Medication and its Role in the Treatment of Alcohol Use Disorder
The U.S. Preventive Services Task Force (USPSTF) recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use. 1 Binge drinking and heavy drinking are both forms of risky or hazardous drinking. Binge drinking is defined by National Institute on Alcohol Abuse and Alcoholism (NIAAA) as consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours. NIAAA defines heavy alcohol use as more than 4 drinks on any day for men or more than 3 drinks for women. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines heavy alcohol use as binge drinking on 5 or more days in the past month. 2 Binge drinking and heavy drinking can increase an individual’s risk of developing an alcohol use disorder.
According to the National Survey on Drug use and Health 2018 an estimated 14.8 million people aged 12 or older had an alcohol use disorder, corresponding to 5.4% of the population.3 Individuals diagnosed with an alcohol use disorder should be recommended treatment. One available treatment option is the use of medications. Medications used in the treatment of alcohol use disorders can be provided in the primary care setting or specialty medicine setting. Most often the use of medication is done in conjunction with psychosocial treatments such as 12 step programs, individual therapy, and/or group addiction counseling. Medications are not a cure but a tool some individuals benefit from. Individuals with alcohol use disorder are at risk for alcohol withdrawal and may require medical management of withdrawal prior to initiating treatment. Your doctor can work with you to determine what setting (outpatient or inpatient) is appropriate.
Four medications are approved by the U.S. Food and Drug Administration (FDA) to treat alcohol use disorder: disulfiram, oral naltrexone, long acting injectable naltrexone, and acamprosate.
- Disulfiram was the first medication approved for the treatment of alcohol abuse or alcoholism and is considered a second line agent (naltrexone and acamprosate are first line). Disulfiram causes negative physical symptoms when alcohol is consumed. Typical aversive symptoms can include fast heart rate, skin flushing, low blood pressure, nausea and vomiting. Disulfiram is most effective when taken in a monitored environment or at home with the help of a loved one to ensure adherence.
- Naltrexone is available as an oral tablet and a long acting injection (monthly). Naltrexone works by inhibiting or blocking the brains mu opioid receptor. It is not an opioid and is not addictive. Naltrexone is used for both alcohol use disorders and opioid use disorder. It is best to start Naltrexone when abstinent from alcohol or when symptoms of alcohol withdrawal have subsided. By blocking the brains opioid receptors, the pleasurable effects of alcohol are diminished or not felt. Naltrexone can help to maintain sobriety, reduce cravings for alcohol and reduce the amount consumed if a relapse occurs. Individuals with severe liver disease are not good candidates for Naltrexone.
- Acamprosate is available as an oral medication taken three times per day. It has been shown to reduce cravings and withdrawal distress. Acamprosate’s mechanism of action is not fully understood. Available research suggests interaction with the glutamate neurotransmitter system. Acamprosate has been shown to reduce post-acute or protracted withdrawal symptoms such as insomnia and anxiety. Individuals with severe kidney disease are not good candidate for Acamprosate.
Alcoholism affects individuals physically, emotionally and spiritually therefore treatment should target all three areas. No single treatment approach is effective for everyone. Medications can be considered in conjunction with brief therapy or more extensive psychosocial treatments. Please speak to your doctor to discuss available treatment options and determine an individualized treatment plan to assist in your recovery goals.
- US Prevention Services Task Force. Published recommendations. https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P. Accessed September 24, 2020.
- National Institute on Alcohol abuse and Alcoholism. Drinking levels defined. https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking. Accessed September 24, 2020.
- Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/