What medications are used to treat alcohol abuse?

Medications for Alcohol Abuse Treatment

The most effective FDA-approved medications for treating alcohol abuse are naltrexone, acamprosate, and baclofen, with the choice depending on liver function status and specific patient needs. 1

First-Line Medications

For Patients Without Liver Disease

• Naltrexone - Reduces alcohol craving and decreases relapse rates by 10% for binge drinking and 5% for any drinking 2

  • Dosage: 50 mg once daily 3
  • Mechanism: Opioid receptor antagonist that controls craving for alcohol 1
  • Efficacy: Demonstrated superior abstention rates (51% vs 23%) and lower relapse rates (31% vs 60%) compared to placebo 3
  • Contraindication: Should be avoided in patients with alcoholic liver disease due to hepatotoxicity 4, 5

• Acamprosate - Maintains rather than induces remission 1

  • Dosage: 1,998 mg/day for patients ≥60 kg 4
  • Mechanism: Structurally similar to GABA, reduces withdrawal symptoms including alcohol craving 1, 4
  • Advantage: No hepatic metabolism, making it safer for patients with mild liver disease 4

For Patients With Liver Disease

• Baclofen - First choice for patients with alcoholic liver disease 4
  • Dosage: Not exceeding 80 mg/day (French ANSM recommendation) 1
  • Standard regimen: 10 mg three times daily 4
  • Mechanism: GABA-B receptor agonist 1
  • Evidence: Demonstrated safety and efficacy in promoting alcohol abstinence in patients with alcoholic liver disease and cirrhosis 1, 4

Second-Line and Investigational Options

• Topiramate - Promising for reducing heavy drinking 1

  • Benefits: Decreases liver enzyme levels in treated patients 1
  • Limitation: Not specifically tested in patients with alcoholic liver disease 1, 5

• Gabapentin - May reduce alcohol ingestion 6, 7

  • Limitation: Long-term studies are lacking 6

• Disulfiram - Creates aversive reaction when combined with alcohol 8

  • Mechanism: Inhibits aldehyde dehydrogenase causing acetaldehyde buildup 4
  • Caution: Contraindicated in patients with alcoholic liver disease due to hepatotoxicity 4, 8
  • Warning: Can cause severe and sometimes fatal hepatitis even after months of therapy 8

Management of Alcohol Withdrawal

• Benzodiazepines - Gold standard for alcohol withdrawal syndrome 1

  • Recommendation: Use symptom-triggered regimen rather than fixed dosing to prevent accumulation 1
  • For patients with hepatic dysfunction: Short and intermediate-acting benzodiazepines (lorazepam, oxazepam) are safer 1, 5
  • Duration: Should not be used beyond 10-14 days due to abuse potential 1

• Thiamine supplementation - Essential during withdrawal 5

  • Higher doses for malnourished patients or those with suspected Wernicke's encephalopathy 1, 5

Important Clinical Considerations

• Despite availability of effective medications, less than 9% of eligible patients receive pharmacotherapy for alcohol use disorder 2
• Abstinence is the most important therapeutic intervention for all patients with alcohol-related liver disease 1
• All pharmacological treatments should be combined with psychosocial support and counseling for optimal outcomes 1, 4
• Monitoring with the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) helps guide treatment intensity (score >8 indicates moderate withdrawal, ≥15 indicates severe withdrawal) 1, 5

Treatment Algorithm

1. Assess liver function to determine appropriate medication
2. For normal liver function: Start with naltrexone 50 mg daily or acamprosate 1,998 mg/day 3
3. For impaired liver function: Use baclofen 10 mg three times daily 4
4. For alcohol withdrawal: Use lorazepam or oxazepam with symptom-triggered dosing, especially with liver dysfunction 1
5. Add psychosocial support to all medication regimens 1