Treatment Guide
Disulfiram (Antabuse) is a prescription drug that interferes with the body’s metabolism of alcohol, resulting in unpleasant effects when alcohol is consumed. It is not a cure for alcoholism and does not stop cravings, but is used as a physical and psychological deterrent— if you drink while taking it, you will get sick.
The negative effects of taking disulfiram and alcohol together can be felt almost immediately after consumption and can last from 30 minutes to several hours, for as long as there is alcohol in the bloodstream. Reactions range from mild to severe and can include nausea, vomiting, headache, chest pain, blurred vision, confusion and respiratory difficulty.
It is necessary to abstain from alcohol for 24 hours before taking disulfiram. Disulfiram should only ever be given to someone who is trying to quit drinking and is fully aware of the consequences of drinking while taking it. Cough syrups, wine vinegar, and other products containing alcohol should be avoided while taking disulfiram.
There is some evidence that disulfiram use is most successful when paired with supervision by a third party. An agreement to have a family member, health provider or other person encourage and monitor use has been shown to increase compliance and therefore effectiveness.
Naltrexone is a prescription drug that works as an opioid antagonist: it decreases cravings for alcohol by blocking opiate receptors in the brain, reducing the pleasure one feels when consuming alcohol. Naltrexone is available in both oral (Revia, Depade) and injectable (Vivitrol) forms and is also used to treat other addictions. Naltrexone should not be confused with naloxone (Narcan), a drug that is used to treat opiate overdoses. Nalmefene, a drug that is made from the same chemical compound as naltrexone, is used to treat alcohol addiction in the UK. Studies have shown that naltrexone is effective in reducing relapse rates and heavy drinking days in people addicted to alcohol.
Naltrexone Uses
The opioid antagonists naltrexone and nalmefene are not aversive therapy, meaning that they do not cause the illness-producing reactions that disulfiram (Antabuse) is known for if alcohol is consumed while taking the drug. Naltrexone is not a narcotic and is not addictive. Naltrexone can cause damage to the liver if taken in high doses but is not likely to do so when taken as directed.
Most doctors recommend that naltrexone be taken while abstinent from alcohol to help reduce cravings. For those who also use opioids, It is important that no opioids (such as heroin or opioid pain medication) are used for a minimum of 7-14 days prior to starting naltrexone. Since naltrexone blocks the brain’s opiate receptors, an opiate-dependent person who uses naltrexone will enter into immediate full opiate withdrawal.
The oral form of naltrexone is taken once per day. If taken as the injectable Vivitrol, a shot must be administered by a health care provider every four weeks, which is the length of time the drug remains active in the body. A 2017 pilot study found that patients adhered to their medication routines similarly whether they took naltrexone orally every day or as a monthly injection.
Naltrexone has been shown to be most effective when used as part of a larger treatment plan that may combine counseling, social support and medication.
While some physicians believe a patient must detox and abstain from alcohol while using naltrexone, others believe that some alcohol use at the onset of treatment is necessary for the drug to work. This latter approach is known as the Sinclair Method.
Related: NPR: Naltrexone effective for alcohol use disorder>
The Sinclair Method is a treatment protocol developed by Dr. John David Sinclair in which the prescription drug naltrexone is used to reduce cravings for alcohol. It is somewhat controversial in that it calls for the use of naltrexone in combination with the patient’s normal drinking habits, that is, patients do not need to go through detox first, or abstain from drinking in the first phase of treatment. In fact, proponents of the Sinclair Method insist that naltrexone must be used in combination with drinking to be effective.
The process by which naltrexone is believed to work within the Sinclair Method is called pharmacological extinction. Naltrexone must be taken each and every time the patient consumes alcohol, approximately one hour before drinking. When naltrexone is active in the body during alcohol consumption, endorphins normally released by drinking are blocked, along with the pleasurable feelings usually associated with drinking and, over time, alcohol loses its appeal.
Because the use of naltrexone blocks the enjoyment one feels from drinking alcohol, drinking is gradually reduced over a period of a few months. Some people who have used the Sinclair Method are reportedly able to enjoy a drink or two socially without drinking to excess as a result of treatment. Others choose to abstain altogether, but arrive at abstinence without acute cravings.
Problems with the Sinclair Method have generally resulted from lack of compliance—that is, patients forget to take naltrexone before drinking, or choose not to. Relapse to old drinking habits is not immediate, but can be rapid when the medication is discontinued.
The methodology and mechanism behind the Sinclair Method is described in detail in a book called The Cure for Alcoholism by Dr. Roy Eskapa. Clinics that practice this method include the Contral Clinic in Finland and New Era Assisted Recovery, a clinic in Florida. Note that the method practiced at the Contral Clinic is similar to and based upon the Sinclair Method, but includes counseling as an essential part of treatment.
American actress Claudia Christian has become an advocate for the Sinclair Method, and has created the C Three Foundation dedicated to promoting it, with a European offshoot.
Acamprosate is a prescription medication that has been shown to reduce cravings for alcohol in alcohol-dependent patients when used as part of a comprehensive program that includes counseling or other support. Acamprosate restores the balance of chemicals in the brain that have been disrupted by long-term alcohol abuse, helping the brain to begin working normally again. It is non-addictive.
Acamprosate may reduce sweating, anxiety and sleep disturbances that many experience during the early stages of alcohol abstinence. However, it is not intended for use as a detox aid as it will not help with the more severe effects of alcohol withdrawal. Acamprosate is generally taken as two tablets three times per day, so a measure of discipline is required to ensure the drug stays active in the patient’s body. People who have kidney problems might not be able to take this medicine or might need to take lower doses.
SAMHSA Fact Sheet on Acamprosate>
Topiramate (Topamax) is a prescription medication used to treat seizures and prevent migraines. It is also sometimes prescribed off-label for the management of alcohol dependence. It has not yet been FDA approved for this purpose.
Scientific research indicates that topiramate shows promise for reducing cravings for alcohol, thus helping heavy drinkers consume less. It is believed that topiramate decreases the desire to drink, perhaps by reducing the neurochemical surge that alcoholics get when they consume a drink.
A meta-analysis of seven randomized controlled trials, which included 1,125 people, found that topiramate was useful in helping people with alcohol use disorder to stay abstinent. In these studies, topiramate worked better than placebo to decrease alcohol use and to increase the number of days without drinking. There may be a genetic factor that affects topiramate’s efficacy in treating AUD within specific groups.
More research is needed to understand the role topiramate could play in treating alcohol use disorder.
U.S. National Library of Medicine: Topiramate>
Medscape: Topiramate in the Treatment of Alcohol Use Disorders>
Baclofen (Lioresal) is a prescription medication used to treat muscle spasms. It is sometimes prescribed off-label to treat alcohol use disorder (AUD), and has been widely used for this purpose in France. It has not yet been approved by the FDA for treatment of AUD.
Scientific studies are not yet conclusive on baclofen’s efficacy in treating alcohol use disorder. A 2015 study showed that high-dose baclofen supported abstinence in alcohol dependent patients and was well tolerated. However, the largest clinical trial to date, a 2010 study by Dr. James Garbutt, did not find baclofen to be more effective than a placebo.
The most recent study, a meta-analysis of 12 randomized controlled trials (RCTs) involving 590 people, found that while baclofen is associated with higher rates of abstinence than placebo, it was ineffective in other measures related to AUD treatment. The 2018 study found that taking baclofen led neither to an increase in the number of days a person remained abstinent, nor to a decrease in heavy drinking, craving, anxiety or depression, suggesting that using baclofen as an AUD treatment is premature. The study authors noted that further research is warranted and that baclofen may be an effective option for AUD patients with liver disease who cannot physically tolerate other medications.
Preliminary results from the Bacloville clinical trial [1] [2] in France, in which individually-titrated doses of baclofen were given to participants in increasing doses, found a higher rate of safe drinking (fewer than 2 drinks a day for women, 4 drinks per day for men) in those given baclofen versus those given placebo after a year. Further results from this study are pending.
However, the results of two other clinical trials, the Alpadir Study (France) and Beraha study (Netherlands), both presented at the World Congress for Alcohol and Alcoholism in Berlin in September 2016, showed no difference between baclofen and placebo groups.
A 2017 study assessing safety and efficacy of baclofen for treating people with alcohol use disorder and high levels of anxiety showed that baclofen affected subjective and physiological responses to alcohol, but did not support an anti-craving or anti-reinforcing effect.
A 2016 study found that neither low nor high doses of baclofen were effective in the treatment of AUD although both had markedly high success rates due to the intensive psychosocial support in place.
Dr. James Garbutt, whose 2010 study did not show baclofen to be more effective than placebo, is currently engaged in a new study testing baclofen in higher doses than were used in the previous study.
Further research is needed to discover whether baclofen can be effectively used to treat AUD.
Gabapentin is a generic anti-convulsant drug currently used to treat seizures and some types of pain. It is sometimes prescribed off-label to treat alcohol use disorder. It has not yet been approved by the FDA for this purpose.
A 2013 study showed that gabapentin helped increase abstinence rates in 150 heavy drinkers. In conjunction with short individual weekly counseling sessions, gabapentin was found to be more effective than placebo in helping the alcohol dependent participants to stop or decrease their drinking. It also helped to treat some of the symptoms that may lead people to relapse: insomnia, dysphoria, and craving. The researchers who conducted the study state that larger studies in more diverse populations are needed in order to confirm and expand upon their findings.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recently completed a six-month clinical trial to study the safety and efficacy of gabapentin enacarbil and will soon publish the results. Gabapentin enacarbil, an extended-release formulation of the generic drug gabapentin, is currently sold as Horizant and is used to treat restless leg syndrome and certain types of nerve pain. It is hoped that this long-acting form of gabapentin, which is better absorbed into the bloodstream, will be even more successful in treating AUD. One of the limitations of the 2013 gabapentin study was that the participants had to take the medication 3 times a day and would sometimes forget to take the middle dose. The extended release form, which only needs to be taken twice a day since it stays evenly in the bloodstream longer, may help circumvent that problem.
The new study enrolled 346 patients in a randomized, double blind, placebo-controlled clinical trial of gabapentin enacarbil in patients with AUD at 10 sites across the United States. More information on this study>
Further study is needed to determine gabapentin’s effectiveness in treating AUD.
Although medications for alcohol addiction have been available for many years, many physicians are still untrained in their administration and use. While we at PGDF, as well as other organizations, are working to improve knowledge of addiction in primary care, as of this writing, you are most likely to find medication for AUD by seeking an addiction psychiatrist. A psychiatrist is a medical doctor specializing in treatment of behavioral health conditions, and is able to prescribe medication and oversee a holistic, long-term treatment plan.
If you have health insurance, be sure to check mental health services coverage under your plan. You may need to contact your primary care physician or your insurance company for a referral to an addiction specialist.
If you have completed or are considering clinical treatment, many facilities include medication prescription and management as part of their care. Be sure to ask any facility that you are considering how their medication management program works.
American Academy of Addiction Psychiatry: About Addiction Psychiatry>
Search for an addiction psychiatrist in your area>
Resources for caregivers
If you do not have access to an addiction specialist and your primary care physician is unfamiliar with medications for AUD, you can provide them with the following information to help orient them. Please note that most of the following links are to articles on the PGDF blog that link to scientific or mainstream news sources.
NPR: Naltrexone effective for alcohol use disorder>
Alcohol use disorder is undertreated, medications underused>
Wall Street Journal article summarizes current treatments for AUD>
From CNN Health: Are Medications for Alcoholism Underutilized?>
Larry King Now: Rethinking Alcoholism>
Diane Rehm Show: New Ways of Treating Alcoholism>
Agency for Healthcare Research and Quality publishes new resources on medication for AUD>
SAMHSA: Medications for the Treatment of Alcohol Use Disorder: A Brief Guide>
WebMD Summary of Medications for AUD>
SAMHSA: Physicians’ Pocket Guide to Medication for the Treatment of Alcohol Use Disorder>
Up to Date: Review of Literature on Pharmacotherapy for AUD>
Finding new, effective medications for alcohol addiction is a high priority for scientific researchers. As we hear about new compounds that are being studied for this use, we will post them here.
Ibudilast: Asthma drug may be useful in treating AUD>
OSU6162: Novel drug stabilizes dopamine to treat alcohol dependence>
Liraglutide: Diabetes drug may decrease craving for alcohol>
Isradipine: Blood pressure drug may erase addiction “triggers”>
D-cycloserine: Antibiotic shows promise for AUD treatment>