatrist and does sometimes prescribe one of these things. Francis, you're on WNYC. Thank you for calling in.

Francis: Hi, Brian. I'm actually a general psychiatrist, but I'm board-certified in a couple of specialties. I called in about Adderall about a month ago.

Brian Lehrer: Great.

Francis: Absolutely. I just wanted to amplify the message today that not everyone, but a lot of patients, if I tell them that the two ones I use the most, which is naltrexone and acamprosate, also known as Campral, they're non-toxic, and it doesn't help everyone but it's certainly worth a try.

I remember a big review article that came out a few years ago, surprised to me that there was actually no level of drinking that did not increase cancer risk. Both people have a formal diagnosis of alcoholism. Online, there's a guy started a company online to try to get people to take naltrexone. It's like advertisements people trying to get them because there's very little to lose by trying this treatment. I have one person who, four years ago, started taking both at the same time, and he instantly stopped drinking. He was about to lose his job as a contractor, and he just praises me every three months when I see him.

Brian Lehrer: You're talking about naltrexone and the other one was called the acamprosate?

Francis: The old brand name is Campral, C-A-M-P-R-A-L, and the generic is acamprosate.

Brian Lehrer: Do you want to talk at all from your clinical experience about the mechanisms? How do these drugs help somebody stop drinking?

Francis: Yes, so naltrexone works a little bit like Chantix. You take it, and for people who are genetically predisposed to get kind of a high or euphoric response from drinking. This is a marginal effect. It doesn't eliminate drinking altogether, but you just feel that you don't get as much out of it, so you don't drink as much. Obviously, this doesn't work for everyone who's committed to getting a nice buzz, but if you can get to take the pill, you'll probably drink less.

Acamprosate, on the other hand, works in the brain's glutamate system, and the glutamate system is on overdrive when you're feeling withdrawal symptoms, so it takes the edge off of that craving. They're both listed as anti-craving medicines and they're massively under-prescribed. We think that to medicalize the disorder, you would want more proper treatments and more people to know about it and seek proper treatment.

Brian Lehrer: Francis, thank you.

Francis: A lot of times, it just helps people moderately.

Brian Lehrer: Thank you very much for calling in, again, with a very informative take, given your professional relationship to substance use disorders. Anyone else want to call in with your personal story from any aspect of this or with a question for our guest? 212-433-WNYC, 212-433-9692. Rachel, what were you thinking listening to Dr. Francis there?

Rachel DuRose: I think it sounded a lot like everything I was hearing from the experts I spoke to when I was working on my article. All of the doctors I spoke to while writing it were just surprised and disappointed at how underprescribed these medications still are. They also did want to emphasize that these medications are not a silver bullet alone. They are not as effective in treating someone as when you combine the medication with either social support groups like Alcoholics Anonymous or with traditional forms of therapy. Really, when addressing AUD, most of the experts I spoke to emphasized this approach of pulling in different parts of treatment and finding a treatment path that works for the individual.

Brian Lehrer: Another doctor told us off the air that she would never prescribe meds for alcohol use disorder because-- or almost never, that they are for only the most severe alcohol abuse cases. These drugs are tough on the liver. I wonder if you have any thoughts on that from your research.

Rachel DuRose: Well, there is some research showing that some of these drugs are hard on the liver. The experts I spoke to emphasized that alcohol is also hard on the liver. As the person who wrote and said because alcohol is-- it's used in only the most extreme cases, these medications oftentimes. In the most extreme cases, the people being prescribed this are possibly already causing damage to their liver through their alcohol consumption.

Additionally, some of the research I found showed that the risk of this liver damage was minimal. Also, most of these medications are prescribed for short periods of time, six months at a time, for example. Really, it's the chronic use of these medications that seems to result in liver damage from what I found.

Brian Lehrer: Here's another addiction medicine doc calling in. Lipi in Manhattan, you're on WNYC. Hi, Lipi.

Lipi: Hi, Brian. Thanks so much for having me on. For the past decade, I've had the honor of caring for patients with various substance use disorders, including alcohol use disorder. Look, at the end of the day, it's a tough condition. It's a tough disease to treat, but the good news is that studies show that most people who are connected to the appropriate treatment and care get better. The problem we're facing, and Rachel has clearly seen this in her research, is that most people don't access care. A large barrier to that is stigma, stigma towards people who have an alcohol problem. People still associate it as a moral failing or a moral weakness. That's part of it.

The other problem is that most people, again, Rachel pointed this out, most healthcare professionals, doctors like me, do not learn about addiction in their medical training. I learned about it on the job when I became an addiction medicine boarded physician when my primary care patients in Boston-- Boston has a homeless population. The leading cause of death was drug overdose. Yes, opioids certainly are getting a lot of attention, but alcohol actually kills more people than opioids do. Medications really do help.

I know, as somebody else mentioned, that they avoid prescribing naltrexone or medications because of the damage to the liver. Yes, some of these medications can have liver toxicity. However, again, as Rachel pointed out, alcohol is far, far more harmful. Naltrexone, which is perhaps one of the best of the medications, actually can be very effective. You just have to have that examination with the doctor to look at your liver function tests, and then go from there. I agree, medications, along with counseling, behavioral therapies, and strong support can really make a difference and help people achieve long-term recovery.

Brian Lehrer: Doctor, I'm curious if you've considered Ozempic for this because it's been in the news as something that can also block addictive behaviors.

Lipi: I'm so glad you brought that up, Brian. A lot of people are asking about Ozempic. Here's the short answer to that. I think that we need a lot more research to look at this. I'm all for all possible treatments and treatment options. It could be considered off-label use for now because, as you know, Ozempic right now is for patients with diabetes and obesity. However, there is some promising outcomes possibly for Ozempic in the use of addictive disorders. I just think we need a little bit more research targeted to individuals who have a substance use disorder, but I think there's promise in there. I just would not use it until we have a little bit more data on that, Brian.

Brian Lehrer: Thank you so much for calling in and all that context, Dr. Lipi from Manhattan. Rachel, what were you thinking as you were listening to her? I think your article does touch on Ozempic also, right?

Rachel DuRose: It does mention Ozempic, and I'm glad you brought it up now because something I wanted to mention is that most of the professionals I spoke to, while they're hopeful for the idea that there could be more medicines including Ozempic that could treat AUD, they also wanted to emphasize that we have three FDA-approved existing medicines that do seem to work. Really, the first hurdle that we should be addressing at the moment is getting people more access to these medications, getting greater access to other treatment methods, and investing in those systems that already exist, those medicines that already exist before trying to use something that hasn't been tested as thoroughly to try to treat this disorder.

Brian Lehrer: Michelle in South Carolina, you're on WNYC. Hi, Michelle.

Michelle: Hi. I am a 58-year-old female, married, with a 12-year-old. I'm educated, I'm fit, and I have alcohol use disorder. It's pretty severe. I have wanted to stop for years and I've tried for years. I'm self-medicating with Antabuse right now. I haven't had a drink for seven days, but I have been in this predicament many, many times before. If I don't take it every day and two days go by, I will slip back into the old habit. I can go about five days before the medication starts to wear off. For some people, it's longer, like two weeks. I've had a couple of different--

Brian Lehrer: Is Antabuse a different medication than the ones we've been talking about?

Michelle: Yes. Did you want to ask your guest about it? They could probably explain it better than I can.

Brian Lehrer: Yes, I'll do that. Michelle, I think you're wanting to make a point about your experience and what others can learn from it. Is that right?

Michelle: I'm not sure what my point is. I guess so. I've never told anyone this except for my best friend. My husband knows, but we've never ever talked about it. It's at the point now where it's almost breaking up our marriage. We've been together for 22 years.

Brian Lehrer: It goes back a little bit to what the previous caller, the doctor, was saying, perhaps that stigma is one of the biggest problems, -

Michelle: Absolutely.

Brian Lehrer: - preventing people from getting treatment.

Michelle: 100%. Otherwise, I would've gone to rehab before. I've never told any of my doctors. I am taking other medication for depression, and I've been taking that for 25 years. The stigma, especially around a female having AUD, it's so shameful. It's true what the previous guest was saying about that you are looked at that you have moral failings that-- it's so different. I think that about myself. I just recently-- I still don't believe it, that it's a disease. I've been watching some YouTubes in the last week or so because I'm trying so hard this time. Like I said, I'm 58. I've been trying to quit since I was probably 20.

Brian Lehrer: Michelle, thank you for your openness on this. I think it's really helpful to other listeners that you called in and have been as open and articulate about it as you have. Thank you very much for your call. By the way, I see that Antabuse is, I guess, the commercial name for another drug that you also wrote about in your article, Rachel, Disulfiram.

Rachel DuRose: Yes. It was actually the first FDA-approved drug if I'm not mistaken. Most of the experts I spoke to said it was a second-line option because the way it works is it makes someone feel ill if they drink alcohol. For those who are really struggling, they'll sometimes go off the medication because they decide, "I want to be able to drink," and their disorder is really preventing them from staying on the medication.

I also want to thank the last caller for sharing their story. I think we keep emphasizing the need to end the stigma around the idea that alcohol overuse is a choice. One of the best ways to do that is by talking openly about it and being able to share and speak about having the disorder like we would with any other disorder or disease.

Brian Lehrer: Indeed. I think I misheard her on the name of the medication she's taking, so I'll say it correctly now. Antabuse. Not the way I said it in the previous comment. Delilah in Brooklyn, you're on WNYC. Hi, Delilah.

Delilah: Hi, Brian. I've called many times, listened to you every single day. I have a decent history of alcoholism in my family. My father died of some alcohol-related issues. I, from a very young age, had alcohol use disorder. I was a binge drinker. It would cause me health problems and I would just do stupid stuff. I was never one of those people that drank every day, but I tried so many times to quit. I went to outpatient rehab, I went to detox, tried so many different things, and I would always just fall back into honestly just social pressure, like you go to a wedding and they have a tray of champagne.

It's really hard when something is everywhere and everyone's doing it. I would be like, "Okay, I'm not going to drink at this wedding." Then half an hour in, it's like, "I can't do this. I'm going to have a drink." Then the next thing you know, you're drunk. I was prescribed Disulfiram Antabuse. I swear, I think it saved my life. I think it was the only possible way that I could have stopped drinking at the time I did. I took it as a pill. I did sometimes not take it and pretend I did so that I could secretly drink at an event, or sometimes I would take it and I'd be like, "Okay, I'm going to make myself throw up." Then I would just like have to mental through that and keep it down.

Once it's in your body, you can't drink for a couple days, and it's very freeing. It's like, "Okay, you know what? I took that pill this morning. I simply can't drink at this wedding. I can't give in." However, you can choose to not take the pill. That's the problem. I have a friend who recently got a shot of Disulfiram, so he can't drink for three months. I think I would've benefited greatly from that.

One thing I want to say is, because of the way I look, I've always held a job. I had so many doctors over the years in New York City say things to me like, "You can't be an alcoholic. Oh, no, you can't possibly need Antabuse. That's for really bad." I'd be like, "No, I want it. I do need it. I will drink if I don't have this pill." Don't look at me and judge and say, "Oh, no, you can do it." No, I'm telling you I can't. I need a pill.

Brian Lehrer: Because you look like functioning.

Delilah: My best intentions, I will still pick up that drink at the wedding. My best intentions to not drink at that wedding or at that party, if I don't have this pill in me, I will give in and drink when I see everyone else drinking. That pill, I believe, saved my life.

Brian Lehrer: Thank you so much. Another really helpful story for other people to hear. Again, we appreciate your candor opening up about something that's probably really difficult for you to talk about. We're just about out of time in the segment, Rachel. I guess as a closing point and relating to the last two amazing callers who we had, a big part of your article, or a big point of your article is that many more people could be getting these treatments that seem effective for our callers, and that's the nub of this, right?

Rachel DuRose: Absolutely. There's many reasons people aren't being treated. Some of it is the stigma from the community, from individuals who are suffering from AUD not wanting to admit that they're suffering and get that treatment. The other part is what we touched on, which is the lack of awareness, particularly within the medical community. Of the 940,000 physicians in the US, approximately 3,000 specialize in addiction medicine according to a study by the Association of American Medical Colleges. There's this hurdle that we need to overcome. There's awareness, both of the disorder itself and the treatment options that needs to be elevated both to the public and within the medical community.

Brian Lehrer: Rachel DuRose, now editorial production coordinator at the Harvard Business Review. Formerly a Vox Future Perfect Fellow, where she wrote the article we've been discussing titled, Alcohol Overuse Causes 140,000 American Deaths Annually. Why Is It So Undertreated? Thank you so much for coming on and prompting amazing calls from our listeners. Thank you very much.

Rachel DuRose: Thank you so much for having me.

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