Medications for Alcohol Use Disorder
Many patients with alcohol use disorder, benefit from medications. Following is a list of some of the medications most commonly used to help such patients.
Note: 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 risk-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 medicine 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, the compulsion to drink will be less, allowing people to drink more slowly and have an easier time quitting when they want to. Naltrexone is effective at reducing alcohol consumption for those who want to cut down, and for those who want to quit for good, it can reduce the risk of relapse. Naltrexone typically works well for individuals with a certain genetic background – those who have a strong family history of alcoholism.
Naltrexone can also block craving. When people think about alcohol, the memories of past drinking activate the same nerve paths in the brain that are activated when someone is drinking. No matter how these nerve paths are activated, they work through the release of natural opioids, i.e., endorphins, and this action is what drives the brain process of craving. As naltrexone blocks the effect of these natural opioids, it blocks craving.
Naltrexone is tablets are usually given at a dose of50 mg/day, although many patients start at a lower dose to reduce any side effects. 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 naltrexone to block craving typically last a month.
For someone who recognizes that they are drinking too much, taking naltrexone an hour before drinking can help them reduce the amount of alcohol they consume. When this method of taking naltrexone continues faithfully over time with the intention of extinguishing any alcohol craving, the method is referred to as the Sinclair Method. See more details about this on the Sinclair Method page.
Naltrexone has other uses as well. Injectable depo naltrexone is often used to help people with opiate use disorder. A related drug, naloxone, is used to revive someone who has overdosed on opiates. Naltrexone has also been used to help people with process addictions, such as gambling, pornography, or internet addiction. At very low doses, naltrexone can reduce inflammation and pain.
Physicians often like to prescribe naltrexone because its effects are well known, and it is relatively safe. 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. Naltrexone can cause psychiatric side effects as well. If someone has been using opiates and takes a naltrexone pill, they will immediately develop severe withdrawal symptoms. That’s why patients should wait several days after stopping opiates before taking their first naltrexone pill.
Another issue with naltrexone is that if someone taking it requires surgery or emergency pain relief, the effect of any 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.
Acamprosate is an FDA approved medication which helps heavy drinkers stop drinking. Acamprosate can reduce persistent symptoms of abstinence such as craving, 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. I helped study this drug and published this article about how it works on 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, is taken every day to help reinforce someone's desire to be abstinent. 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.
Disulfiram works by blocking the normal metabolism of alcohol. 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 is used “off label” to help reduce the craving for alcohol, and often has a better effect than naltrexone. Topiramate seems to reduce craving associated with anxiety, and is particularly helpful early in early abstinence to help people with alcohol use disorder avoid a relapse to heavy drinking. It can be used together with naltrexone to have a greater effect than either drug has when used individually. Topiramate has a peak blood level occurring approximately 90 minutes after an oral dose. Because topiramate can be given safely to patients with evidence of liver damage, it is especially helpful for very heavy drinkers.
Topiramate was originally used to treat epilepsy, but is now also FDA approved as a treatment for migraines. It is also sometimes used "off label" to help people lose weight.
Possible side effects 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 used “off label” to reduce alcohol craving; it is very commonly used in France and Australia. Patients taking baclofen often describe a significant loss of cravings, and a progressive indifference to alcohol allowing them to reduce consumption to a healthy level or quit entirely. Here is a letter I published about this.
Some people drink, in part, to calm symptoms of anxiety and stress. These symptoms can sometimes trigger a relapse for patients who have achieved abstinence for a period of a few weeks, months or even years. Baclofen can prevent this problem by acting on the GABA receptor system to alleviate 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 may help 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. This titration from a low to a high dose, for purposes of avoiding side-effects, can take up to several months before reaching a dose level that achieves 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. Baclofen can be given safely to patients with evidence of liver damage, so it may be especially helpful for very heavy drinkers. Side effects are common, but usually not serious. Some patients report having nausea, vertigo, sleepiness, fatigue, lightheadedness and abdominal pain when taking baclofen.
Ondansetron is approved by the FDA to treat nausea, but at a fraction of that dose, it is effectively used “off label” to reduce alcohol consumption. Research indicates that it can markedly reduce alcohol craving in people who have inherited a specific gene which influences serotonin function or who have experienced alcohol problems by the time they have reached their early twenties. It can be combined with naltrexone to produce even greater effects than either drug used alone. Adverse effects associated with ondansetron at the low dose employed are few, but include constipation and headache. Ondansetron can adversely affect the electrical conduction of the heart, so it is avoided in patients with underlying heart conditions. Here is a letter I published about this.
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 to treat high blood pressure. It is also used to treat 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. These effects can be dramatic, especially at higher doses. 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. Many 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, and 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.