For people diagnosed with alcohol use disorder (AUD), the traditional therapeutic goal has long been total abstinence. It’s a time-tested approach that, for many people, continues to be the best solution.
It is, however, no longer the only solution. Increasingly, research is showing that substantially reducing alcohol consumption short of abstinence can yield meaningful improvements in health and functioning, and abstinence may not be necessary for all individuals, according to Yale addiction specialist Stephanie O’Malley.
In current AUD treatment, many clinicians now tailor treatments that fit individuals and their specific needs, explained O’Malley, the Elizabeth Mears and House Jameson Professor of Psychiatry at Yale School of Medicine. The biggest obstacle, however, continues to be getting people to seek help in the first place — something that O’Malley says the shift in treatment goals may help.
Our hope is that if there is greater recognition that reductions in drinking are an acceptable outcome for many people, then more people will access treatment.
“Unfortunately, rates of treatment-seeking are very low, and I think it’s partly because many people assume that abstinence is the only goal in treatment,” O’Malley said. “Our hope is that if there is greater recognition that reductions in drinking are an acceptable outcome for many people, then more people will access treatment.”
O’Malley is on the editorial board of JAMA Psychiatry and is a past member of the Data and Safety Monitoring Board for the Clinical Trials Network of the National Institute on Drug Abuse. A consultant to pharmaceutical companies, O’Malley is also a member of the American Society of Clinical Psychopharmacology’s Alcohol Clinical Trial Initiative, a public-private partnership working to improve methods for clinical trials.
Last year, O’Malley co-authored a review of 34 published papers which concluded that reducing alcohol consumption by at least one or two identified World Health Organization (WHO) risk-drinking levels is associated with a cascade of improvements in health and functioning. The WHO risk-drinking levels include very high, high, moderate, low, and no risk (abstinence) alcohol consumption, based on average drinks or grams of alcohol consumed, with different cut-offs specified for men and women.
“While abstinence represents the lowest risk, the finding that a large proportion of individuals with AUD can achieve and maintain clinically meaningful reductions in their drinking short of abstinence is encouraging,” O’Malley said.
In a recent interview, O’Malley discussed evolving treatments for alcohol use disorder, the promise of new medications, and why not everyone needs to fully abstain.
This conversation had been edited for length and clarity.
What You Need To Know
What do people need to understand about treatment for alcohol use disorders today?
While abstinence remains an important treatment option, a more individualized treatment approach now supports reductions in drinking for patients who don’t need to abstain completely. A host of therapies and medications are available, with new ones on the horizon.
What is a good resource to learn more about drinking?
The National Institute on Alcohol Abuse and Alcoholism provides an online tool, “Rethinking Drinking,” that people can use to evaluate their drinking, develop a plan to change their drinking, and learn strategies for reducing alcohol consumption.
Can you talk about the traditional objective in treating alcohol use disorder?
Stephanie O’Malley: Abstinence was historically the primary goal of treatment for anyone dealing with problematic alcohol use, and it still is in some programs. Moving toward more differentiated treatments has been a long process. However, increasing evidence suggests that reductions in drinking also benefit a person’s wellbeing and health, even when abstinence isn’t, or doesn’t need to be, the goal.
In addition, researchers are trying to better understand the characteristics of individuals that can predict whether they will respond to one treatment or to another. Research is also ongoing into new and repurposed medications. In 2025, the U.S. Food and Drug Administration qualified a new drinking reduction endpoint for clinical trials of medications to treat AUD, a step that could accelerate the development of new treatments.
What is the present rate of AUD in the United States?
O’Malley: The percentage of people ages 12 and older who met criteria for AUD in the prior year has decreased somewhat, from 10.6% in 2021 to 9.7% in 2024. Thus, the most recent data suggests approximately 29.5 million individuals [in the U.S.] meet the criteria for alcohol use disorder, so it’s a large percentage of the population. Within this population, individuals may be diagnosed with mild, moderate, or severe AUD, and they may have different treatment needs. Of individuals with AUD, less than 20% meet criteria for severe AUD.
When did the move toward more individualized treatment begin?
O’Malley: In the past, it was very controversial to claim that it was possible for people with AUD to reduce their drinking without being fully abstinent. Over the years, however, research into the effectiveness of treatment has provided evidence that drinking reduction outcomes, short of abstinence, are possible. For example, studies of naltrexone [an FDA-approved prescription medication used to treat AUD] at Yale and the University of Pennsylvania found that naltrexone helped people reduce the amount that they drank when they consumed any alcohol. In our 2025 review, we found that reductions in drinking were associated with improvements in how patients feel and function, not only in the immediate term but ongoing, and many more people were able to successfully reduce as opposed to totally abstaining.
What part should primary care physicians play in screening?
O’Malley: Primary care providers play an important frontline role in assessing AUD risk. In some health care systems, they already routinely ask patients about alcohol use. There are now studies showing that if a medical care provider asks a patient about their drinking and determines that it is risky, patients will listen to feedback. As a group, research suggests that patients are responsive to advice to change their drinking and show measurable improvements. Often, they have been thinking about their drinking already, so having a medical care provider broach the topic and discuss the benefits of reducing their drinking can be very useful.
What factors indicate the best course of treatment for AUD?
O’Malley: Determining the best course of treatment involves several considerations, such as assessing the level of physical dependence on alcohol, the availability of social support, and other health and psychiatric concerns. Another important factor is understanding what the patient is concerned about. If you know this, you can link specific benefits to their concerns to promote motivation to change. For example, if they’re not sleeping well, you can link reductions in drinking to improvements in sleeping that can occur when people reduce their drinking and explain why. Doing an analysis of a person’s situation lets you problem solve and tailor treatments.
And there are many treatments available today?
O’Malley: Many people are only familiar with the fellowship of Alcoholics Anonymous, which supports abstinence. Twelve-step facilitation therapy is one form of formal treatment that supports participation in mutual self-help groups like Alcoholics Anonymous. But there are other treatments like motivational enhancement therapy for people who are on the fence about wanting to change their drinking, cognitive behavioral therapies that teach new coping skills, and therapies that promote mindfulness to avoid relapse, among others. There are a range of programs and medications that can be provided on an outpatient basis.
What medications are currently being used?
O’Malley: The Food and Drug Administration has approved three for AUD: acamprosate, disulfiram, and naltrexone. They all act in different ways. But there are also medications that are being used off-label with success. And there is increasing interest in the GLP-1 receptor agonists, some of which are FDA-approved for weight management. Recent small clinical trials suggest that they may also reduce alcohol consumption among individuals with AUD. Trials are ongoing to determine just how effective GLP-1s may be.
As you’ve said, the first step is getting people into treatment. What are some of the overlooked signs that someone may have a drinking problem?
O’Malley: It is important that people realize that even if their drinking doesn’t meet the standard of a “disorder,” drinking at high levels can still be problematic for their health and functioning. Some indications of a problem include when drinking takes up more time to the exclusion of other activities — so, coming home and not going outside and hanging out with your kids, but being more likely to sit in front of the TV and drink. Another is having difficulty controlling the amount you drink. So, you might decide, “Tonight I’m not going to have anything to drink,” or “I’m just going to have one or two,” and then you find that it’s difficult to do. Basically, drinking more than you intended, for longer than you intended, is a warning signal.
