Naltrexone for alcohol
Clinical review pending. This guide was written from the sources it cites but has not yet been reviewed by a licensed clinician.
Naltrexone is an FDA-approved medication for alcohol use disorder that blocks opioid receptors involved in the rewarding effects of drinking and in craving. It comes as a 50 mg pill taken once a day or a 380 mg injection given every 4 weeks. It isn’t an opioid, isn’t addictive, and any licensed prescriber can write it.
The big catch is opioids. If you take any opioid, including for pain, naltrexone is off the table until that changes.
What it does, and how well
Naltrexone doesn’t make you sick if you drink, the way disulfiram does. It takes some of the payoff out of drinking and can quiet the pull toward the next one.
In a 2014 JAMA meta-analysis of outpatient trials, the 50 mg daily pill had a number needed to treat of 12 for preventing a return to heavy drinking. That means roughly one extra person avoids going back to heavy drinking for every 12 who take naltrexone instead of a placebo. It is not a claim that it works for 1 in 12. For preventing any drinking at all the estimate was weaker and much less certain (NNT 20, with a confidence interval from 11 to 500).
So naltrexone fits well if your goal is to stop drinking heavily, even if you haven’t decided on never drinking again. The 2015 SAMHSA and NIAAA prescribing guide notes it works best in people who can stop drinking on their own for several days before they start it.
Pill or monthly shot?
| Naltrexone tablet | Extended-release injection (Vivitrol) | |
|---|---|---|
| Dose | 50 mg once a day | 380 mg every 4 weeks |
| Given by | You, at home | A clinician, deep into the buttock muscle |
| Approved for | Alcohol dependence and blocking opioids | Alcohol dependence in people able to stay off alcohol as outpatients; also opioid dependence |
| Trial evidence on drinking | NNT 12 for heavy drinking | No significant effect on returning to any or heavy drinking, but about 4.6 percentage points fewer heavy drinking days |
| Extra warnings | Liver | Liver, injection-site reactions, depression and suicidal thoughts |
The shot removes the daily decision to take a pill. The trade-off is that it’s a monthly appointment, and in Medicaid managed care plans it is more often covered with prior authorization or quantity limits (see the insurance section).
The opioid conflict
Naltrexone blocks opioids. That’s useful for people treating opioid addiction and a real problem for anyone who needs opioids for another reason. The labels say not to use it if you:
- are taking opioid pain medicine
- are currently dependent on opioids, including methadone or buprenorphine
- are in opioid withdrawal
- have a positive urine opioid screen or fail a naloxone challenge test
The label specifies that people treated for alcohol must be opioid-free, tramadol included.
The opioid-free window
If you’ve been dependent on short-acting opioids, the label recommends at least 7 to 10 days opioid-free before starting. People switching from buprenorphine or methadone may be at risk of sudden withdrawal for as long as two weeks. Starting too early can set off that withdrawal, which is why a prescriber may check with a urine screen or a naloxone challenge first.
If you’re likely to need opioid pain medicine soon, such as for planned surgery, raise it with your prescriber before you start.
Higher overdose risk after you stop
This is the warning that matters most for anyone who has ever used opioids. Once naltrexone wears off, your body can be more sensitive to opioids than before. A dose you used to take could be dangerous. The labels tell prescribers to discuss access to naloxone or nalmefene, the overdose-reversal drugs. If opioids are anywhere in your history, ask for naloxone when you get the prescription.
The liver warning
The tablet label carries a hepatotoxicity warning: cases of hepatitis and significant liver problems were seen. Liver injury showed up at doses up to 300 mg a day, far above the usual 50 mg. The current generic label has no boxed warning. If signs of acute hepatitis appear, naltrexone should be stopped.
The APA guideline says naltrexone shouldn’t be used in acute hepatitis or liver failure. For the injection, the SAMHSA/NIAAA guide’s panel advises avoiding it when liver enzymes are more than 5 times the upper limit of normal, except where the benefits outweigh the risks. If you have known liver disease, bring it up at the first visit.
Side effects push some people to stop. In the 2014 review, the number needed to harm was 48 for dropping out because of side effects.
Who can prescribe it
Any clinician licensed to prescribe medication. “Naltrexone can be prescribed and administered by any practitioner licensed to prescribe medications,” per SAMHSA. That includes your primary care doctor. NIAAA makes the same point: any physician can prescribe AUD medications, not only addiction specialists.
It also isn’t a controlled substance. Naltrexone doesn’t appear on the DEA’s list of controlled drugs. Buprenorphine, by contrast, is Schedule III. And SAMHSA notes naltrexone causes no withdrawal symptoms when you stop taking it.
Can you get it by telehealth?
Federal rules probably don’t stand in the way. The Ryan Haight Act’s in-person exam requirement for telemedicine prescribing, and the DEA’s temporary telemedicine flexibilities (which run through December 31, 2026), cover controlled substances, and naltrexone isn’t one. That’s our reading of the rules, not a federal statement. Your state’s telehealth and licensing rules, your insurer’s rules and the prescriber’s own judgment still apply.
The injection needs a clinician to give it, so a telehealth visit can start the process but someone has to administer the shot in person.
Will insurance cover it?
Often. In a study of 241 Medicaid managed care plans using 2021 data, 84.2% covered the naltrexone pill and 72.6% covered the injection. Prior authorization and quantity limits were rare except for the injection, where 42.8% of covering plans used them. That study didn’t include fee-for-service Medicaid or private plans. The paying for treatment guide covers the rest.
To find programs that prescribe naltrexone near you, use the ZIP code finder or browse treatment by state. For how naltrexone stacks up against acamprosate and disulfiram, see medications for alcohol use disorder.
Sources
- Naltrexone Hydrochloride Tablets USP label, DailyMed (published Sep 9, 2026)
- VIVITROL prescribing information, DailyMed (revised May 2026)
- Jonas DE, et al. Pharmacotherapy for Adults With Alcohol Use Disorders in Outpatient Settings. JAMA, 2014;311(18):1889-1900 (May 14, 2014)
- SAMHSA/NIAAA, Medication for the Treatment of Alcohol Use Disorder: Pocket Guide (2015)
- American Psychiatric Association, Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder (January 2018)
- NIAAA Alcohol Treatment Navigator, FAQs (no date shown)
- SAMHSA, Naltrexone (last updated Dec 22, 2025)
- DEA Diversion Control Division, Controlled Substances - Alphabetical Order (Oct 21, 2026)
- DEA, DEA extends telemedicine flexibilities (Dec 31, 2025)
- Federal Register, Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications (Dec 31, 2025)
- Stewart MT, et al. Alcohol Use Disorder Medication Coverage and Utilization Management in Medicaid Managed Care Plans. JAMA Network Open, 2025;8(3):e250695 (2025)