From the Guidelines
Acamprosate is the most effective medication for maintaining abstinence in patients with alcohol use disorder, as it has the highest quality evidence supporting its use, as shown in a 2020 systematic review and network meta-analysis published in the BMJ 1.
Medications for Alcohol Use Disorder
Several medications are used to treat alcohol use disorder, including:
- Disulfiram (250-500mg daily), which causes unpleasant reactions when alcohol is consumed, deterring drinking through negative reinforcement
- Naltrexone (50mg daily oral or 380mg monthly injection), which reduces alcohol cravings by blocking opioid receptors that mediate alcohol's pleasurable effects
- Acamprosate (666mg three times daily), which helps maintain abstinence by normalizing brain chemistry disrupted by chronic alcohol use
- Topiramate (up to 300mg daily) and gabapentin (900-1800mg daily), which are sometimes used off-label to reduce cravings and withdrawal symptoms ### Treatment Considerations These medications work best when combined with counseling or therapy, and treatment duration varies by individual but typically continues for at least 6-12 months 2, 3, 4. Side effects differ between medications, with disulfiram causing liver problems, naltrexone causing nausea or headaches, and acamprosate commonly causing diarrhea. A healthcare provider should determine the most appropriate medication based on the patient's specific situation, drinking patterns, medical history, and treatment goals.
Evidence-Based Recommendations
The most recent and highest quality study, a 2020 systematic review and network meta-analysis published in the BMJ, found that acamprosate was the only intervention with enough high-quality evidence to conclude that it is better at maintaining alcohol abstinence than placebo 1. Other studies have also supported the use of acamprosate, naltrexone, and disulfiram in treating alcohol use disorder, but with more limited evidence 2, 3, 4.
From the FDA Drug Label
To reduce the risk of precipitated withdrawal in patients dependent on opioids, or exacerbation of a preexisting subclinical withdrawal syndrome, opioid-dependent patients, including those being treated for alcohol dependence, should be opioid-free (including tramadol) before starting naltrexone hydrochloride treatment A dose of 50 mg once daily is recommended for most patients The placebo-controlled studies that demonstrated the efficacy of naltrexone hydrochloride as an adjunctive treatment of alcoholism used a dose regimen of naltrexone hydrochloride 50 mg once daily for up to 12 weeks.
Medications for Alcohol Use Disorder (AUD):
- Naltrexone (PO) is used as an adjunctive treatment for AUD, with a recommended dose of 50 mg once daily for most patients [5] [6].
- The treatment should be part of a comprehensive plan that includes management of comorbid conditions, community-based support groups, and good medication compliance.
From the Research
Medications for Alcohol Use Disorder (AUD)
The following medications are approved by the U.S. Food and Drug Administration to treat AUD:
Off-Label Medications
Off-label medications that may be beneficial in reducing heavy alcohol use include:
- Topiramate 7, 8, 9, 10, 11
- Gabapentin 8, 10, 11
- Baclofen 9, 10, 11
- Ondansetron 7, 8
- Varenicline 10, 11
- Nalmefene 10, 11
- Sodium oxybate 11
- Antidepressants (e.g., sertraline, fluoxetine) 7, 8, 11
Mechanism of Action
These medications work by: