Medications for the Treatment of Alcohol Use Disorder

Acamprosate (Campral) is a prescription medication that may prevent individuals who already have stopped drinking from returning to alcohol use.  The precise way acamprosate works is not understood fully but it likely helps restore the proper balance of certain neurotransmitters – GABA and glutamate – in the brain that becomes disrupted with chronic alcohol use. Acamprosate also may reduce cravings for alcohol.

Although acamprosate can be started and taken while someone is drinking alcohol, studies have shown that it is more effective when started after someone has stopped drinking.

The main contraindication to taking acamprosate is severe kidney disease.  The prescribing healthcare professional can answer questions and provide guidance about the use of acamprosate for alcohol use disorder.  

Naltrexone, an antagonist of opioid receptors in the brain, is a prescription medication that is available in oral (Revia) and long-acting injectable (Vivitrol) formulations. Both formulations are indicated for the treatment of alcohol use disorder, but only the long-acting injectable formulation is indicated for the treatment of opioid use disorder. Information about long-acting injectable naltrexone for the treatment opioid use disorder can be found in the section on medications for opioid use disorder. 

For alcohol use disorder, naltrexone has been shown to reduce heavy alcohol use during an episode of drinking and, if someone has decreased or stopped drinking, prevent a return to heavy alcohol use if drinking does occur.  By blocking opioid receptors in areas of the brain associated with reward, the positive reinforcement that comes from alcohol use is reduced. Without this positive reinforcement, alcohol cravings may decrease, heavy alcohol use may decrease, and those who have stopped drinking may not return to heavy alcohol use if they start drinking again.

An individual must have a trial of oral naltrexone before starting long-acting injectable naltrexone to ensure they do not have an allergic reaction or intolerable side effects. Due to the risk of causing severe and long-lasting opioid withdrawal, both oral and injectable naltrexone are contraindicated in individuals regularly taking opioids.

It is recommended that individuals taking opioids regularly do not take any opioids for seven to ten days before naltrexone is started. Some practitioners may choose to do urine toxicology testing to confirm that opioids are not present in an individual’s system before starting naltrexone.  Because there is a risk of liver damage with naltrexone, it is contraindicated for individuals with severe liver disease. The prescribing healthcare professional can answer questions and provide information about the use of naltrexone for alcohol use disorder.

Disulfiram (Antabuse) is a prescription medication that can help prevent a return to alcohol use after an individual has stopped drinking completely.  Disulfiram blocks a liver enzyme that is necessary for breaking down an alcohol byproduct called acetaldehyde  When someone taking disulfiram drinks even a small amount of alcohol, the buildup of acetaldehyde in the blood causes unpleasant symptoms such as flushing, nausea, vomiting, rapid heart rate, and headache.

Concerns about experiencing this unpleasant reaction discourage those taking disulfiram from drinking alcohol. More severe reactions including chest pain, difficulty breathing, heart failure, and death are also possible.  Those who choose to take disulfiram should be informed fully about the physical effects that can occur if they drink alcohol. Disulfiram should be started at least 12 hours after the last use of alcohol. The reaction to alcohol can occur up to 14 days after someone stops taking disulfiram.

It is important to caution individuals that they can experience the reaction with any product containing alcohol such as certain mouthwashes and cold remedies, alcohol-containing mouthwash, and food prepared with alcohol.

Disulfiram is contraindicated in pregnancy, for those with severe heart disease or psychosis, and is not recommended for those with liver disease. There have been rare reports of severe liver damage associated with disulfiram so prescribers will need to check liver function tests before starting the medication and at regular intervals while someone is taking disulfiram.  The prescribing healthcare professional can answer questions and provide information about the use of disulfiram for alcohol use disorder.