Medications for Alcohol Use Disorder
Many patients with alcohol use disorder, but not all, benefit from medications. Following is a list of some of the medications most commonly used to help such patients. The list is not, nor is it intended to be, comprehensive. Nor is it offered because all patients need medications or because Dr. Umhau and colleagues invariably prescribe them. They do not. On the contrary: deciding whether to prescribe any medicine, and if so, which one or ones, is a decision made on an individual basis after considering each patient's circumstances. Each prescription reflects a cost-benefit analysis, because no drug is free of side effects, and no drug has only a single action. Rather, every drug brings both risks and benefits, and the prescriber attempts to weigh each such set of risks and benefits in light of the individual patient's problems. If Dr. Umhau or one of his colleagues recommends a medicine for you, you should ask questions sufficient to help you understand what the medicine is, what it's for, what potential side effects to look for, how much to take, when to take it, how to take it, and how long to take it. Do not stop taking medicines, or charge any medicines dose, without checking first with your provider. Doing so could make your condition worse, or cause new problems.
Following is a brief description of what has become common practice.
Naltrexone is the most widely used Food and Drug Administration (FDA) approved medication to reduce alcohol drinking. Naltrexone works by blocking the effect of endorphins, the natural opioids normally released by drinking. Therefore, the pleasure that drinking gives will be less. Naltrexone is effective at reducing alcohol consumption and relapse, and seems to work particularly well with individuals who have a strong family history of alcoholism. I like to prescribe naltrexone because its effects are well known, and it is relatively safe. Naltrexone works best at 50 mg/day, although for the first dose or two, many patients start at 25 mg. Injectable depo naloxone is a long-acting form of naltrexone which can be very helpful for people who have trouble remembering to take pills. The effects of the injectable drug can last for more than a month. For someone who recognizes that they are drinking too much, taking naltrexone an hour before drinking has been shown to help. This method of using naltrexone is called the Sinclair Method, which I describe in detail on the Sinclair Method page.
Naltrexone can commonly cause a mild headache or nausea, but these symptoms usually resolve after the first week or so. Many people find that if they eat a meal with the naltrexone, they don’t notice any nausea. Although it rarely happens, Naltrexone can also cause liver problems, so liver function is monitored with blood tests, and is not given when the liver is severely damaged. Another issue with naltrexone is that if someone taking it requires emergency pain relief, the effect of opiate pain medicines will be blocked. In this case, alternate methods of pain control will be necessary. Carrying a wallet card which notifies emergency personnel about naltrexone use is a good idea. At the bottom of the website is a wallet card pdf. you can print out for this purpose. Also, if someone is using opiates, and takes a naltrexone pill with opiates in their system, they will immediately develop severe withdrawal symptoms. That’s why patients should wait several days after stopping opiates before taking their first naltrexone pill.
Acamprosate is an FDA approved medication which has been shown to help alcoholics stop drinking. Acamprosate can reduce persistent symptoms of abstinence such as insomnia, anxiety, restlessness, and the state of unease and dissatisfaction that comes with not drinking alcohol. Acamprosate is chemically similar to an amino acid and acts on the glutamate neurotransmitter system in the brain. Acamprosate has relatively mild side effects, which are typically limited to stomach upsets or diarrhea. Inconvenience can be the major disadvantage to taking Acamprosate because it must be taken three times a day. Acamprosate doesn’t affect the liver, so it’s often used if someone cannot tolerate naltrexone.
Disulfiram, also known as Antabuse, blocks the normal metabolism of alcohol so that when someone drinks while taking this medication, they experience a very unpleasant reaction that can include flushing, nausea, vomiting, headaches, chest pain, blurred vision, confusion, respiratory difficulty, and palpitations. This reaction can last for 12 hours and persist as long as 14 days after the last dose of disulfiram. There is a risk of liver damage with disulfiram, so patients taking this drug must have regular blood tests. Although disulfiram has been used for helping alcoholics stay sober for more than 30 years, the severity of this reaction has limited its widespread use. It is sometimes useful in selected high-risk situations to prevent a relapse.
Topiramate was originally used to treat epilepsy, and is now also FDA approved as a treatment for migraines. It is used “off label” to help alcoholics stop drinking. Topiramate can reduce craving and is particularly helpful early in early abstinence to help alcoholics avoid returning to regular drinking. Side effects may include drowsiness, dizziness, loss of coordination, loss of appetite, cognitive impairment, weight loss, tingling of the hands/feet, diarrhea, eye problems and nausea. Topiramate may decrease the effectiveness of estrogen-containing oral contraceptives, and taking topiramate in the 1st trimester of pregnancy may increase risk of cleft lip/cleft palate in the infant. Therefore, women of childbearing age who use this drug must use alternative, non-hormone based forms of contraception. Topiramate can cause a reduction in sweating, putting people at greater risk of heat related problems like heatstroke.
Baclofen is an FDA approved muscle relaxant sometimes used “off label” to reduce alcohol craving; it is very commonly used in France and Australia. Baclofen can be given safely to patients with evidence of liver damage, so it may be especially helpful for very heavy drinkers. Some patients report having nausea, vertigo, transient sleepiness, and abdominal pain on baclofen.
Some people drink, in part, to calm symptoms of anxiety and stress and can be the reason for relapse for patients who have been successful in achieving abstinence for a period of a few weeks, months or even years. Baclofen can act on the GABA receptor system in a way different than alcohol and may alleviate underlying stress and alcohol cravings. Baclofen has a secondary action that limits or “attenuates” the brain neurotransmitter dopamine. Dopamine is in part responsible for the euphoric and rewarding effects of alcohol. Consequently, baclofen may also decrease the positive feedback loop associated with alcohol consumption. This helps the brain “unlearn” the rewarding effect of excessive alcohol consumption.
Baclofen treatment requires starting the medication at a low dosage, and “titrating” the medication up to higher doses to reduce the impact of side-effects including fatigue, lightheadedness, and nausea. This titration from a low to a high dose, for purposes of avoiding significant side-effects, can take up to several months before the dose has been titrated up to an adequate level to achieve a reduction or elimination in alcohol use.
Baclofen has a peak blood level approximately 1-2 hours after an oral dose and it’s effect usually lasts just five to six hours - the half life ranged from 3.8 hours to 6.4 hours. Frequent consultation with a physician and careful compliance with dosing is essential for baclofen to be effective in reducing alcohol use. Patients who start baclofen describe a significant loss of cravings, and a progressive indifference to alcohol allowing them to reduce consumption to a healthy level or quit entirely.
Ondansetron is approved by the FDA to treat nausea, particularly nausea associated with chemotherapy. It has also been used “off label” to treat alcoholics with an early onset type of alcoholism, or alcoholism associated with a specific gene which can influence serotonin function. Adverse effects associated with ondansetron include diarrhea and headache. Ondansetron can adversely affect the electrical conduction of the heart, so it is avoided in patients with underlying heart conditions.
Gabapentin has been approved by FDA for the treatment of epilepsy, and neuropathic pain. It has been used “off label” for alcoholism and other drugs of abuse, however its use is limited because it may itself become a drug of abuse. Gabapentin can cause drowsiness, dizziness, headache, and fatigue, but these adverse effects are less common at lower doses.
Prazosin, is an older medication used for hypertension and for men with urine flow issues associated with the prostate gland. Prazosin is also used “off label” in post traumatic stress disorder and to reduce the impact of the terrifying dreams that accompany this disorder. In one research study, when patients were given it for this purpose, they noticed they lost their desire to drink. This led to other studies suggesting that prazosin may help alcoholics maintain sobriety. Prazosin is a difficult medicine to take, however, because it must be taken three times a day, and the dose must be increased slowly over several weeks. As a blood pressure medicine, it can cause excessively low blood pressure, and the most common side effect of prazosin is fainting. Fainting may occur when standing suddenly.
Omega-3 fatty acids
Scientists who study the brain know the importance of omega-3 fat, especially the long omega-3 fats DHA and EPA. Although these essential fatty acids are critical components of the nervous system, they are not abundant in the typical American diet, and levels are depleted further by excessive alcohol use. Many patients report marked improvement in their mood and thought process once they start taking fish oil, which is the common source of these fats. One of my projects when I worked at NIH was to measure the brain utilization of radiolabeled DHA using PET scanning. My research determined that the half-life of DHA in the brain was greater than 2 years, suggesting that the fats we eat today could have an influence for years to come. For an overview of omega-3 fatty acids, you can refer to a chapter I wrote in the book “Low-Cost Approaches to Promote Physical and Mental Health”, pp.87-101.
Sources of Omega 3 Fatty Acid
The American Psychiatric Association recommends that individuals with mood, impulse-control or psychotic disorders should consume at least 1 gram of EPA + DHA per day. The most natural way to benefit from omega-3 fatty acids is to eat lots of seafood every day, particularly deep sea oily fish like salmon, mackerel, and sardines. However, for many people, taking fish oil is a more practical approach. Individuals in recovery commonly begin by taking 3 grams of Omega 3 fatty acids as fish oil. May people take a daily dose of 5 grams or more as this higher dose may be necessary to provide an anti-inflammatory effect. Look for a product that contains both EPA and DHA daily, and add the milligrams of each together to determine the total amount of omega-3 fat it contains. Vegan forms of DHA are available. For many people, flax and chia may be an inexpensive alternative source of omega-3 fat. However, most research has been done with DHA and EPA, found in fish and not in flax and chia.