Social Position Tied to Alcohol Use Disorder Therapy Success – Medscape

Report on Socioeconomic Disparities in Alcohol Use Disorder Treatment and Implications for Sustainable Development Goals

Executive Summary

A prospective register-based cohort study conducted in Sweden reveals significant disparities in the effectiveness of pharmacotherapy for Alcohol Use Disorder (AUD) based on socioeconomic position (SEP). The findings indicate that while medication is effective for individuals with a high SEP, it offers no significant benefit to those in low and middle SEP groups. This disparity directly challenges the principles of Sustainable Development Goal 3 (Good Health and Well-being) and Sustainable Development Goal 10 (Reduced Inequalities), highlighting systemic barriers to equitable healthcare outcomes.

Introduction: Aligning AUD Treatment with Global Health Goals

Achieving SDG 3, which aims to ensure healthy lives and promote well-being for all, includes Target 3.5: “Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.” This study investigates the real-world effectiveness of AUD pharmacotherapy, a key strategy for meeting this target. However, the results expose a critical intersection with SDG 10, which calls for reducing inequality within and among countries. The research demonstrates that access to effective treatment is not uniform, and socioeconomic status remains a powerful determinant of health outcomes, undermining the goal of universal health coverage.

Methodological Framework

• Study Design: A prospective register-based cohort study was conducted in Sweden.
• Participant Cohort: The study included 148,626 individuals aged 16-64 who received a first-time AUD diagnosis between 2005 and 2019.
• Socioeconomic Position (SEP) Metric: SEP was determined by the highest level of educational attainment, a key indicator linked to SDG 4 (Quality Education). Participants were categorized into three groups:
  1. Low SEP (≤ 9 years of education)
  2. Middle SEP (10-12 years of education)
  3. High SEP (> 12 years of education)
• Primary Outcome and Exposure: The primary outcome measured was AUD-related hospitalization. The exposure was the time-varying use of four approved AUD pharmacotherapies: acamprosate, disulfiram, nalmefene, and naltrexone.
• Statistical Analysis: Subdistribution hazard ratios (SHRs) were calculated, adjusting for sociodemographic factors and other medications, to assess the risk of hospitalization.

Key Findings: A Challenge to SDG 3 and SDG 10

The study’s results reveal a stark divide in treatment efficacy, directly impeding progress towards inclusive health and well-being as outlined in the SDGs.

• Disparity in Treatment Efficacy: Pharmacotherapy was associated with a 17% reduced risk for AUD-related hospitalization (SHR, 0.83) exclusively in the high SEP group.
• Ineffectiveness for Lower SEP Groups: For individuals in the low SEP (SHR, 1.02) and middle SEP (SHR, 1.01) groups, pharmacotherapy showed no statistically significant effect on reducing hospitalization risk compared to the reference group (low SEP individuals not using pharmacotherapy).
• Unequal Treatment Uptake: A higher proportion of individuals in the high SEP group (52.5%) utilized pharmacotherapy compared to those in the low SEP group (41.5%), indicating disparities in treatment access.
• Interaction Effect: Additive interaction analysis confirmed that approximately 10% of the risk reduction in the high SEP group was attributable to the positive interaction between high SEP and pharmacotherapy use.

Analysis of Disparities and SDG Implications

The findings underscore that providing medical treatments is insufficient to guarantee equitable health outcomes. The failure of pharmacotherapy to benefit lower SEP groups suggests that underlying social determinants of health critically impact medical efficacy. This reality presents a major obstacle to achieving SDG 3, as its targets for substance abuse treatment cannot be met if interventions only work for the socioeconomically advantaged. Furthermore, this evidence directly illustrates the health-related inequalities that SDG 10 aims to eliminate. The study implies a need for integrated care models that combine pharmacotherapy with psychosocial support, tailored to overcome the barriers faced by individuals with lower educational attainment and socioeconomic resources.

Study Limitations

• Potential for selection bias due to the exclusion of individuals with incomplete SEP data.
• Risk of exposure misclassification from using prescription drug register data, which does not confirm adherence.
• The scope was limited to four specific medications, potentially misclassifying users of other treatments.
• Data on medications administered directly in clinical settings may have been missed.

Conclusion and Recommendations for Equitable Health Outcomes

This report concludes that socioeconomic position is a critical factor in the effectiveness of AUD pharmacotherapy in Sweden. The observed disparities highlight a failure to provide equitable healthcare and undermine progress towards Sustainable Development Goals 3 and 10. To ensure that health interventions “leave no one behind,” it is imperative to investigate and address the social and systemic factors that create these inequalities. Further research into the role of combined psychosocial and pharmacological treatments across different socioeconomic strata is essential for developing policies that promote genuine health equity for all.

SDGs Addressed in the Article

SDG 3: Good Health and Well-being

• The article’s central theme is health, specifically focusing on Alcohol Use Disorder (AUD), a major public health concern. It examines the effectiveness of pharmacotherapy in treating this disorder, which directly aligns with the goal of ensuring healthy lives and promoting well-being. The primary outcome measured, “AUD-related hospitalisation,” is a key health metric.

SDG 10: Reduced Inequalities

• The core finding of the study is the disparity in health outcomes based on socioeconomic position (SEP). The article states that the benefits of pharmacotherapy for AUD were observed “only among individuals with a high SEP,” while having “no significant effect in the low and middle SEP groups.” This highlights a significant inequality in the effectiveness of and access to healthcare, a central concern of SDG 10.

SDG 4: Quality Education

• The study uses “highest educational attainment (years of education)” as the sole determinant for categorizing individuals into low, middle, or high socioeconomic positions. This demonstrates the critical role of education as a determinant of socioeconomic status and, consequently, health outcomes. While not the main focus, it underscores the connection between educational level and the ability to benefit from health interventions, linking it to the broader goals of quality education.

Specific Targets Identified

Targets under SDG 3: Good Health and Well-being

1. Target 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.
   • The article directly addresses this target by evaluating the effectiveness of four specific pharmacotherapies (acamprosate, disulfiram, nalmefene, and naltrexone) for treating Alcohol Use Disorder (AUD). The study’s purpose is to understand how to improve treatment outcomes for the harmful use of alcohol.
2. Target 3.8: Achieve universal health coverage, including… access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines… for all.
   • The research reveals a gap in achieving this target. While medications for AUD are available, their effectiveness is not universal. The finding that pharmacotherapy “reduced the risk for AUD-related hospitalisation by 17% in the high SEP group but had no significant effect in the low and middle SEP groups” shows that access to *effective* healthcare is not being experienced equally by all socioeconomic strata.

Targets under SDG 10: Reduced Inequalities

1. Target 10.3: Ensure equal opportunity and reduce inequalities of outcome…
   • The study’s conclusion that “Using any type of AUD pharmacotherapy was associated with a lower risk of hospitalisation only among individuals in high SEP” is a direct measurement of an inequality of outcome. The disparity in health results between different socioeconomic groups, despite the availability of treatment, points to a failure in ensuring equal opportunities for positive health outcomes.

Indicators for Measuring Progress

Indicators for Target 3.5 (Strengthen treatment of substance abuse)

1. Coverage of treatment interventions for substance use disorders (related to official indicator 3.5.1).
   • The article provides specific data that can serve as an indicator: the proportion of individuals with AUD who used pharmacotherapy. It states, “A higher proportion of individuals with a high SEP (52.5%) than of those with a low SEP (41.5%) used pharmacotherapy for AUD.” This directly measures treatment coverage and its variation across groups.
2. Rate of AUD-related hospitalisation.
   • The primary outcome of the study, “AUD-related hospitalisation,” serves as a direct indicator of the harm caused by alcohol use. The study’s goal was to measure the reduction in this rate as a sign of treatment effectiveness. This can be used to track progress in mitigating the negative health consequences of AUD.

Indicators for Target 10.3 (Reduce inequalities of outcome)

1. Rate of AUD-related hospitalisation, disaggregated by socioeconomic status (educational attainment).
   • The article’s methodology and results are built around this indicator. It compares the subdistribution hazard ratio (SHR) for hospitalisation among pharmacotherapy users in the high SEP group (SHR, 0.83) versus the low (SHR, 1.02) and middle (SHR, 1.01) SEP groups. This disaggregated data is essential for measuring health outcome inequality.
2. Proportion of population receiving AUD pharmacotherapy, disaggregated by socioeconomic status.
   • The article implies this indicator by reporting the different usage rates between SEP groups (52.5% for high SEP vs. 41.5% for low SEP). This measures inequality in access to, or uptake of, treatment, which is a key factor leading to the inequality of outcomes.

Summary Table of SDGs, Targets, and Indicators

Source: medscape.com