Alcohol Use Disorder and Pharmacotherapy: What’s Shame Got to Do With It?

See article by Terechin et al

To the Editor: A recent article in the PCC detailed practical pharmacologic and psychosocial approaches to the treatment of alcohol use disorder (AUD). While the case vignette demonstrated a positive response to these treatments, fewer than 10% of patients with AUD access care. Here, we focus on one barrier briefly mentioned by the authors: a patient’s sense of shame regarding their own heavy drinking.¹

Shame refers to a painful, self-directed emotion accompanied by a sense that one is intrinsically defective or broken and differs from guilt in an important way. Guilt focuses on specific actions (“I drank too much and that was bad”), whereas shame implicates the whole person as inherently flawed (“I am a hopeless drunk and always will be”). This sense of shame can arise in clinical encounters, when patients perceive themselves as falling short of their own expectations or those of their clinician.²

Patients rarely articulate these beliefs out loud. Instead, it often appears indirectly: missed appointments, minimization of drinking, hesitation to initiate medications, or disengagement after a difficult interaction. Clinicians’ negative views on AUD may surface during clinical encounters; they may shorten visits, appear dismissive, or use condescending words. When clinician stigma meets a patient’s internalized shame, the patient is even less likely to seek or accept treatment.^3,4

Returning to the case vignette,¹ Ms B achieved clinically meaningful reductions in drinking, likely reflecting effective use of the treatment approaches described. Still, she remains at risk of relapsing. When she does, she is likely to experience aversive emotions, accompanied by urges to hide, withdraw, or avoid scrutiny, which in turn can lead to ongoing drinking rather than a return to recovery.⁵ Addressing these experiences does not require psychiatric expertise. It can be integrated into routine primary care through simple, practical strategies.⁴ Clinicians can normalize emotional responses (“many people feel embarrassed or discouraged after a relapse”), offer brief education about the neurobiology of AUD, and explore relapse triggers and alternative ways to respond when they arise.^3,4 Anticipating such “slips” with the patient can go a long way toward minimizing their impact; scheduling timely follow-ups with language such as “I will see you back in 4 weeks just to make sure we are still on the right track” can show patients that you not only care about their progress but also are open to hearing about setbacks.³ In our experience, reframing relapses as learning opportunities, rather than a personal failure, can be very helpful. In short, we suggest that emphasizing a nonjudgmental approach in the treatment of AUD can potentially reduce the barrier to success created when a patient’s shame prevents open and honest discussion.

Terechin et al were shown the letter and declined to reply.

Article Information

Published Online: July 9, 2026. https://doi.org/10.4088/PCC.26lr04197
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(4):26lr04197
To Cite: Modesto-Lowe V, Rodrigues G, Chaplin M. Alcohol use disorder and pharmacotherapy: what’s shame got to do with it? Prim Care Companion CNS Disord 2026;28(4):26lr04197.
Author Affiliations: Quinnipiac University, North Haven, Connecticut (Modesto-Lowe); Afya Faculdade de Ciências Médicas da Paraíba, Cabedelo, PB, Brazil (Rodrigues); Farrell Treatment Center, New Britain, Connecticut (Chaplin); University of Connecticut, Farmington, Connecticut (Chaplin).
Corresponding Author: Vania Modesto-Lowe, MD, MPH, Quinnipiac University, 370 Bassett Road, North Haven, CT 06473 ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
ORCID: Vania Modesto-Lowe: https://orcid.org/0000-0003-3036-2566