What medications help with alcohol cravings?

Gabapentin for Alcohol Cravings

Gabapentin is the GPI (gabapentinoid) that helps with alcohol cravings, with optimal efficacy at 1800 mg/day (600 mg three times daily), demonstrating dose-dependent improvements in abstinence rates and craving reduction. 1

Evidence for Gabapentin's Efficacy

Gabapentin demonstrates significant linear dose-response effects on complete abstinence: 4.1% with placebo versus 11.1% with 900 mg versus 17.0% with 1800 mg daily (p=0.04). 1 The number needed to treat is 8 for abstinence and 5 for non-excessive drinking at the 1800 mg dose. 1

Mechanism and Clinical Benefits

• Gabapentin improves symptoms related to relapse in a dose-dependent manner, specifically targeting insomnia, dysphoria/mood disturbances, and alcohol craving. 1
• The medication works through GABAergic mechanisms, though it is distinct from benzodiazepines and carries no abuse potential for long-term use. 1

Guideline Positioning

• The American College of Physicians recommends gabapentin as a second-line treatment for alcohol dependence, particularly valuable in patients with liver disease or when first-line treatments (naltrexone, acamprosate) are contraindicated. 1
• The French Association for the Study of the Liver and European Association for the Study of the Liver both recognize gabapentin's effectiveness in treating alcohol use disorder, though they note the need for careful benefit-risk assessment. 1

Critical Advantages Over Alternatives

Gabapentin offers distinct safety advantages in patients with alcoholic liver disease:

• No hepatotoxicity risk unlike naltrexone, which can cause hepatocellular injury and is contraindicated in liver disease. 2, 3
• Safe in severe liver disease unlike disulfiram, which carries hepatotoxicity concerns. 1, 3
• Favorable safety profile with no serious drug-related adverse events in clinical trials and discontinuation rates similar to placebo (9/150 participants). 1

Practical Dosing Algorithm

Start with 300 mg three times daily (900 mg/day) and titrate to 600 mg three times daily (1800 mg/day) over 1-2 weeks:

• The 1800 mg/day dose demonstrates optimal efficacy based on the reference clinical trial. 1
• Treatment duration should be at least 12 weeks according to efficacy data, though guidelines generally suggest 3-6 months for alcohol dependence treatment. 1

Essential Integration with Psychosocial Treatment

• Gabapentin must always be combined with psychosocial interventions such as cognitive-behavioral therapy, motivational interviewing, and structured counseling. 1
• This combination demonstrates superior efficacy compared to usual care alone. 1

Comparison to FDA-Approved Medications

While naltrexone and acamprosate remain first-line FDA-approved options, they have important limitations:

• Naltrexone (50 mg daily) reduces heavy drinking with an NNT of approximately 20, but carries hepatotoxicity risk and is contraindicated in liver disease. 3, 4
• Acamprosate (666 mg three times daily) reduces drinking frequency with an NNT of approximately 12 and has no hepatotoxicity, making it safe in liver disease. 3
• Recent evidence suggests naltrexone has greater effect on drinking when craving is highly salient, while acamprosate's role in reducing craving was not supported. 5

Special Consideration for Liver Disease

In patients with alcoholic liver disease, baclofen (30-60 mg daily) is the only medication specifically studied and proven safe in this population, including those with compensated and decompensated cirrhosis. 3 However, baclofen should not be used in patients with hepatic encephalopathy due to risk of impaired mentation. 3

Gabapentin serves as an excellent alternative to baclofen for patients with liver disease who cannot tolerate or have contraindications to baclofen, offering comparable safety without the encephalopathy concerns. 1