Alcohol Use Disorder

Alcohol occupies a strange place in American life: it's legal, everywhere, and woven into celebration — and it's also the substance responsible for more health harm than any other in New Hampshire. Surveys consistently place northern New England among the regions with the country's higher rates of binge drinking, so if alcohol has become a problem for you or someone you love, you are in very large company.

Modern medicine understands alcohol use disorder as exactly that — a disorder, with recognizable brain changes, genetic and environmental risk factors, and effective treatments. It is not a weakness of will or a moral failing, any more than diabetes is. That reframing matters, because shame is one of the main reasons people wait years longer than they need to before getting help. For the broader science of how substance use disorders develop and heal, see our companion article on understanding substance use.

The DSM-5 defines alcohol use disorder by 11 criteria — things like drinking more or longer than intended, unsuccessful attempts to cut down, craving, continuing despite consequences, and needing more to get the same effect. Meeting 2–3 criteria in a year is mild AUD, 4–5 is moderate, and 6 or more is severe. There's no single line between "fine" and "alcoholic" — it's a continuum, and people move along it in both directions.

That continuum includes what many people call "gray-area drinking": drinking that doesn't meet criteria for a disorder but that nags at you — the nightly glasses that crept up, the mornings you regret, the quiet bargains about cutting back. Gray-area drinking is real, common, and a completely legitimate reason to take stock. You do not need a diagnosis to decide your relationship with alcohol could be better.

One of the most damaging ideas in popular culture is that a person has to "hit rock bottom" before help can work. The research says the opposite: like most health conditions, AUD is easier to treat earlier, before consequences pile up and drinking becomes more entrenched. Waiting for a catastrophe isn't a treatment strategy — it's just a catastrophe.

The outlook is also far better than most people assume. National survey data show that most people who develop AUD improve or recover, and many do so without ever entering formal treatment — through their own efforts, community support, or life changes. Treatment stacks the odds further in your favor; it's an accelerant, not a last resort.

It's also normal to feel two ways about changing. Wanting to drink less andnot wanting to give it up is not denial — it's ambivalence, and it's where nearly everyone starts. Good clinicians expect it and work with it rather than arguing against it. You don't have to be 100% sure to take a first step like a screening, a conversation with your doctor, or a single meeting.

AUD has a genuinely strong evidence base — the problem is that most people never hear about it. Three medications are FDA-approved for alcohol use disorder:

• Naltrexone — a daily pill (or monthly injection) that blunts the rewarding effect of alcohol and reduces heavy drinking days and craving.
• Acamprosate — helps the brain re-stabilize after stopping, supporting abstinence and easing the restlessness and unease that follow quitting.
• Disulfiram — creates an unpleasant reaction if alcohol is consumed; a deterrent that works best with supervision and strong motivation.

The landmark COMBINE trial— one of the largest studies ever conducted on alcohol treatment — found that naltrexone delivered with straightforward medical management in a doctor's office worked about as well as specialist behavioral therapy. In other words, effective treatment can start with an ordinary primary care visit. Meta-analyses since have confirmed that naltrexone and acamprosate meaningfully reduce return to drinking.

Behavioral treatments carry equally solid evidence: cognitive behavioral therapy (identifying triggers and building coping skills), motivational interviewing (resolving ambivalence by drawing out your own reasons for change), and contingency management (structured rewards for recovery goals). Depending on severity and personal preference, goals can be abstinence or moderation — for milder AUD, cutting back is a legitimate, evidence-supported target, while abstinence tends to be the safer goal for severe AUD.

For decades, researchers were politely skeptical of Alcoholics Anonymous. That changed with a rigorous 2020 Cochrane review, which found that AA and clinically delivered twelve-step facilitation performed as well as or better than established therapies like CBT for sustaining abstinence — and at essentially no cost. The active ingredients appear to be very human ones: connection, accountability, structure, and spending time with people who are further down the same road.

AA isn't the only option. SMART Recovery offers a secular, skills-based alternative grounded in CBT and motivational principles, with meetings online and around New Hampshire. Recovery community organizationsacross the state host peer support, recovery coaching, and sober social events. The research is pragmatic on this point: the best mutual-help group is the one you'll actually attend. It's fine to shop around — every meeting has its own personality.

If you love someone whose drinking worries you, you've probably heard that you should stage a dramatic confrontation, or that there's "nothing you can do until they're ready." Neither is true. The best-studied family approach is CRAFT (Community Reinforcement and Family Training), which teaches family members to reinforce sober behavior, allow natural consequences, improve communication, and invite the person toward help at receptive moments — all while taking care of themselves. In trials, CRAFT got roughly two-thirds of initially treatment-refusing loved ones into treatment, far outperforming confrontational interventions.

Two companion reads may help: supporting a loved one covers communication and boundaries without burning out, and harm reductionexplains how to keep someone safer even while they're still drinking.

New Hampshire has a single front door for substance use services: The Doorway. Dial 211 from anywhere in the state to be connected with screening, treatment referrals, and recovery supports near you — no insurance required to ask. The SAMHSA National Helpline at 1-800-662-4357 is a free, confidential, 24/7 national line for treatment referrals. And many NH therapists treat alcohol use directly alongside the anxiety, depression, or trauma that often travels with it.