Can gabapentin be used to treat Alcohol Use Disorder (AUD)?

Gabapentin for Alcohol Use Disorder

Gabapentin can be considered as a second-line pharmacotherapy for alcohol use disorder, but only when FDA-approved first-line medications (naltrexone, acamprosate) cannot be used, and it should not replace psychosocial interventions which remain the cornerstone of AUD treatment. 1

Evidence Quality and Guideline Recommendations

The evidence for gabapentin in AUD is notably weak compared to other pharmacotherapies:

• Major liver disease guidelines explicitly state that gabapentin has "no consistent results in large samples" for relapse prevention in AUD 1
• The American Association for the Study of Liver Diseases lists gabapentin as a non-FDA-approved option at doses of 600-1,800 mg/day, but emphasizes it has not been studied in patients with alcohol-associated liver disease 1
• European guidelines identify topiramate and baclofen as the "most promising" pharmacotherapies for AUD, notably excluding gabapentin from this designation 1

Clinical Context: When to Consider Gabapentin

Gabapentin may have a role in specific clinical scenarios:

• Patients with contraindications to naltrexone or acamprosate (e.g., naltrexone's hepatotoxicity concerns, acamprosate's renal excretion requirements) 1
• Patients with higher baseline alcohol withdrawal symptoms, where limited evidence suggests potential benefit, though one large RCT paradoxically showed worsening outcomes in patients with low withdrawal symptoms 2
• Patients with comorbid conditions that gabapentin treats (chronic pain, anxiety, insomnia), though this remains speculative 2

Critical Safety Concerns

Dose-Dependent Adverse Events

• Falls and fractures increase significantly with gabapentin use (incidence rate ratio 1.35), with a clear dose-response relationship peaking at ≥2,400 mg/day (RR 1.90) 3
• Altered mental status occurs more frequently in gabapentin-exposed patients (RR 1.12), particularly at doses 600-2,399 mg/day 3
• Monitor closely for renal dysfunction and worsening mental status/sedation, especially since gabapentin is 75% renally excreted 1

Dependence and Withdrawal Risk

• Severe gabapentin dependence can develop, requiring prolonged tapers up to 18 months in documented cases 4
• This represents a significant clinical pitfall when prescribing gabapentin for AUD, as you may be substituting one substance dependence for another 4

Gabapentin for Alcohol Withdrawal Syndrome

The evidence for gabapentin in acute AWS management is insufficient:

• A 2022 meta-analysis of 2,030 hospitalized patients found no significant differences between gabapentin and benzodiazepines for time to symptom resolution, benzodiazepine requirements, complications, or length of stay 5
• Benzodiazepines remain the gold standard for AWS due to proven efficacy in reducing withdrawal symptoms and preventing seizures and delirium tremens 1
• Gabapentin may be considered as part of benzodiazepine-sparing protocols in select patients, but this approach requires validation in larger studies 1

Practical Dosing Algorithm

If you decide to use gabapentin for AUD after exhausting first-line options:

• Start at 600 mg/day divided into three doses (the minimum dose showing efficacy in AUD trials) 1
• Titrate to 900-1,800 mg/day based on response and tolerability 1, 2
• Avoid doses ≥2,400 mg/day due to substantially increased fall and fracture risk 3
• Assess renal function before initiation and monitor throughout treatment given predominant renal excretion 1
• Screen for fall risk factors (age >65, prior falls, osteoporosis, polypharmacy) before prescribing 3

What Should Be Prioritized Instead

Psychosocial interventions remain the most relevant element of AUD treatment and cannot be replaced by any pharmacotherapy 1:

• Brief interventions using the "5 A's" model (Ask, Advise, Assess, Assist, Arrange) 1
• Motivational interviewing with empathic, non-confrontational approach 1
• FDA-approved medications (naltrexone, acamprosate) have better evidence with number needed to treat of 12-20 1

Key Pitfall to Avoid

Do not prescribe gabapentin as a first-line agent for AUD simply because it is "easier" than naltrexone or acamprosate—the evidence does not support this approach, and you risk creating gabapentin dependence while providing suboptimal AUD treatment 1, 2, 4.