Medications for alcohol use disorder (AUD)
Medications for Alcohol Use Disorder (AUD) are designed to help reduce cravings, prevent relapse, or eliminate the desire to drink.
These medications are not FDA-approved specifically for AUD, but evidence supports their use in selected patients.
Three medications are FDA-approved in the United States for treating alcohol use disorder: naltrexone, acamprosate, and disulfiram.
Two other medications, topiramate and gabapentin, are commonly considered off-label alternatives.
Medication can reduce cravings, decrease heavy drinking, or help maintain abstinence, and it is often combined with counseling or other behavioral treatments.
Naltrexone
Common first-line option
Dose: Oral, usually 50 mg once daily; extended-release injection, 380 mg intramuscularly every 4 weeks.
Naltrexone (Brand names: ReVia®, Depade®, Vivitrol®)
Naltrexone is an opioid antagonist. It blocks the reward pathway in the brain, reducing the pleasurable “buzz” and the urge to drink.
Best For: People trying to stop drinking completely or those looking to reduce heavy drinking days.
Oral pill-daily.
Extended-release injection (Vivitrol, given once a month).
Cannot be taken by individuals who are currently taking opioid pain medications or are in opioid recovery, as it will precipitate opioid withdrawal.
Requires monitoring if severe liver disease is present.
Mechanism: Blocks opioid receptors, reducing alcohol’s rewarding effects and the urge to drink.
Best suited for: People seeking to reduce heavy drinking or stop drinking. It can be started while a person is still drinking.
It is not used with opioid medications or current opioid dependence; it can precipitate opioid withdrawal and block opioid pain relief.
Assess liver function and liver disease before treatment.
Acamprosate
Acamprosate is a good option after abstinence has been achieved.
Acamprosate (Brand name: Campral®)
It stabilizes chemical signaling in the brain (glutamate and GABA) that gets disrupted by long-term heavy drinking, helping to relieve protracted withdrawal discomfort, like anxiety and insomnia.
Oral delayed-release tablets, typically taken three times daily.
Safe for individuals with liver impairment (unlike naltrexone), but doses need adjustment for severe kidney disease.
Common side effects include diarrhea, gas, and stomach upset.
Dose: 666 mg orally three times daily in adults with normal renal function.
Mechanism: Modulates neurotransmitter systems involved in the brain’s adaptation to chronic alcohol exposure.
Avoided with severe renal impairment (creatinine clearance 30 mL/min or less); reduce the dose in moderate renal impairment.
Diarrhea is a common adverse effect.
Disulfiram
Dose: Usually 250 mg orally once daily; 125–500 mg daily may be used depending on the clinical situation.
Disulfiram (Brand name: Antabuse®)
Disulfiram blocks the enzyme that metabolizes alcohol in the liver.
If a person drinks even a small amount of alcohol while taking it, it causes a severe physical reaction (flushing, nausea, vomiting, rapid heartbeat, and severe headache).
Best For: Highly motivated individuals committed to complete abstinence who benefit from a strong physical deterrent.
Daily oral tablet.
Acts as a deterrent, not a craving reducer.
Users must strictly avoid hidden alcohol sources (e.g., mouthwash, cough syrups, cooking wines).
Mechanism: Inhibits aldehyde dehydrogenase, causing an unpleasant and potentially dangerous reaction if alcohol is consumed.
Best suited for: Selected patients committed to abstinence, particularly when medication adherence can be supported.
Important cautions: It does not directly reduce cravings.
Alcohol must be avoided in beverages, medications, and other products; reactions may occur for up to 1–2 weeks after stopping.
Use cautiously or avoid with significant cardiac disease, liver disease, or psychosis.
Topiramate: Gradual dose titration; often targets 200–300 mg/day or more, as tolerated Cognitive slowing, paresthesias, weight loss, kidney stones.
Gabapentin Often 900–1,800 mg/day in divided doses; may help cravings, sleep disturbance, and some withdrawal symptoms
These are established treatment options, but selection depends on the patient’s drinking goal, kidney and liver function, other medications, and ability to adhere to treatment.
Baclofen Sometimes considered when other options are unsuitable, particularly in selected patients with liver disease Sedation, dizziness, potentially dangerous withdrawal if abruptly stopped
Topiramate and gabapentin have more established evidence for AUD than baclofen.
With difficulty taking daily medication
Monthly extended-release injectable naltrexone may improve adherence.
Significant renal or hepatic disease
Acamprosate requires adequate renal function; naltrexone requires assessment of liver status and opioid exposure.
Disulfiram is generally avoided in significant liver disease.
Assessment of drinking pattern, withdrawal risk, liver function, renal function, current medications, and treatment goals.
Alcohol withdrawal: These medications do not replace treatment for acute alcohol withdrawal.
Benzodiazepines are generally first-line for clinically significant withdrawal when medically indicated.
Avoid abrupt cessation without medical advice if there has been drinking heavily and regularly.
Withdrawal can cause seizures or delirium tremens and may be life-threatening.
Combine treatment approaches: Counseling, cognitive behavioral therapy, and mutual-support programs can improve outcomes.
Must abstain alcohol before starting? Naltrexone Yes Acamprosate Yes Generally yes; start after stopping Disulfiram Yes Yes; at least 12 hours, and the patient must be sober Topiramate No Gabapentin No
The abstinence requirements and safety considerations are important when choosing treatment.
Bottom line: Naltrexone and acamprosate are generally the preferred initial medications.
Naltrexone is especially useful for reducing heavy drinking, while acamprosate is particularly useful for maintaining abstinence.
For an individualized recommendation, the most important questions are whether the goal is to reduce drinking or stop completely, whether the person is currently drinking, and whether there is significant liver or kidney disease or any opioid use.
Severe alcohol withdrawal can be life-threatening and requires inpatient medical detoxification.
Treatment for alcohol use disorder is highly personalized based on overall health, liver function, and personal recovery goals.