Medications for Alcohol Use Disorder

Three medications are FDA-approved for treating alcohol use disorder: naltrexone, acamprosate, and disulfiram. These medications work through different mechanisms and suit different treatment goals. Understanding your options helps you make an informed choice about medication-assisted treatment.

What You'll Discover:

• The three FDA-approved medications for alcohol use disorder.

• How each medication works in the body.

• Which medications require abstinence versus allow continued drinking.

• The effectiveness of medication-assisted treatment.

• How to choose between medication options.

• How to access medication-assisted treatment.

Medication-assisted treatment for alcohol use disorder remains underutilized despite strong evidence supporting its effectiveness. Many people don't know these medications exist or assume they're only for severe cases.

Understanding your medication options empowers you to have informed conversations with healthcare providers and choose an approach that matches your goals.

Overview of FDA-Approved Medications

The FDA has approved three medications specifically for treating alcohol use disorder.

Naltrexone - Blocks opioid receptors to reduce the pleasurable effects of alcohol. Available in oral and injectable forms. Can be used while still drinking.

Acamprosate (Campral) - Helps stabilize brain chemistry disrupted by chronic alcohol use. Primarily helps maintain abstinence after quitting. Requires abstinence to begin.

Disulfiram (Antabuse) - Creates an unpleasant reaction if you drink alcohol. Works as a deterrent rather than addressing underlying cravings. Requires abstinence to use safely.

Each medication works through a different mechanism and suits different treatment approaches. Some support abstinence-based recovery. Others allow continued drinking while working toward reduction.

Naltrexone: How It Works

Naltrexone works by blocking opioid receptors in the brain that are involved in alcohol's rewarding effects.

When you drink alcohol, it triggers the release of endorphins, the brain's natural opioids. These endorphins create pleasurable feelings that reinforce drinking behavior. Over time, your brain learns to associate alcohol with reward, strengthening the drive to drink.

Naltrexone blocks the receptors where endorphins would normally bind. When you drink while taking naltrexone, alcohol produces less pleasure. The usual reward doesn't arrive. This weakens the reinforcement loop driving continued drinking.

Research published in medical journals confirms naltrexone's effectiveness for reducing heavy drinking days and supporting abstinence goals.

Key characteristics of naltrexone:

• Can be taken while still drinking

• Works gradually by weakening alcohol's reward

• Reduces cravings for alcohol

• Available as daily oral tablets (50mg) or monthly injection (Vivitrol)

• Does not cause illness if you drink

• Allows for reduction-based treatment

• Generally well-tolerated with manageable side effects

Naltrexone is particularly well-suited for people who want to reduce drinking rather than quit immediately. You take the medication before drinking, and over time, drinking naturally decreases as it becomes less rewarding.

The Sinclair Method is a specific protocol that uses naltrexone taken one hour before drinking to systematically extinguish the learned association between alcohol and pleasure.

Acamprosate: How It Works

Acamprosate helps restore normal brain chemistry that has been disrupted by chronic alcohol use.

Long-term heavy drinking changes the balance of neurotransmitters in the brain, particularly glutamate and GABA. When you stop drinking, this disrupted chemistry creates discomfort, anxiety, and cravings that can drive relapse.

Acamprosate appears to modulate glutamate activity and help stabilize brain function during early recovery. This reduces the physical and psychological discomfort that makes early abstinence difficult.

Key characteristics of acamprosate:

• Requires abstinence before starting

• Helps maintain abstinence rather than achieve it

• Reduces anxiety and discomfort in early sobriety

• Must be taken three times daily (typically two 333mg tablets each time)

• Does not block alcohol's effects

• Does not cause illness if you drink

• Works best for people with strong abstinence motivation

Acamprosate works best for people who have already achieved initial abstinence and want support maintaining it. It's not effective for reducing drinking while you're still consuming alcohol.

Disulfiram: How It Works

Disulfiram works as a deterrent by causing an extremely unpleasant reaction if you drink alcohol.

Normally, your liver processes alcohol in two steps. First, alcohol is converted to acetaldehyde. Then acetaldehyde is converted to harmless acetate. Disulfiram blocks the second step, causing acetaldehyde to accumulate.

Acetaldehyde buildup causes severe symptoms including flushing, nausea, vomiting, rapid heartbeat, headache, and difficulty breathing. The reaction is so unpleasant that it creates a powerful incentive not to drink.

Key characteristics of disulfiram:

• Requires complete abstinence to use safely

• Works through fear of reaction rather than reducing cravings

• Drinking while taking it causes severe illness

• Once-daily dosing (typically 250-500mg)

• Must avoid all alcohol including cooking wine, mouthwash, and alcohol in medications

• Can cause dangerous reactions with any alcohol exposure

• Works best with external accountability or supervision

Disulfiram works best for people with strong motivation who want an external barrier against drinking. It doesn't reduce the desire to drink, only the ability to drink without consequence.

Because effectiveness depends on actually taking the medication, disulfiram works best when taken under supervision, such as by a spouse or at a clinic.

Comparing the Three Medications

The medications differ significantly in how they work and what they require.

Naltrexone vs. Acamprosate

Naltrexone reduces the reward from drinking and can be used while still consuming alcohol. Acamprosate helps maintain abstinence but doesn't work if you're still drinking. Naltrexone suits reduction goals. Acamprosate suits abstinence maintenance.

Naltrexone vs. Disulfiram

Naltrexone reduces desire to drink over time without causing illness. Disulfiram creates illness if you drink but doesn't reduce cravings. Naltrexone allows for gradual reduction. Disulfiram requires immediate complete abstinence.

Acamprosate vs. Disulfiram

Both require abstinence. Acamprosate reduces discomfort and cravings during sobriety. Disulfiram provides a deterrent against drinking but doesn't address underlying cravings.

For many people seeking to reduce drinking without requiring immediate abstinence, naltrexone offers the most flexible approach.

Effectiveness of Medication-Assisted Treatment

Research consistently shows that medication-assisted treatment improves outcomes for alcohol use disorder.

Studies compiled by SAMHSA confirm that these medications significantly reduce drinking, support abstinence, and decrease alcohol-related problems.

Naltrexone effectiveness:

Multiple studies show naltrexone reduces heavy drinking days by approximately 25% compared to placebo. It also reduces the amount consumed when drinking does occur. Long-term studies show sustained benefits with continued use.

A meta-analysis of naltrexone studies found the number needed to treat (NNT) was approximately 12, meaning for every 12 people treated, one additional person achieves the desired outcome compared to placebo.

Acamprosate effectiveness:

Research shows acamprosate increases abstinence rates and reduces drinking days for people who have already stopped drinking. Effects are modest but meaningful for those in early recovery.

European studies have generally shown stronger effects for acamprosate than American studies, possibly due to differences in treatment settings and patient populations.

Disulfiram effectiveness:

Disulfiram shows mixed results in studies because effectiveness depends heavily on compliance. When taken consistently under supervision, it can support abstinence. However, many people simply stop taking it when they want to drink.

Despite this evidence, medication-assisted treatment remains underutilized. Less than 10% of people with alcohol use disorder receive any medication for it. Many people and even some healthcare providers don't know these options exist.

Who Should Consider Medication-Assisted Treatment

Medication-assisted treatment can help a range of people with problematic drinking.

You don't have to be severely addicted - Medications work for people across the spectrum of alcohol use disorder, from mild to severe. You don't have to hit "rock bottom" to benefit.

You don't have to want complete abstinence - Naltrexone in particular supports reduction goals. You can work toward drinking less rather than not at all.

Previous attempts don't have to have failed - Medication can be a first-line treatment. You don't have to prove willpower alone doesn't work.

You can use it with or without therapy - Medications work independently but can be combined with counseling for additional support.

Good candidates for medication-assisted treatment include people who:

• Want to reduce their drinking

• Have tried to cut back unsuccessfully

• Experience cravings that are hard to resist

• Have had negative consequences from drinking

• Want additional support beyond willpower alone

• Meet criteria for alcohol use disorder at any severity level

Choosing Between Medications

Several factors influence which medication might be right for you.

Your treatment goal - If you want to reduce drinking gradually, naltrexone is typically the best choice. If you want support maintaining abstinence you've already achieved, acamprosate may help. If you want a deterrent that makes drinking impossible, disulfiram provides that.

Your relationship with abstinence - Can you commit to not drinking at all? Disulfiram and acamprosate require this. Naltrexone allows continued drinking while working toward reduction.

Your lifestyle - Daily medications require consistent dosing. Monthly injectable naltrexone (Vivitrol) removes daily decision-making but requires office visits.

Other medications - Some medications interact with these treatments. Naltrexone cannot be used with opioid medications. Disulfiram interacts with various drugs.

Medical conditions - Liver or kidney problems affect medication choices. A healthcare provider can help determine safety.

Most people seeking medication-assisted treatment find naltrexone offers the most practical approach because it doesn't require abstinence and works gradually by reducing alcohol's appeal.

How to Access Medication-Assisted Treatment

Getting medication for alcohol use disorder has become increasingly accessible.

Primary care physicians - Any licensed physician can prescribe these medications. You don't need an addiction specialist. Many primary care doctors are comfortable prescribing them.

Psychiatrists - Mental health providers often prescribe medications for alcohol use disorder, especially if there are co-occurring mental health conditions.

Addiction medicine specialists - Doctors specializing in addiction medicine have extensive experience with these medications.

Telehealth services - Online providers can prescribe oral naltrexone and other medications for alcohol use disorder. This offers convenience and privacy.

What to expect:

A provider will typically assess your drinking history, overall health, and treatment goals. They may order liver function tests before starting certain medications. You'll receive a prescription and instructions for use.

For naltrexone specifically, learn more about how to use it effectively for reducing alcohol consumption.

Common Concerns About Medication-Assisted Treatment

People often have reservations about using medication for alcohol problems.

"Isn't this just trading one drug for another?"

These medications are not addictive. They don't produce euphoria or cause dependence. They're treatment tools, not substances of abuse. This concern often stems from confusion with medications used for opioid dependence.

"Shouldn't I be able to quit without medication?"

Alcohol use disorder involves brain changes that make willpower alone insufficient for many people. Using medication is no different than using medication for any other medical condition. It's not a character failing.

"Will I have to take it forever?"

Duration varies by person and medication. Some people use medication short-term to establish new patterns. Others use it longer. The goal is reduced harm from drinking, however that's achieved.

"Are there side effects?"

Each medication has potential side effects. Naltrexone commonly causes nausea initially, which usually resolves. Acamprosate can cause diarrhea. Disulfiram's effects are its mechanism. Your provider can discuss specific concerns.

Why Medication-Assisted Treatment Is Underused

Despite strong evidence supporting these medications, they remain dramatically underutilized.

Several factors contribute to this gap between evidence and practice.

Stigma - Many people view medication for alcohol problems as a sign of weakness or believe recovery should happen through willpower alone. This stigma prevents people from seeking effective treatment.

Lack of awareness - Many people with alcohol use disorder don't know these medications exist. Even some healthcare providers are unaware or unfamiliar with prescribing them.

Treatment philosophy - Some traditional treatment approaches emphasize abstinence and view medication as inappropriate. This philosophy may prevent providers from offering evidence-based options.

Insurance barriers - While these medications are generally covered, prior authorizations and cost concerns can create obstacles.

Prescriber hesitation - Some primary care providers feel uncomfortable prescribing these medications despite being legally able to do so. They may feel it's outside their expertise.

The result is a significant treatment gap. Millions of people could benefit from medication-assisted treatment but never receive it. Increasing awareness of these options helps close this gap.

Off-Label Medications

In addition to the three FDA-approved medications, some providers prescribe other medications off-label for alcohol use disorder.

Topiramate - An anticonvulsant that has shown promise for reducing heavy drinking in some studies. Not FDA-approved for this use but sometimes prescribed.

Gabapentin - Another medication that may help reduce drinking and improve sleep during early recovery. Also not FDA-approved for alcohol use disorder.

Baclofen - A muscle relaxant that has been studied for alcohol dependence, particularly in Europe.

These medications have less evidence than the FDA-approved options and are not first-line treatments. However, they may be options for people who don't respond to or can't take the approved medications.

Conclusion

Three FDA-approved medications can help treat alcohol use disorder: naltrexone, acamprosate, and disulfiram. Each works differently and suits different treatment goals.

Naltrexone reduces alcohol's rewarding effects and allows for gradual reduction while still drinking. Acamprosate helps maintain abstinence by stabilizing brain chemistry. Disulfiram creates a deterrent by causing illness if you drink.

For many people seeking to reduce drinking without committing to immediate abstinence, naltrexone offers the most flexible and practical approach.

Take the online Alcohol Use Assessment to see if medication-assisted treatment with naltrexone could help you reduce your drinking.