What medications can help individuals stop drinking?

Medications for Alcohol Cessation

Naltrexone and acamprosate are the first-line medications for helping individuals stop drinking, with baclofen being the preferred option for patients with alcoholic liver disease. 1

First-Line Medications

Naltrexone

• FDA-approved for alcohol dependence
• Mechanism: Opioid receptor antagonist that reduces alcohol cravings
• Dosing: 50 mg daily orally or 380 mg monthly injection
• Efficacy: Lowers risk of relapse to heavy drinking
• Caution: Hepatotoxicity concerns make it unsuitable for patients with alcoholic liver disease 1, 2

Acamprosate

• FDA-approved for alcohol dependence
• Mechanism: NMDA receptor antagonist that reduces withdrawal symptoms
• Dosing: 666 mg three times daily
• Efficacy: Decreases rate of relapse, maintains abstinence, and decreases severity of relapse when it occurs
• Advantage: No hepatic metabolism, making it potentially safer for patients with liver concerns 1, 3

Special Considerations for Patients with Liver Disease

Baclofen

• Mechanism: GABA-B receptor agonist
• Dosing: 30-60 mg daily
• Evidence: Only medication specifically tested and proven effective in patients with alcoholic cirrhosis
• Benefit: Demonstrated improved abstinence rates in cirrhotic patients with alcohol use disorder 1, 4

Gabapentin

• Mechanism: Modulates GABA activity
• Advantage: Not metabolized by the liver, primarily excreted renally
• Dosing: 600-1,800 mg daily
• Caution: Requires dose adjustment in renal impairment; monitor for sedation 1, 4

Medications to Avoid in Liver Disease

Disulfiram

• Creates aversive reaction when alcohol is consumed
• Contraindicated in patients with alcoholic liver disease due to hepatotoxicity 1, 4

Naltrexone

• Despite FDA approval for alcohol dependence, not recommended in patients with alcoholic liver disease due to hepatotoxicity concerns 1, 4, 2

Medication Selection Algorithm

1. For patients without liver disease:

   • Start with naltrexone (50 mg daily) or acamprosate (666 mg three times daily)
   • Choose naltrexone if patient has strong cravings
   • Choose acamprosate if patient has significant anxiety or withdrawal symptoms

2. For patients with alcoholic liver disease:

   • First choice: Baclofen (10 mg three times daily, titrate as needed)
   • Second choice: Acamprosate (if no contraindications)
   • Third choice: Gabapentin (start at lower doses and titrate carefully)

3. For all patients:

   • Combine medication with counseling and support for best outcomes
   • Monitor for medication adherence
   • Evaluate response after 4-6 weeks and adjust treatment as needed

Important Clinical Considerations

• All pharmacotherapy should be combined with psychosocial interventions for optimal outcomes 1
• Complete abstinence should be the goal, as there is no safe amount of alcohol consumption for those with a history of alcohol use disorder 1
• The risk of recidivism (relapse) is high (67-81% over one year) even with medication 1
• Brief interventions using motivational interviewing techniques have shown positive impact on alcohol consumption and related morbidity/mortality 1

Remember that medication alone is not sufficient - the combination of pharmacotherapy with counseling and support provides the best chance for successful alcohol cessation and maintenance of sobriety.