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Medications for alcohol use disorder

By Alcohol.help editors, Editorial staff ·

Clinical review pending. This guide was written from the sources it cites but has not yet been reviewed by a licensed clinician.

Four medications are FDA-approved for alcohol use disorder in the US: naltrexone tablets, the monthly naltrexone injection (Vivitrol), acamprosate and disulfiram. NIAAA says none of them is addictive, any clinician licensed to prescribe can write them, and in 2025 only 2.6% of people with alcohol use disorder received one.

The four approved drugs compared

Medication How it’s taken Who it tends to suit
Naltrexone tablets (approved for alcohol in 1994) 50 mg by mouth once a day People who want to cut down or stop; works best if you can go several days without drinking before starting
Extended-release naltrexone (Vivitrol) 380 mg injection deep into the buttock muscle every 4 weeks, given by a clinician People who are able to stay off alcohol while living at home and going to outpatient care
Acamprosate (approved 2004) Two 333 mg tablets three times a day People who have already stopped drinking when they start it
Disulfiram (Antabuse, approved 1951) 250 mg or 500 mg tablets, started only after at least 12 hours without alcohol People whose goal is not drinking at all and who fully understand the risks

Naltrexone, in both forms, blocks opioid receptors involved in the rewarding effects of drinking and in craving. Acamprosate helps people who have already stopped drinking keep from starting again. Disulfiram stops the body from breaking down alcohol at the acetaldehyde stage, so drinking causes flushing, a throbbing headache, nausea and heavy vomiting.

Each one has cautions. Naltrexone can’t be taken with opioid pain medicine (including tramadol) or while dependent on opioids, it carries a liver warning, and overdose risk is higher if you use opioids after stopping it. The injection follows the same opioid rules and adds injection-site reactions and warnings for liver injury, depression and suicidal thoughts. Acamprosate needs a lower dose with moderate kidney impairment, isn’t for severe kidney impairment, calls for watching for depression, and does not treat withdrawal. Disulfiram reactions can happen up to 14 days after the last dose, hidden alcohol in sauces and cough mixtures counts, and the drug isn’t for severe heart disease or psychosis; it has also caused rare cases of fatal hepatitis.

Acamprosate means six pills a day. Disulfiram’s reaction isn’t mild: severe reactions can include heart rhythm problems, convulsions and death, which is why the label says it must never be given to someone who is intoxicated or who doesn’t know they’re taking it.

What the evidence shows

A 2014 JAMA meta-analysis by Jonas and colleagues pooled 122 randomized trials and one cohort study, covering 22,803 adults treated in outpatient care.

Results are reported as “number needed to treat,” or NNT. An NNT of 12 means that if 12 people take the drug instead of a placebo, about one more of them avoids going back to drinking. It does not mean the drug works for only 1 in 12 people. It’s the extra margin the drug adds over placebo.

  • Acamprosate had an NNT of 12 to prevent a return to any drinking.
  • Naltrexone tablets, 50 mg a day, had an NNT of 20 to prevent a return to any drinking, though the confidence interval ran from 11 to 500, so that estimate is shaky. For preventing a return to heavy drinking, the NNT was 12.
  • In head-to-head trials, acamprosate and naltrexone showed no statistically significant difference.
  • Injectable naltrexone had no significant effect on returning to any or heavy drinking, but about 4.6 percentage points fewer heavy drinking days.
  • For disulfiram, the authors found that well-controlled trials don’t adequately support it for preventing a return to drinking.

On side effects, naltrexone had a number needed to harm of 48 for quitting the drug because of them. Acamprosate and topiramate showed no significant increase in dropouts.

The practical read: naltrexone looks strongest if your goal is to stop drinking heavily, and acamprosate if you’ve already stopped and want to stay stopped. Disulfiram has the weakest trial evidence of the four, though the APA still lists it as an option for people set on not drinking at all.

What the guidelines recommend

The American Psychiatric Association’s 2018 guideline recommends offering naltrexone or acamprosate to people with moderate to severe alcohol use disorder who want to cut down or stop, prefer medication or haven’t done well with therapy alone, and have no reason they can’t take it. It gives disulfiram a weaker “suggests” for people aiming for abstinence who understand the risks.

The VA and Department of Defense guideline (2021) puts naltrexone, oral or injectable, and topiramate in its strongest category for moderate to severe alcohol use disorder. Acamprosate and disulfiram get a weaker recommendation there.

So acamprosate sits at the top tier in one guideline and a step down in the other, and topiramate does the reverse. Neither ranking is “right.” Your prescriber will weigh your kidneys, your liver, any opioid use, and what you’re trying to achieve.

Off-label options: topiramate and gabapentin

Topiramate and gabapentin aren’t FDA-approved for alcohol use disorder, but both guidelines mention them. The APA suggests either one for people who prefer them or who couldn’t tolerate, or didn’t respond to, naltrexone and acamprosate. The VA/DoD suggests gabapentin when first-line drugs are ruled out or haven’t worked. The Jonas review found moderate evidence that topiramate cut heavy drinking days by about 9 percentage points.

How underused these drugs are

The 2025 National Survey on Drug Use and Health counted 25.7 million people aged 12 and older with past-year alcohol use disorder. Of those, 2.6%, about 679,000 people, received a medication for it. For opioid use disorder the comparable figure was 15.7%.

The survey only asked about the four approved drugs, so people prescribed topiramate or gabapentin weren’t counted. Even allowing for that, the gap is wide. NIAAA calls these medications “vastly underused.”

You don’t need a specialist. NIAAA notes that primary care clinicians can offer these medications along with brief counseling. Asking your own doctor by name for naltrexone or acamprosate is a reasonable place to start.

Before you start

These drugs prevent relapse; none of them treats withdrawal. If you drink heavily every day, read how to stop drinking safely before you stop. And if you take or might need opioids, naltrexone has rules you’ll want to understand first: see naltrexone for alcohol.

To find a program near you that prescribes these medications, enter your ZIP code in the finder or browse treatment by state. How we build that list is explained on our data page.

Sources

About the author

Alcohol.help editors, Editorial staff. Guides are written from the sources cited on each page: FDA drug labels, NIAAA and SAMHSA publications, clinical practice guidelines and federal survey data. No clinician has reviewed them yet; that review is pending and will be named on the page when it happens.

More guides

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Naltrexone for alcohol

Naltrexone blocks the reward from drinking. Pill vs monthly shot, the opioid rules, the liver warning, and who can prescribe it, including by telehealth.

How to help someone who drinks too much

A family approach called CRAFT got 64% of reluctant drinkers into treatment in a trial, vs 30% for a staged intervention. How to start, and protect yourself.

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