What medications are used for alcohol cessation?

From the Guidelines

Acamprosate is the most effective medication for maintaining alcohol abstinence, as evidenced by the most recent and highest quality study 1. When considering medications for alcohol cessation, several options are available, including acamprosate, naltrexone, and disulfiram.

• Acamprosate (Campral) is taken at 666mg three times daily and helps reduce cravings by normalizing brain chemistry disrupted by chronic alcohol use.
• Naltrexone (ReVia, Vivitrol) blocks opioid receptors at 50mg daily orally or as a monthly 380mg injection, reducing the pleasurable effects of alcohol and decreasing heavy drinking days.
• Disulfiram (Antabuse) creates an unpleasant reaction when alcohol is consumed by taking 250-500mg daily, serving as a deterrent. However, according to the most recent study 1, acamprosate is the only intervention with enough high-quality evidence to conclude that it is better at maintaining alcohol abstinence than placebo. The study also suggests that other interventions, such as disulfiram, have limited evidence to support their effect on abstinence 1. Treatment with these medications typically continues for at least 6-12 months, with some patients benefiting from longer durations. Before starting these medications, patients should undergo medical evaluation to assess liver function and potential contraindications, as some medications, such as naltrexone, may not be recommended in patients with advanced liver disease 1. Side effects vary by medication: acamprosate may cause diarrhea and anxiety; naltrexone can cause nausea and headaches; and disulfiram requires complete alcohol abstinence to avoid severe reactions including nausea, flushing, and potentially dangerous cardiovascular effects. These medications work best as part of a comprehensive treatment approach that includes behavioral therapy and addressing underlying mental health conditions, as recommended by previous guidelines 1.

From the FDA Drug Label

Naltrexone hydrochloride, an opioid receptor antagonist, competitively binds to such receptors and may block the effects of endogenous opioids Opioid antagonists have been shown to reduce alcohol consumption by animals, and naltrexone hydrochloride has been shown to reduce alcohol consumption in clinical studies. The medication naltrexone is used as an aid to the treatment of alcoholism.

• The recommended dose is 50 mg once daily for most patients.
• Naltrexone should be considered as only one of many factors determining the success of treatment of alcoholism.
• The efficacy of naltrexone as an aid to the treatment of alcoholism was tested in placebo-controlled, outpatient, double blind trials 2.
• A dose of 50 mg once daily is recommended for most patients 2.

From the Research

Approved Medications for Alcohol Cessation

• The US Food and Drug Administration (FDA) has approved three medications for the treatment of alcohol use disorder: disulfiram, naltrexone, and acamprosate 3.
• Nalmefene is approved by the European Medicines Agency (EMA) for the reduction of alcohol consumption 4, 5.
• Acamprosate and naltrexone have been evaluated in numerous clinical trials and represent evidence-based treatments for alcohol use disorders 4, 6.

Off-Label Medications for Alcohol Cessation

• Off-label medications, such as baclofen, gabapentin, ondansetron, and topiramate, are commonly prescribed for the treatment of alcohol use disorders 4, 5.
• Baclofen has shown mixed results in clinical trials and is currently licensed for the treatment of alcohol use disorders in France only 4, 5, 3.
• Gabapentin may be close to approval in the USA for the treatment of alcohol use disorders 4.
• Topiramate, gabapentin, and varenicline have shown encouraging results in clinical trials and may be useful in patients with comorbid nicotine dependence 4, 5.

Efficacy of Medications for Alcohol Cessation

• Acamprosate and naltrexone have been shown to be effective in supporting continuous abstinence and increasing the total number of abstinence days 6.
• Disulfiram appears to be effective only when intake is supervised 6.
• The use of combinations of pharmacological interventions has not shown significant benefit over single agents, but may be beneficial in specific subpopulations or when addressing specific symptoms of alcohol use disorder 7.