Alcohol Use Disorder Medication Is Safe, Effective, and Seriously Underused

For Adam, drinking alcohol was like turning on a Christmas tree.

“My brain would light up and I’d want more and more,” he said in an interview with The Pew Charitable Trusts. “But taking naltrexone, it’s like someone unplugged the tree. It never lights up.”

Because there is a stigma around alcohol use disorder (AUD), Adam asked to be identified by his first name only.

Naltrexone is one of three medications approved by the U.S. Food and Drug Administration(FDA) to treat AUD. It works by blocking chemical interactions in the brain that make drinking pleasurable. Some patients take it regularly to abstain from alcohol; others take it as needed an hour before consuming alcohol to curb overuse. Acamprosate is prescribed primarily for people who have stopped drinking to reduce cravings and help them maintain abstinence. Disulfiram is an aversion therapy; it discourages drinking by inducing nausea, vomiting, and other painful side effects when people consume alcohol. It can be dangerous for patients with certain conditions like heart or liver disease, so doctors tend to prescribe it less often than the other FDA-approved drugs.

“One of the first times I took naltrexone, I couldn’t finish a glass of wine,” Adam said. “I just kept forgetting about it”—a big change for someone who had been drinking since childhood and heavily as an adult.

The National Institute on Alcohol Abuse and Alcoholism defines AUD as a “medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences.”

“There’s a misconception that the only way to treat alcohol use disorder is abstinence,” said Katie Witkiewitz, Ph.D., director of the Center on Alcohol, Substance use, And Addictions at the University of New Mexico. “But people avoid treatment because they don’t want to stop. There are a lot of pathways to recovery and a lot of those pathways include some level of use. ‘Relapse’ is not a great term; recovery is just bumpy.”

“Before naltrexone, I would get sober,” Adam said, “but then I’d go to a bar and get drunk, and then 45 days of sobriety were wasted. I learned nothing and I’d think, now I’ve got to start all over again so I might as well keep drinking—as opposed to disrupting that cycle that I was stuck in and saying instead, 45 days sober is really good; drinking for one day did not undo all of that; I’m going to use this as a learning experience and do 90 days the next time.”

Dr. Paul Linde, a former emergency room psychiatrist who now treats people with AUD as medical director for psychiatry and collaborative care at Ria Health, explained that people who consume large amounts of alcohol daily may need inpatient care to stop drinking safely.

“But we get patients who can’t take a break from their life because of their job, they’re a single parent, or they’re caring for elderly parents,” he said. In those cases, he often provides care, including naltrexone, via telehealth as an alternative to residential or intensive outpatient care.

For people who have stopped drinking and have abstinence as their goal, Linde also prescribes acamprosate. “They come back and say, ‘I don’t even think about alcohol,’” he said.

Despite stories like these and studies demonstrating that medications effectively help people reduce or stop drinking, these drugs are rarely prescribed. In 2022, of the 29.5 million people 12 years of age and older in the United States with AUD, only 634,000—or 2.1%—received any medication for it.

Siloes separating medical and behavioral health and stigma in the U.S. health system contribute to the underuse of medication.

“For more than 100 years, we’ve carved addiction treatment out from the rest of the medical system,” said Dr. Sarah Wakeman, an addiction medicine physician, researcher, and senior medical director for substance use disorder at Mass General Brigham. “There are a few thousand addiction specialists like me across the country but hundreds of thousands of primary care doctors. Just like any other health condition, we have specialists for really complex cases, but anyone who goes to medical school should learn how to manage mild and moderate conditions. There’s no way we’ll ever address the crisis of alcohol use disorder if we expect only specialists to treat this.”

Yet doctors are often reluctant to screen for and treat AUD.

“Too many providers are afraid to even ask questions,” said Witkiewitz. “Maybe they don’t want to know because they don’t feel like they have resources or referral sources. The stigma around drinking doesn’t facilitate these open-ended and nonjudgmental discussions.”

Adam tried different abstinence-only treatments for years, but no provider ever mentioned medication to him. One experience was particularly stigmatizing.

“I went to an outpatient addiction center and didn’t like it,” he said. “I was taken into a room, searched, asked very invasive questions. The worst part was feeling like I had already let them down just by being there. You’re treated differently when you’re seen as an addict. When you’re treated like a patient, you get much better treatment.”

Another barrier: Patients are often unaware that there are medications and do not know to ask their providers about them. Adam only learned about naltrexone because he is a science fiction fan and saw an interview with an actor on “Babylon 5,” Claudia Christian, who advocates for the medication through the C Three Foundation.

“People who want help with their alcohol use should feel empowered to ask their primary care provider about medication options for AUD,” said Frances McGaffey, associate manager of Pew’s substance use prevention and treatment initiative, “but it’s unfair to put the onus on them, and it’s understandable if they’re afraid to start this conversation because of stigma. Doctors, medical educators, policymakers, and insurers need to drive more informed, more open, and less judgmental conversations about alcohol use disorder and the full range of treatments that can support recovery.”

“Recovery means living a different, better life,” said Adam. “Recovery is getting to know yourself all over again, and becoming your own friend and your own advocate for your own health.”

If you’re concerned about your alcohol consumption, you can use the Check Your Drinking tool, created by the Centers for Disease Control and Prevention, to assess your drinking levels and make a plan to reduce your use.

Josh Wenderoff works on Pew’s health programs.