Medications for Alcohol Use Disorder: Naltrexone, Acamprosate, and Disulfiram

Medications That Work

Alcohol use disorder is a medical condition — and like most medical conditions, it can be treated with medication. Three medications are FDA-approved for alcohol use disorder: naltrexone, acamprosate, and disulfiram. These medications are underutilized — research suggests that fewer than 10% of people with alcohol use disorder receive medication-assisted treatment — but they are effective, and they can significantly improve outcomes when combined with behavioral treatment and peer support.

Understanding how these medications work, who they are appropriate for, and what to expect from them is important for anyone navigating alcohol use disorder.

Naltrexone

Naltrexone is an opioid receptor antagonist — it blocks the opioid receptors in the brain that mediate the pleasurable effects of alcohol. When alcohol is consumed in the presence of naltrexone, the rewarding effects are significantly reduced. Over time, this reduces the motivation to drink and can help people drink less or stop drinking entirely.

Naltrexone is available in two forms: a daily oral tablet (ReVia, Depade) and a monthly injectable formulation (Vivitrol). The injectable formulation has the advantage of eliminating the need for daily adherence — a significant benefit for people who struggle with medication compliance.

Naltrexone is most effective when combined with behavioral treatment. The COMBINE study — one of the largest clinical trials of alcohol use disorder treatment — found that naltrexone combined with behavioral therapy produced significantly better outcomes than either treatment alone.

Naltrexone is contraindicated in people who are currently using opioids or who are in opioid withdrawal — it will precipitate severe withdrawal in opioid-dependent individuals. It is also contraindicated in people with acute hepatitis or liver failure. It can be used in people with mild to moderate liver disease, but liver function should be monitored.

Acamprosate

Acamprosate (Campral) works differently from naltrexone. It modulates the glutamate and GABA systems in the brain — the systems that are dysregulated by chronic alcohol use and that drive the anxiety, restlessness, and discomfort of post-acute withdrawal. By stabilizing these systems, acamprosate reduces the protracted withdrawal symptoms that can drive relapse in early recovery.

Acamprosate is most effective for people who have already achieved abstinence and are trying to maintain it — particularly people who experience significant anxiety, restlessness, and discomfort in early recovery. It is taken three times daily and is generally well-tolerated. It is not metabolized by the liver, making it safe for people with liver disease.

Acamprosate does not reduce the pleasurable effects of alcohol — it reduces the discomfort of not drinking. This makes it complementary to naltrexone, which reduces the pleasure of drinking. Some people benefit from taking both medications simultaneously.

Disulfiram

Disulfiram (Antabuse) works through a completely different mechanism: it blocks the metabolism of alcohol, causing a highly unpleasant reaction when alcohol is consumed. The disulfiram-alcohol reaction includes flushing, nausea, vomiting, headache, palpitations, and in severe cases, cardiovascular collapse. The threat of this reaction deters drinking.

Disulfiram is most effective when it is taken under supervision — when a family member, sponsor, or healthcare provider observes the person taking it daily. Without supervision, adherence is poor — people who want to drink simply stop taking the medication. With supervision, it can be a powerful deterrent.

Disulfiram is not appropriate for everyone. It requires a commitment to abstinence (not just reduced drinking), and it carries risks for people with certain medical conditions (heart disease, liver disease, psychosis). It also requires avoiding all alcohol-containing products — including mouthwash, some medications, and certain foods.

Talking to Your Doctor

If you are interested in medication-assisted treatment for alcohol use disorder, talk to your primary care doctor or an addiction medicine specialist. These medications are safe, effective, and covered by most insurance plans. They are not a substitute for behavioral treatment and peer support — but they are a valuable addition to a comprehensive recovery plan.

The stigma around medication-assisted treatment — the belief that "real recovery" doesn't use medication — is not supported by evidence. Using every tool available to support your recovery is not weakness; it is wisdom.