What are effective medications for alcohol use disorder (alcohol treatment)?

From the Guidelines

Acamprosate is the most effective medication for maintaining alcohol abstinence, 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. When considering medications for alcohol treatment, several options are available, but the choice should be based on the strongest evidence.

• Naltrexone (50mg daily) reduces alcohol cravings by blocking opioid receptors in the brain, making drinking less pleasurable.
• Acamprosate (666mg three times daily) helps restore brain chemical balance disrupted by chronic alcohol use.
• Disulfiram (250-500mg daily) causes unpleasant reactions when alcohol is consumed, serving as a deterrent. However, Acamprosate is the only intervention with enough high-quality evidence to conclude that it is better at maintaining alcohol abstinence than placebo 1. Other medications like baclofen, topiramate, and gabapentin have shown some effectiveness in treating alcohol use disorder, but their evidence is not as strong as acamprosate's, as noted in a 2022 guideline published in Liver International 1 and a 2018 guideline published in the Journal of Hepatology 1. It's essential to start these medications only under medical supervision, as alcohol withdrawal can be dangerous, and medication selection should be tailored to individual needs, medical history, and treatment goals, as recommended in a 2013 guideline published in Clinical and Molecular Hepatology 1. Treatment typically continues for at least 6-12 months, though some people benefit from longer use. These medications work best as part of a comprehensive treatment program, including counseling and support groups.

From the FDA Drug Label

Naltrexone hydrochloride has been shown to produce complete blockade of the euphoric effects of opioids in both volunteer and addict populations. The efficacy of naltrexone hydrochloride as an aid to the treatment of alcoholism was tested in placebo-controlled, outpatient, double blind trials. In one of these studies, 104 alcohol-dependent patients were randomized to receive either naltrexone hydrochloride tablets 50 mg once daily or placebo. In this study, naltrexone hydrochloride proved superior to placebo in measures of drinking including abstention rates (51% vs 23%), number of drinking days, and relapse (31% vs. 60%).

Naltrexone is a medication that can be used to treat alcohol dependence. The recommended dose is 50 mg once daily. Studies have shown that naltrexone can help reduce the risk of relapse and improve abstention rates in patients with alcohol dependence.

• Key benefits of naltrexone include:
  • Reduced risk of relapse
  • Improved abstention rates
  • Decreased alcohol consumption
• Important considerations:
  • Patients should be opioid-free for at least 7-10 days before starting naltrexone treatment
  • Naltrexone should be used as part of a comprehensive treatment plan that includes counseling and support groups 2 2

From the Research

Medications for Alcohol Use Disorder

The following medications are available to help patients reduce drinking and maintain abstinence:

• Naltrexone: strong evidence shows that it reduces heavy-drinking days 3, 4, 5, 6
• Gabapentin: strong evidence shows that it reduces heavy-drinking days 3, 5, 6
• Acamprosate: strong evidence shows that it prevents return-to-use in patients who are currently abstinent 3, 5, 6
• Topiramate: moderate evidence supports its use in decreasing heavy-drinking days 3, 5, 6
• Varenicline: may be beneficial in reducing heavy alcohol use, especially in patients with comorbid nicotine dependence 5, 6
• Baclofen: may be beneficial, but results are inconclusive 5, 6
• Disulfiram: commonly prescribed, but little evidence supports its effectiveness outside of supervised settings 3, 5, 6

Targeted Opioid Receptor Antagonists

Targeted opioid receptor antagonists, such as naltrexone and nalmefene, can be used on an 'as-needed' basis to reduce heavy drinking in alcohol-dependent individuals 4

• Nalmefene: has been studied on an 'as-needed' basis and has been approved by the European Medicines Agency as an adjunctive treatment for alcohol dependence 4

Combined Pharmacotherapy

Combined pharmacological interventions may be beneficial in treating alcohol use disorder, especially when addressing specific symptoms or used in specific subpopulations 7

• Combinations of naltrexone with other medications, such as gabapentin, ondansetron, or acamprosate, have been evaluated, but results are limited by low statistical power and heterogeneity of drug combinations and outcome measures 7