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Medications for Alcohol Use Disorder

Elisabeth Poorman, MD, MPH
Brianna M. McQuade, PharmD, MHPE
Sarah Messmer, MD

American Family Physician. 2024;109(1):71-78.

Author disclosure: No relevant financial relationships.

Excessive alcohol use is a leading cause of preventable death in the United States, with alcohol-related deaths increasing during the pandemic. The Substance Abuse and Mental Health Services Administration recommends that physicians offer pharmacotherapy with behavioral interventions for patients diagnosed with alcohol use disorder. Several medications are available to help patients reduce drinking and maintain abstinence; however, in 2019, only 7.3% of Americans with alcohol use disorder received any treatment, and only 1.6% were prescribed medications to treat the disorder. Strong evidence shows that naltrexone and gabapentin reduce heavy-drinking days and that acamprosate prevents return-to-use in patients who are currently abstinent; moderate evidence supports the use of topiramate in decreasing heavy-drinking days. Disulfiram has been commonly prescribed, but little evidence supports its effectiveness outside of supervised settings. Other medications, including varenicline and baclofen, may be beneficial in reducing heavy alcohol use. Antidepressants do not decrease alcohol use in patients who do not have mood disorders, but they may help patients who meet criteria for depression to decrease their alcohol intake. Systematic policies are needed to expand the use of medications when treating alcohol use disorder in inpatient and outpatient populations.

Excessive alcohol use is a leading cause of preventable death in the United States, contributing to an estimated 1 in 5 deaths among adults 20 to 49 years of age between 2015 and 2019.1 Alcohol-related deaths in the United States have been increasing steadily for the past two decades at a rate of 2.2% per year.2 This trend accelerated significantly after the start of the COVID-19 pandemic; preliminary data show that where alcohol was listed as a proximate cause on the death certificate, a 25.9% increase in deaths occurred in the first 12 months after March 2020 (79,000 to 95,000 deaths) compared with the previous year.2 Excessive alcohol consumption is also a major risk factor for many common chronic conditions, including high blood pressure, sleep apnea, and liver disease.3 The health effects of alcohol are most closely related to the total amount of alcohol consumed, as well as the number of heavy-drinking days, with a linear increase in alcohol-related mortality for every heavy-drinking day.4 A heavy-drinking day is defined as three or more standard drinks in a day for a woman and four or more in a day for a man.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Patients who have AUD should be offered pharmacotherapy.3,8,10,11 A Consistent results from multiple trials
Naltrexone (Revia) is first-line treatment for patients with AUD to decrease heavy-drinking days and to improve abstinence.10,14,15 A Consistent results from multiple RCTs
Gabapentin, which is safe for patients who are still drinking, should be prescribed for those with AUD to decrease heavy-drinking days.12,19 A Consistent results from multiple RCTs
Acamprosate should be used for patients with AUD who are currently abstinent to prevent return-to-use.10,22–25 A Consistent results from multiple RCTs
Topiramate should be used to decrease heavy-drinking days in patients with AUD.10,26–30 B Mixed evidence from multiple RCTs evaluating patient-oriented outcomes
Oral naltrexone, 50 mg, and intramuscular naltrexone (Vivitrol), 380 mg, appear to be safe in patients with liver disease, including compensated cirrhosis, and may improve and prevent alcoholic liver disease.42,43 B Consistent results from multiple observational studies

AUD = alcohol use disorder; RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort

ELISABETH POORMAN, MD, MPH, is an assistant professor of internal medicine and addiction medicine at the University of Illinois Chicago and medical director of the inpatient addiction consult service at the Jesse Brown Veterans Health Affairs Medical Center.

BRIANNA M. MCQUADE, PharmD, BCACP, MHPE, is a clinical assistant professor in the Department of Pharmacy Practice at the University of Illinois Chicago—College of Pharmacy.

SARAH MESSMER, MD, is an assistant professor of clinical medicine and pediatrics in the Department of Medicine at the University of Illinois Chicago—College of Medicine.

Address correspondence to Elisabeth Poorman, MD, MPH, University of Illinois Medical Center at Chicago: University of Illinois Hospital, 840 South Wood St., Chicago, IL 60612 (elisabeth.poorman@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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