No, Suboxone is NOT standard of care for alcohol use disorder
Suboxone (buprenorphine/naloxone) is FDA-approved exclusively for opioid use disorder, not alcohol use disorder, and your patient appears to be receiving inappropriate treatment. 1
The Standard Medications for Alcohol Use Disorder
The evidence-based pharmacotherapy for AUD consists of three FDA-approved medications 2:
- Naltrexone (oral 50 mg/day or long-acting injectable)
- Acamprosate (2-3 g/day)
- Disulfiram (250-500 mg/day)
For reducing alcohol consumption: Naltrexone or nalmefene are first-line, with naltrexone reducing return to any drinking by 5% and binge-drinking risk by 10% 3. Acamprosate, disulfiram, and baclofen all show efficacy for maintaining abstinence 4, 5.
For maintaining abstinence: Acamprosate is first-line. Disulfiram, baclofen, and naltrexone are also effective 4, 5.
Why This Matters Clinically
The confusion here likely stems from the fact that naltrexone (an opioid antagonist) is effective for AUD, but your patient is receiving buprenorphine (a partial opioid agonist). These are completely different medications with opposite mechanisms 6.
While naltrexone reduces alcohol cravings and is mentioned as potentially useful for co-occurring alcohol and opioid use disorders 6, buprenorphine has no established role in AUD treatment. The FDA label for Suboxone explicitly states it is indicated only for opioid use disorder 1.
What You Should Do
Verify the actual diagnosis: Does this patient have:
- Opioid use disorder being treated appropriately with Suboxone?
- Alcohol use disorder being treated inappropriately with Suboxone?
- Both disorders, with only the opioid disorder being addressed?
If the patient truly has AUD without OUD: They need to be transitioned to evidence-based AUD pharmacotherapy. The most robust evidence supports:
- Naltrexone (NOT buprenorphine): 50 mg daily orally or 380 mg monthly injection
- Acamprosate: 666 mg three times daily
- Disulfiram: 250-500 mg daily (if motivated for aversive therapy and no liver disease)
All should be combined with psychosocial interventions such as cognitive behavioral therapy or motivational enhancement therapy 2, 7, 2.
Common Pitfall
The online MAT provider may be inappropriately prescribing buprenorphine off-label for AUD, which lacks evidence and regulatory approval. Despite recent regulatory changes making buprenorphine easier to prescribe for OUD, this does not extend its indication to AUD 8, 9. Medications are prescribed to less than 9% of AUD patients who would benefit 3, but when prescribed, they should be the correct, evidence-based medications.
Bottom line: Contact the patient's online provider to clarify the diagnosis and treatment rationale, or refer the patient to appropriate AUD treatment with FDA-approved medications combined with counseling 2, 10.