What medications are used to treat alcohol use disorder?

Medications for Alcohol Use Disorder

For patients with alcohol use disorder (AUD), FDA-approved medications including acamprosate, naltrexone, and baclofen should be prescribed as part of a comprehensive treatment program, with baclofen being the preferred option for patients with alcoholic liver disease due to its safety profile and proven efficacy in this population. 1, 2

First-Line Medication Options

For Patients With Liver Disease:

• Baclofen (30-60 mg/day): First choice for patients with alcoholic liver disease
  • Only medication tested in randomized controlled trials specifically in patients with alcoholic cirrhosis 1
  • Has limited hepatic metabolism and demonstrated safety in liver disease 1, 2
  • Mechanism: GABA-B receptor agonist that reduces alcohol cravings 1

For Patients Without Liver Disease:

• Naltrexone (50 mg daily oral or 380 mg monthly injection):

  • Reduces heavy drinking days by approximately 10% 3
  • Reduces risk of return to any drinking by 5% 3
  • Mechanism: Opioid receptor antagonist that blocks pleasurable effects of alcohol 4, 5
  • Caution: Hepatotoxicity concerns at higher doses; requires liver function monitoring 1, 4

• Acamprosate (666 mg three times daily):

  • Most effective for maintaining abstinence after detoxification 2
  • No hepatic metabolism, making it safer for patients with mild liver impairment 1
  • Mechanism: NMDA receptor antagonist 1
  • Dose adjustment needed with renal impairment (333 mg TID) 2

Second-Line and Non-FDA Approved Options

• Gabapentin (600-1,800 mg/day):

  • No hepatic metabolism; primarily renally excreted 1
  • Effective for reducing heavy drinking days 6
  • Monitor for renal dysfunction and sedation in patients with alcoholic liver disease 1

• Topiramate (75-400 mg/day):

  • Moderate evidence for decreasing heavy drinking days 6
  • Not extensively metabolized; primarily renal excretion 1
  • Not specifically studied in alcoholic liver disease 1

• Disulfiram:

  • Not recommended for patients with liver disease due to hepatotoxicity risk 1
  • Limited evidence of effectiveness outside supervised settings 6

Medication Selection Algorithm

1. Assess liver function status:

   • If liver disease present → Baclofen (30-60 mg/day)
   • If normal liver function → Proceed to step 2

2. Determine treatment goal:

   • For abstinence maintenance → Acamprosate (666 mg TID)
   • For reduction in heavy drinking → Naltrexone (50 mg daily)

3. Consider contraindications:

   • Opioid use → Avoid naltrexone
   • Renal impairment → Adjust acamprosate dose or consider naltrexone/baclofen
   • Seizure history → Consider topiramate or gabapentin as adjuncts

Psychosocial Support (Essential Component)

All pharmacotherapy should be combined with:

• Brief motivational interventions 1
• Cognitive behavioral therapy 2
• Support groups (e.g., Alcoholics Anonymous) 2
• Family therapy and education 2

Important Clinical Considerations

• Medication underutilization: Despite evidence supporting their efficacy, medications are prescribed to less than 9% of patients who would benefit 3, 6

• Monitoring requirements:

  • For naltrexone: Regular liver function tests 2, 4
  • For baclofen: Monitor for sedation, especially at higher doses 1
  • For acamprosate: Monitor renal function 2

• Treatment duration: Clinical trials typically evaluated 12 weeks of treatment 1, 4, but longer durations may be beneficial for maintaining abstinence

• Combination approaches: Integrating AUD treatment with medical care shows the best outcomes for management of advanced alcoholic liver disease 1

• Medication efficacy metrics: Number needed to treat to prevent return to any drinking is approximately 12 for acamprosate and 20 for naltrexone 1

The evidence strongly supports that pharmacotherapy combined with psychosocial interventions significantly improves outcomes in alcohol use disorder treatment, with medication selection guided primarily by the presence of liver disease and specific treatment goals.