Medication for the Treatment of 

Alcohol Use Disorder: 

A Brief Guide 

U.S. Department of Health and Human Services 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

Division of Pharmacologic Therapies 

1 Choke Cherry Road 

Rockville, MD 20857 
Acknowledgments

This publication was prepared for the Substance Abuse and Mental Health Services Administration 

(SAMHSA) by JBS International, Inc. under contract number HHSS283200700003I/HHSS28342007T, 

with SAMHSA, U.S. Department of Health and Human Services (HHS). CDR Alina Salvatore, R.Ph., 

M.S., and LCDR Brandon T. Johnson, M.B.A., served as the Contracting Officer Representatives. 

Disclaimer 

The views, opinions, and content expressed herein are the views of the authors and do not necessarily 

reflect the official position of SAMHSA, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 

or HHS. Nothing in this document constitutes an indirect or direct endorsement by SAMHSA, NIAAA, or 

HHS of any non-federal entity’s products, services, or policies and any reference to a non-federal 

entity’s products, services, or policies should not be construed as such. No official support of or 

endorsement by SAMHSA, NIAAA, or HHS for the opinions, resources, and medications described is 

intended to be or should be inferred. The information presented in this document should not be 

considered medical advice and is not a substitute for individualized patient or client care and treatment 

decisions. 

Public Domain Notice 

All materials appearing in this volume except those taken directly from copyrighted sources are in the 

public domain and may be reproduced or copied without permission from SAMHSA or the authors. 

Citation of the source is appreciated. However, this publication may not be reproduced or distributed for 

a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. 

Electronic Access and Printed Copies

This publication may be downloaded or ordered at http://store.samhsa.gov. Or call SAMHSA at 1­

877-SAMHSA-7 (1-877-726-4727) (English and Español). 

Recommended Citation 

Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse 

and Alcoholism, Medication for the Treatment of Alcohol Use Disorder: A Brief Guide. HHS Publication 

No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration, 

2015. 

Originating Office

Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. HHS Publication 

No. (SMA) 15-4907. Printed 2015. 

i 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

CONTENTS 

Introduction ............................................................................................................................... 1
 

Considering Medications ......................................................................................................... 2
 

Screening and Assessing Patients .........................................................................................7
 

Screening for Risky Alcohol Use ......................................................................................7
 

Assessing the Need for Medication-Assisted Treatment ..................................................7
 

Developing a Treatment Plan and Selecting a Medication ....................................................9
 

Setting Goals for Medication-Assisted Treatment ............................................................9
 

Components of the Treatment Plan .................................................................................9
 

Educating the Patient and Obtaining Informed Consent ..................................................9
 

Evaluating the Need for Medically Managed Detoxification ...........................................10
 

Integrating Pharmacologic and Nonpharmacologic Therapies.......................................11
 

Addressing Co-Occurring Disorders ..............................................................................11
 

Treating Adolescents and Young Adults ........................................................................12
 

Treating Pregnant and Postpartum Women ...................................................................12
 

Treating Older Adults .....................................................................................................12
 

Selecting a Medication...................................................................................................13
 

Medication-Assisted Treatment ............................................................................................18
 

Initiating Treatment with Disulfiram ................................................................................18
 

Initiating Treatment with Naltrexone...............................................................................18
 

Initiating Treatment with Acamprosate ...........................................................................20
 

Treating People with Co-Occurring Disorders ................................................................20
 

Monitoring Patient Progress ..................................................................................................20
 

Monitoring ...................................................................................................................... 20
 

Adjusting the Treatment Plan .........................................................................................21
 

Summary ................................................................................................................................. 23
 

Appendix A: Members of the Consensus Panel, Staff, and Consultants .....................24
 

Appendix B: Sources of Helpful Information .......................................................................26
 

Appendix C: Acknowledgments ............................................................................................29
 

References .............................................................................................................................. 30
 

ii 
 

                                                                

 

 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

INTRODUCTION
 

Current evidence shows that medications are 

underused in the treatment of alcohol use 

disorder, including alcohol abuse and 

dependence.

* 

* Within this document “alcohol abuse” and “alcohol 

dependence” are used when discussing medication indications 

or research that is based upon this terminology. For a summary 

of important differences between DSM-IV and DSM-5, please 

see the box on this page. 

This is of concern because of the 

high prevalence of alcohol problems in the 

general population.1,2 For example, data show 

that an estimated 10 percent to 20 percent of 

patients seen in primary care or hospital 

settings have a diagnosable alcohol use 

disorder.3,4 People who engage in risky drinking 

often have physical and social problems related 

to their alcohol use. Problems with alcohol 

influence the incidence, course, and treatment 

of many other medical and psychiatric 

conditions.2 

Yet, of the 18.0 million people who met the 

criteria for alcohol dependence or abuse in 

2013, only a small subset (1.4 million) received 

any type of formal treatment (excluding mutualhelp groups)—ranging from a single meeting 

with a counselor to participation in a specialized 

treatment program.3 

Although many experts in addiction believe that 

patients with moderate or severe alcoholrelated problems should be offered medicationassisted treatment (MAT) on a routine basis,1 

considerable resistance to the use of MAT 

persists. A diagnosis of alcohol use disorder 

continues to carry significant social exclusion, 

which affects both the individual who receives 

the diagnosis and the health care professionals 

to whom that individual may turn for care. In 

part, the social exclusion continues because of 

a lack of understanding of alcohol use disorder 

as a treatable medical disorder2

 even though, 

more than 50 years ago, the American Medical 

Association (AMA) affirmed that dependence on 

alcohol and other drugs is a medical disorder.5 

The AMA encouraged physicians and other 

clinicians, health care organizations, and 

policymakers to frame all their activities and 

decisions in ways that reflect that fact. 

To clarify the situation, the National Institute on 

Alcohol Abuse and Alcoholism (NIAAA) and the 

Substance Abuse and Mental Health Services 

Administration (SAMHSA) jointly convened a 

Consensus Panel on New and Emerging 

Pharmacotherapies for Alcohol Use Disorders 

and Related Comorbidities (see Appendix A). 

The panel, which brought together experts in 

alcohol research, clinical care, medical 

education, and public policy, reviewed current 

evidence on the effectiveness of available 

medications for the treatment of alcohol use 

disorders and developed guidance for the use 

of medications in clinical practice.1

 The panel’s 

guidance is summarized in this document. 

Alcohol Use Disorder: A Comparison 

Between DSM-IV and DSM-5 

“In May 2013, the American Psychiatric 

Association issued the 5th edition of the 

Diagnostic and Statistical Manual of Mental 

Disorders (DSM-5). Although there is 

considerable overlap between DSM-5 and 

DSM-IV, the prior edition, there are several 

important differences: DSM–IV described two 

distinct disorders, alcohol abuse and alcohol 

dependence, with specific criteria for each. 

DSM-5 integrates the two DSM-IV disorders, 

alcohol abuse and alcohol dependence, into a 

single disorder called alcohol use disorder 

(AUD) with mild, moderate, and severe 

subclassifications. Under DSM-5, anyone 

meeting any two of the 11 criteria during the 

same 12-month period would receive a 

diagnosis of AUD. The severity of an AUD— 

mild, moderate, or severe—is based on the 

number of criteria met: 

 Mild: The presence of 2 to 3 symptoms 

 Moderate: The presence of 4 to 5 

symptoms 

 Severe: The presence of 6 or more 

symptoms 

The DSM-5 eliminates legal problems as a 

criterion, adds craving as a criterion for an AUD 

diagnosis and modifies some of the criteria 

descriptions with updated language.” 

––National Institute on Alcohol 

Abuse and Alcoholism6 

1 
 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

CONSIDERING MEDICATIONS 

Direct involvement of physicians and other health 

care professionals in identifying and treating 

alcohol use disorder is possible, practical, and 

necessary. The medications described here have 

been shown to be effective in, and are approved 

by the Food and Drug Administration (FDA) for, 

the management of alcohol dependence or the 

prevention of relapse to alcohol use.7,8,9,10,11 

Specifically: 

	 Acamprosate calcium is indicated for the 

maintenance of abstinence from alcohol in 

patients dependent on alcohol who are 

abstinent at treatment initiation. 

	 Disulfiram is an aid in the management of 

selected patients who want to remain in a 

state of enforced sobriety so that supportive 

and psychotherapeutic treatment may be 

applied to best advantage. 

	 Oral naltrexone (naltrexone hydrochloride 

tablet) is indicated for the treatment of alcohol 

dependence. 

	 Extended-release injectable naltrexone is 

indicated for the treatment of alcohol 

dependence in patients who have been able 

to abstain from alcohol in an outpatient 

setting. 

Clinicians should consider prescribing one of 

these medications when treating a patient who is 

dependent on alcohol or who has stopped 

drinking but is experiencing problems including 

cravings or relapses. Patients with moderate or 

severe alcohol use disorder, including those who 

have physiologic dependence or who are 

experiencing cravings and have not improved in 

response to psychosocial approaches alone, are 

particularly strong candidates for medicationassisted treatment.1,2 

Medications should be prescribed as part of a 

comprehensive treatment approach that includes 

counseling and other psychosocial therapies 

(through referral to a psychiatrist, psychologist, or 

professional counselor) and social supports 

(through participation in Alcoholics Anonymous 

and other mutual-help programs).1,2 

Table 1 summarizes information about each 

medication approved by the FDA for the 

treatment of alcohol use disorder and/or the 

prevention of relapse to alcohol use. 

2 
-

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

TABLE 1: Medications Approved for Use in the Treatment of Alcohol Use Dis

† This table highlights some properties of each medication. It does not provide complete information and is not intended as a substitute for the package insert

used by clinicians (see http://www.dailymed.nlm.nih.gov for current package inserts). For patient information about these and other drugs, visit the National 

(http://www.medlineplus.gov). Whether a medication should be prescribed and in what amount are matters to be discussed between an individual and his or 

prescribing information provided here is not a substitute for the clinician’s judgment, and the National Institutes of Health and SAMHSA accept no liability or information in the care of individual patients. 

Disulfiram Naltrexone oral and extended release injectable 

formulations 

dela

Frequency of Administration 

Daily Daily (oral) or monthly (extended-release 

injectable) 

Three times p

Principal Action When taken in combination with alcohol, 

causes a significant physical reaction, involving nausea/vomiting, flushing, and heart palpitations. The knowledge that such reactions are likely if alcohol is consumed acts as a deterrent to drinking. Given sufficient amounts of alcohol in the patient’s system, more severe reactions may occur, such as respiratory depression, cardiovascular collapse, arrhythmias, myocardial infarction, acute congestive heart failure, unconsciousness, convulsions, and death. 

Blocks opiate receptors that are involved in the rewarding effects of drinking and craving for alcohol. Extended-release injectable naltrexone is administered every 4 weeks, thereby minimizing opportunities for nonadherence, as compared with daily oral ingestion. The monthly injection also produces a more consistent and predictable blood level of the drug, because the depot injection bypasses first-pass metabolism. 

Is thought to abstinence by between the gsystems assoexposure and 

Clinical Uses/Ideal Candidates 

Candidates include patients dependent on alcohol who have completed alcohol withdrawal. Ideally, candidates are committed to abstinence and willing to take 

disulfiram under the supervision of a family member or treatment program. 

Oral naltrexone and extended-release injectable 

naltrexone are indicated for the treatment of 

alcohol dependence in patients who can abstain 

from alcohol in an outpatient setting before the initiation of treatment. Naltrexone has not been shown to be effective in patients who are drinking at treatment initiation. Both formulations may have the greatest benefit in patients who can discontinue drinking on their own for several days before treatment initiation. Extended-release injectable naltrexone is also indicated for the prevention of relapse to opioid dependence following detoxification. 

Acamprosate 

maintenance 

are dependenat treatment iThe efficacy oabstinence hasubjects who detoxification alcohol abstintreatment. 
-

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

Disulfiram Naltrexone oral and extended release injectable 

formulations 

dela

Contraindications Contraindicated in the presence of severe 

myocardial disease or coronary occlusion, psychoses, pregnancy, and in those with high levels of impulsivity, suicidality, and hypersensitivity to disulfiram or to other thiuram derivatives used in pesticides and rubber vulcanization. Patients who are taking or have recently taken metronidazole, paraldehyde, alcohol, or alcohol-containing preparations (e.g., cough syrups, tonics) should not be given disulfiram. Disulfiram labeling also includes several important precautions regarding drug–drug interactions. See the package insert for specific contraindications. 

Contraindicated in patients receiving opioid analgesics and those receiving long-term opioid therapy or anticipating a need for opioids (e.g., surgery), because it could precipitate a severe opioid withdrawal or block opioid analgesia; patients currently dependent on opioids, including those being maintained on opioid agonists such as methadone or partial agonists such as buprenorphine; patients in acute opioid withdrawal; patients who have failed the naloxone challenge test or whose urine tests positive for opioids. Contraindicated in patients with a history of sensitivity to polylactide-co-glycolide, carboxymethyl cellulose, or any components of the diluent used for the injectable medication. It should not be given to patients whose body mass precludes intramuscular (IM) injection with the 2­inch needle provided. Inadvertent subcutaneous injection may cause a severe injection-site reaction. Although not in current labeling, the consensus of the panel is that use should be avoided in patients with serum aminotransferase levels greater than five times the upper limit of normal, except where the benefits outweigh the risks. 

Contraindicarenal impairmknown hyperscomponents. 

4 
-

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

Disulfiram Naltrexone oral and extended release injectable 

formulations 

dela

Warnings Use with caution in patients with heart 

disease, diabetes, hypothyroidism, epilepsy, cerebral damage, chronic or acute nephritis, acute hepatitis or other hepatic diseases, and in patients older than 60. Hepatic toxicity (including hepatic failure resulting in liver transplantation or death) has been infrequently reported. Severe and sometimes fatal hepatitis associated with disulfiram may develop after many months of therapy. Hepatic toxicity has occurred in patients with or without a history of abnormal liver function. Patients should be advised to immediately notify their physician of any early symptoms of hepatitis, including fatigue, weakness, malaise, anorexia, nausea, vomiting, jaundice, or dark urine. 

Liver function tests (taken at baseline and 10–14 days later) are suggested to detect any hepatic dysfunction that may result from disulfiram therapy. In addition, complete blood counts and serum chemistries, including liver function tests, should be monitored. Psychotic reactions have been noted, attributable to the unmasking of underlying psychoses in patients. 

Cases of hepatitis and clinically significant liver dysfunction were observed in association with extended-release injectable naltrexone treatment. Discontinue use of naltrexone in the event of symptoms or signs of acute hepatitis. Use with caution in patients with moderate to 

severe renal impairment. Patients should take no opioids, including opioidcontaining medications, for a minimum of 7 days before starting naltrexone to avoid precipitating 

opioid withdrawal. Patients needing opioid analgesia or patients with a history of opioid use disorder may respond to lower doses of opioids after treatment with extended-release injectable naltrexone. Failure to carefully titrate opioid dose could result in potentially life-threatening opioid intoxication and overdose. Patients should be told of the serious consequences of trying to overcome the opioid blockade. 

Before initiatiacamprosate, function throuelectrolytes, aout severe reFor patients wimpairment (cmL/min), a re(one 333 mg recommendedBecause of erenal function baseline and are important 
-

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

Disulfiram Naltrexone oral and extended release injectable 

formulations 

dela

Use in Pregnant and Postpartum Women 

Pregnancy: The FDA has not assigned a pregnancy category. The safe use of this drug in pregnancy has not been established. Therefore, disulfiram should be used during pregnancy only when, in the judgment of the physician, the probable benefits outweigh the possible risks. Nursing: Do not give disulfiram to nursing mothers. 

Pregnancy: FDA Pregnancy Category C‡ Nursing: Transfer of naltrexone and 6ß-naltrexol into human milk has been reported with oral naltrexone. Because animal studies have shown that naltrexone has a potential for tumorigenicity and other serious adverse reactions in nursing infants, an individualized treatment decision should be made whether a nursing mother will need to discontinue breastfeeding or discontinue naltrexone. 

Pregnancy: FNursing: It is acamprosate 

SOURCE: SAMHSA and NIAAA. (2012, September). Report of the SAMHSA-NIAAA Consensus Panel on New and Emerging PharmacotherDisorders and Related Comorbidities. Rockville, MD: SAMHSA. ‡ Animal studies have shown an adverse effect on the fetus and there are no adequate, well-controlled studies in humans, but potential benefits may warrant 

women despite potential risks. 

6 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide

SCREENING AND ASSESSING PATIENTS

Clinicians should routinely screen their patients for

at-risk drinking, provide brief interventions as 

needed, and assess for alcohol use disorder when 

indicated.

2

Screening for Risky Alcohol Use 

Universal screening for alcohol problems can be 

conducted concurrently with screening for other 

medical disorders as part of a routine examination. 

By systematically screening every patient with a 

validated screening tool, the clinician can effectively 

identify patients with risky or dependent levels of 

alcohol use. This approach has been shown to be 

superior to a case-finding approach.

Screening also should be conducted before 

prescribing one of the many medications that may 

interact negatively with alcohol or if a patient reports 

using an over-the-counter product or herbal 

preparation that may precipitate an adverse reaction.

Screening is especially important in patients who:

• Are pregnant or trying to conceive. 

• Are at risk for binge drinking or heavy drinking. 

• Have health problems that may be induced or 

exacerbated by alcohol (e.g., cardiac arrhythmia, 

depression or anxiety, dyspepsia, insomnia, liver 

disease, a history of traumatic injury). 

• Have one or more chronic health problems (e.g.,

diabetes, heart disease, hypertension, 

gastrointestinal [GI] disorders, chronic pain) that 

are not responding to treatment.

7

• Have social or legal problems that may be 

caused or worsened by alcohol use (e.g.,

marital/family issues, driving-while-under-theinfluence convictions).

Screening can be conducted through use of a 

simple, validated self-report instrument such as the 

Alcohol Use Disorders Identification Test (AUDIT) 

(http://www.whqlibdoc.who.int/hq/2001

/WHO_MSD_MSB_01.6a.pdf), which takes fewer

than 5 minutes to complete, or a single interview 

question: “How many times in the past year have 

you had ___ or more drinks in a day?” (five drinks 

for men and four drinks for women). The single 

question can be used at any time, either in 

conjunction with AUDIT or alone.

7 Study results 

have shown that, when used in a primary care 

setting, the single question was 82 percent sensitive 

in detecting individuals who had alcohol problems.

12

A useful overview of screening and intervention 

strategies can be found in a document called 

Alcohol Misuse: Screening and Behavioral 

Counseling Interventions in Primary Care

(http://www.uspreventiveservicestaskforce

.org/uspstf/uspsdrin.htm) (see Appendix B). Many 

U.S. primary care physicians rely on these United 

States Preventive Services Task Force 

recommendations to guide how they conduct 

preventive practice. Clinicians should also consider 

using Screening, Brief Intervention, and Referral to 

Treatment (SBIRT), an approach in which screening 

is followed up as appropriate with brief intervention, 

and with referral to treatment for those needing 

more extensive care (http://www.samhsa.gov/sbirt) 

(see Appendix B).

Assessing the Need for MedicationAssisted Treatment

A patient who reports one or more heavy drinking 

days in the past year (or who has an AUDIT score 

greater than 8) should receive further 

assessment.2,7,8,9,10,11 Consideration should be 

given to the factors motivating a patient toward 

treatment, the patient’s stage of change, the 

potential for relapse, the severity of any 

concomitant medical and psychiatric problems, the 

patient’s ability to tolerate medications, and 

whether the patient is pregnant (in which case, 

medications associated with adverse physical 

effects, such as disulfiram, should be avoided). 

Patient History. Although the evidence 

supporting inclusion of each element is not 

conclusive, consensus opinion is that an 

assessment should include a medical and 

psychiatric history, a substance use history, and an 

evaluation of family and psychosocial supports.

13

Information from family members and significant 

others can provide useful perspectives on the 

patient’s status, as can communication with or 

records from clinicians who treated the patient in 

the past.

13

It also is advisable to access the patient’s 

prescription drug use history through the state’s 

prescription drug monitoring program (PDMP), 

where available,13 to detect unreported use of 

other medications, such as opioid analgesics or 

sedative-hypnotics, that may interact negatively

7 
 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

with alcohol or with alcohol treatment 

medications. 

Physical Examination. The physical 

examination should evaluate neurocognitive 

function, identify sequelae of alcohol use, and 

look for evidence of hepatic dysfunction.14 

Although many patients with alcohol use disorder 

have no specific abnormal findings on physical 

examination, when present, these abnormal 

findings provide evidence of the severity of a 

patient’s alcohol problem. For example, 

longstanding alcohol consumption may be 

marked by many classic features, such as 

physical manifestations of cirrhosis, 

encephalopathy, and vitamin deficiencies. 

Alcohol consumption may also provoke 

tachycardia (including supraventricular 

tachycardias), tremor of the hand or tongue, 

elevated blood pressure, hepatosplenomegaly, a 

tender liver edge, peripheral neuropathy, spider 

angiomata, conjunctival injection, and 

unexplained trauma.2,14,15,16 

Laboratory tests help confirm the presence of 

heavy drinking and identify alcohol-related 

damage. 

Laboratory Testing. Laboratory tests help 

confirm the presence of heavy drinking and 

identify alcohol-related damage. Initial and followup laboratory testing can help motivate patients 

and reinforce their progress in treatment.2 

Although no single laboratory test can definitively 

point to an alcohol use disorder diagnosis in the 

absence of other information,14 the following tests 

can be helpful in identifying heavy drinking and 

possible alcohol-related abnormalities:16,17 

	 Blood alcohol levels are useful measures of 

recent alcohol consumption and can indicate 

physical or legal incapacity to perform specific 

tasks, including driving. 

	 Carbohydrate-deficient transferrin (CDT), 

gamma-glutamyl transpeptidase (GGT), and 

aspartate aminotransferase (AST) levels can 

be useful biomarkers because they often are 

elevated in people who have chronically 

consumed significant amounts of alcohol.16 

Some studies suggest that biomarkers such 

as AST, GGT, and CDT are most useful when 

used in combination.16,17,18,19 

	 Tests for ethyl glucuronide (EtG), an alcohol 

metabolite, are highly sensitive for alcohol; 

however, this sensitivity is a potential 

drawback as well as a strength, because 

exposure to even small amounts of alcohol 

(e.g., those found in some foods and 

cosmetics) can trigger a positive test 

result.16,17,20 However, use of appropriate 

laboratory cutoffs make it more likely that a 

positive test is an indication of recent alcohol 

use.20

	 Phosphatidylethanol, another alcohol 

metabolite, is a promising new biomarker that 

is highly sensitive in detecting chronic drinking 

(three or more drinks a day for 1 or 2 weeks). 

It can be detected in the blood for 2 to 4 

weeks after drinking has stopped.16,20,21,22 

Several laboratory tests can help the clinician 

establish a patient’s overall health status and 

identify alcohol-related damage and 

contraindications to the use of specific 

medications.23,24 These include: 

	 Complete blood count: Alcohol overuse can 

cause anemia and have direct toxic effects on 

bone marrow. An assessment of hematologic 

laboratory indices is useful when considering 

pharmacologic treatment of alcohol use 

disorder. Many people who are alcohol 

dependent have elevated corpuscular volume 

(macrocytosis). 

	 Testing for vitamin deficiencies: Individuals 

with alcohol use disorder may not consume a 

healthful diet, resulting in vitamin deficiencies 

that lead to abnormal cellular function. For 

example, deficiencies in thiamine, folic acid, 

and pyridoxine are seen in people with 

physiological alcohol dependence, and those 

deficiencies contribute to abnormal cell 

function. Vitamin deficiencies may also lead to 

Wernicke-Korsakoff/amnesic syndrome in 

patients whose alcohol consumption is very 

excessive. 

	 Hepatic and renal testing: The use of 

medications to treat alcohol use disorder 

requires evaluation of organ systems that are 

involved in the metabolism and excretion of 

those medications. For example, naltrexone 

and disulfiram should be used with caution in 

patients who have liver disease, whereas 

naltrexone and acamprosate should be used 

with caution in patients with renal impairment. 

Therefore, hepatic and renal system testing 

8 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

should be done as part of the patient
 

assessment. 

	 Other tests: Initial laboratory work should 

include a urine toxicology screen to assess for 

other substances, and women of childbearing 

age should have a pregnancy test. 

DEVELOPING A TREATMENT PLAN AND 

SELECTING A MEDICATION 

If a patient’s initial assessment supports a 

diagnosis of moderate or severe alcohol use 

disorder, the next step is to develop a 

comprehensive treatment plan.24 

Setting Goals for MedicationAssisted Treatment 

The provider and patient should mutually agree 

on an initial goal and be willing to refine and 

revise that goal as treatment progresses.2

 For 

example, in working with a patient who is 

unwilling to set a goal of complete abstinence, 

the clinician should support the patient in 

reducing his or her drinking as an interim goal, 

while maintaining that complete abstinence is the 

safer strategy, with a greater chance of long-term 

7 success.

Certain conditions warrant complete abstinence 

from alcohol rather than a reduction in use. 

These involve individuals who are or may 

become pregnant, are taking a medication that 

may cause a harmful drug interaction, or have a 

medical or psychiatric disorder that is associated 

with or exacerbated by alcohol use.7,24 

If a patient engages in risky drinking but does not 

meet the criteria for an alcohol use disorder, the 

clinician should use his or her professional 

judgment in helping the patient decide whether 

reducing or abstaining from alcohol is the more 

appropriate goal, based on factors such as a 

family history of alcohol problems and the 

patient’s age or history of traumatic injuries 

related to drinking.24 

It may be helpful to provide the patient with a 

copy of National Institute on Alcohol Use and 

Alcoholism’s booklet Rethinking Drinking or to 

refer the patient to the associated Web site (see 

Appendix B). 

Components of the Treatment Plan 

Steps to achieve the patient’s goal should be 

outlined in a treatment plan, which should be 

developed in consultation with the patient and 

address the following points:13 

	 The medication and other therapies to be 

employed, with a rationale for their use 

	 Schedules for follow-up office visits and 

laboratory testing to monitor the patient’s 

progress and health status 

 Reasons for participation in mutual-help 

groups 

 Involvement of family or significant others in 

treatment 

	 A plan for treating co-occurring medical or 

psychiatric conditions and other substance 

use disorders, including smoking 

 Criteria for discontinuing the use of medication 

or other therapies and referring the patient for 

a higher level of care, if indicated 

Whenever a medication is to be used, the 

treatment plan should include steps that will 

promote medication adherence. Depending on 

the needs of the patient, these might include 

specific strategies for remembering to take 

medications, use of blister card packs or pill 

boxes, a schedule for monitoring medication 

adherence that reflects the patient’s history of 

adherence to other medication regimens, and 

steps to involve the patient’s family members in 

monitoring adherence.2,7 

Educating the Patient and 

Obtaining Informed Consent 

Before treatment begins, the patient should 

understand what to expect, including how the 

proposed medication works and the associated 

risks and benefits. This is best achieved through 

face-to-face discussions and the use of written 

9 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

educational materials (see Appendix B for 

sources of helpful information). 

Elements of effective patient education include 

the following points:2,13 

	 Information about alcohol use disorder as a 

chronic medical disorder 

 A description of what to expect from treatment 

 Information about the medication and the 

reasons it was selected, including a 

discussion of potential risks and benefits and 

the time to full effect 

	 For women of childbearing age, explanation of 

the importance of using an effective birth 

control method 

	 Clear information about what to do if the 

patient resumes alcohol use after a period of 

abstinence 

	 The importance of informing all physicians 

and dentists that the patient is taking a 

medication for alcohol use disorder, to avoid 

inadvertent drug interactions, especially when 

surgery (including dental surgery) is being 

considered 

	 Symptoms that should be reported to the 

prescribing physician 

	 A discussion of the importance of concurrent 

psychosocial treatment and participation in a 

mutual-help group 

	 Plans for follow-up care 

The patient should be advised to carry a medical 

alert card identifying the medication-assisted 

treatment, describing potential adverse effects 

(e.g., symptoms of a disulfiram–alcohol reaction), 

and providing contact information for the treating 

physician or institution in an emergency.13 

The fact that a patient has received and 

understands this information should be 

documented in the patient record. Clinicians also 

are advised to obtain a written informed consent 

from the patient before initiating treatment.13 

Evaluating the Need for Medically 

Managed Detoxification 

Alcohol withdrawal syndrome can be severe and 

potentially fatal, so it is particularly important to 

assess the need for medically managed 

withdrawal.25 Patients who need medically 

supervised detoxification may need to be referred 

to an addiction specialist or addiction treatment 

program that can provide medically monitored 

withdrawal treatment. 

Withdrawal generally begins within 24 to 48 

hours after the blood alcohol level drops and can 

persist for 5 to 7 days. Symptoms include 

restlessness, irritability, anxiety, and agitation; 

anorexia, nausea, and vomiting; tremor; elevated 

heart rate; increased blood pressure; insomnia, 

intense dreaming, and nightmares; poor 

concentration and impaired memory and 

judgment; increased sensitivity to sound, light, 

and tactile sensations; auditory, visual, or tactile 

hallucinations; delusions (usually of a paranoid or 

persecutory nature); grand mal seizures; 

hyperthermia; delirium with disorientation 

concerning time, place, person, and situation; 

and fluctuations in level of consciousness.25 

In assessing the likelihood and potential severity 

of withdrawal, the most useful clinical factors are 

the patient’s previous withdrawal experience and 

the number of previous withdrawals (treated or 

untreated), with three or four withdrawal episodes 

indicating an increased likelihood that severe 

withdrawal symptoms will occur unless adequate 

medical care is provided.26 

Use of a standardized clinical rating instrument 

for withdrawal, such as the Clinical Institute 

Withdrawal Assessment for Alcohol Scale, 

Revised (CIWA-Ar) (https://umem.org/files 

/uploads/1104212257_CIWA-Ar.pdf), is helpful 

because it guides the clinician through multiple 

domains of alcohol withdrawal and allows for 

semi-quantitative assessment of nausea, tremor, 

autonomic hyperactivity, anxiety, agitation, 

perceptual disturbances, headache, and 

disorientation.26,27 In multiple studies, the CIWAAr has been found to have high reliability and 

validity, and it takes only 2 to 5 minutes to 

complete.26 

Some benzodiazepines are effective in treating 

the symptoms of alcohol withdrawal. For 

example, diazepam carries a labeled indication 

for relief of acute agitation, tremor, impending or 

acute delirium tremens, and hallucinosis in acute 

alcohol withdrawal. Chlordiazepoxide also is 

frequently used for the management of alcohol 

withdrawal symptoms. 

10 
 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

Integrating Pharmacologic and 

Nonpharmacologic Therapies 

Some patients may respond to psychosocial 

interventions and others to medication therapy 

alone, but most patients benefit from a 

combination of these approaches. The various 

approaches—medications for moderate or 

severe alcohol use disorder, professional 

counseling, and mutual-help groups—are 

complementary; they address different aspects of 

alcohol use disorder: neurobiological, 

psychological, and social. Offering the full range 

of effective treatments increases patient choice 

and the potential for a positive outcome, as no 

single approach is universally successful.7 

Psychosocial Treatments. Psychosocial 

treatments can enhance adherence to the 

treatment plan, including use of prescribed 

medications, and thus improve treatment 

outcomes. Conversely, to the extent that they 

reduce craving and help patients maintain 

abstinence, medications may help patients be 

more receptive to psychosocial interventions.2,28 

Almost all studies of medications for the 

treatment of alcohol use disorder have included 

some type of counseling, and it is recommended 

that all patients for whom these medications are 

prescribed receive at least brief counseling. 

Evidence is accumulating that weekly or biweekly 

brief (i.e., 15–20 minutes) counseling sessions 

combined with use of a medication is an effective 

treatment for many patients in early recovery.2,7,9 

This counseling typically focuses on encouraging 

abstinence, adherence to the medication 

regimen, and participation in mutual-help 

7 groups.

Although psychiatrists may be able to deliver 

psychosocial therapies onsite, most clinicians 

need to refer patients for individual or group 

therapy.2 

Encouraging Participation in Mutual-Help 

Programs. The support of a mutual-help group 

can be helpful to long-term recovery. The oldest, 

best known, and most accessible mutual-help 

program is offered by Alcoholics Anonymous 

(AA). Patients may resist attending AA meetings 

and may fear that disclosure of medication use 

will make them unwelcome.2

 Although some AA 

members have negative attitudes toward 

medication, the organization itself supports 

appropriate medication use.29 Providers should 

encourage patients to try different group 

meetings until they find one that is a good fit. 

Lists of local meetings to give to patients can be 

obtained from http://www.aa.org. 

Other mutual-help groups, although not as 

universally available as AA, have a strong 

presence in many communities. Contact 

information for several groups that may be 

helpful to patients and their families is provided in 

Appendix B. 

Addressing Co-Occurring Disorders 

Research studies show that the most effective 

way to treat co-occurring disorders is through 

integrated treatment,30,31,32 which is defined as 

any mechanism by which treatment interventions 

for multiple co-occurring disorders are delivered 

within the context of a primary treatment 

relationship or service setting. The term 

co-occurring acknowledges the need for a unified 

treatment approach to meet the substance use, 

mental health, and related needs of a patient 

and, thus, is the preferred model of treatment.2 

Integrated treatment assumes that each disorder 

is primary and in need of simultaneous care. 

It is not always possible to provide truly 

integrated care in primary care settings, although 

standardized psychosocial treatments have been 

developed that are more readily provided in 

general practice settings.1,31 When providers 

cannot provide a full range of onsite care, they 

need to identify resources in their practice 

community and develop relationships with those 

providers to streamline and coordinate care as 

much as possible. This includes developing and 

maintaining resources for psychosocial 

services.1,7 In addition, the patient may need 

assistance with obtaining a referral, securing an 

initial appointment within a reasonable time 

frame, and addressing issues with health 

insurance coverage. 

When medication management and addiction 

treatment services are delivered by separate 

providers, close coordination and integration of 

services is essential. All individuals involved in 

the patient’s treatment, including addiction 

medicine specialists, need to establish close 

linkages and open communications.31,32 

11 
 

Pharmacotherapies for alcohol use disorder 

appear to be as effective and safe for older 

adults as for younger adults. 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

Treating Adolescents and Young 

Adults 

Empirical validation of the value of medicationassisted treatment in adolescents is lacking. 

Moreover, none of the available medications is 

approved by the FDA for use in people younger 

than age 18. Therefore, younger adolescents in 

need of treatment should be referred to a 

clinician or program specializing in adolescent 

addiction.1,33 

However, in older adolescents and young adults, 

the limitations of available psychosocial 

interventions for youth and the demonstrated 

effectiveness of pharmacologic interventions in 

adults suggest that it may be reasonable to 

consider pharmacologic treatments for patients in 

this age group.34,35 

There are no specific safety contraindications for 

older adolescents/young adults for the 

medications discussed here, and available 

information supports the safe and judicious use 

of medications in this population.36 This is 

particularly true of older adolescents and young 

adults who have severe alcohol use disorder, as 

well as those who have not achieved success 

with psychosocial interventions alone and those 

who exhibit more adult patterns of moderate and 

severe alcohol use disorder.37 

Treating Pregnant and Postpartum 

Women 

Pregnancy and postpartum care present 

opportunities to screen and intervene for alcohol 

use disorder, which is clearly associated with 

fetal abnormalities and long-term cognitive 

problems in offspring. In fact, research has not 

identified any safe level of drinking during 

pregnancy.38 Use of alcohol during pregnancy 

may result in miscarriage, stillbirth, or premature 

delivery. Complications seen in the infant may 

include fetal alcohol syndrome or fetal alcohol 

spectrum disorder. 

Unfortunately, none of the medications used to 

treat alcohol use disorder have been shown in 

clinical trials to be absolutely safe for pregnant or 

nursing women. Therefore, these medications 

should be used during pregnancy only when, in 

the judgment of the physician, the probable 

benefits outweigh the possible risks.39 Pregnant 

or nursing patients should be referred to an 

addiction specialist or a specialist in managing 

high-risk pregnancies for care.40 

Treating Older Adults 

Alcohol and other substance use are significant 

problems among older adults, in whom alcohol 

use disorder is associated with many health and 

social problems that increase the risk of 

hospitalization, nursing home placement, and 

death.41,42,43 A study projected that the number of 

adults ages 50 and older with a substance use 

disorder will double from 2.8 million (the annual 

average in the period from 2002 through 2006) to 

5.7 million in 2020.44 

Accurately diagnosing an alcohol use disorder in 

an older adult can be done more effectively when 

clinicians are cognizant of the following 

challenges faced by this population group:45 

	 Shame: Older adults are more likely to hide 

their substance-related problems because 

they are more likely to feel shame and less 

likely to seek help or talk about it. 

	 Problem ignored or minimized by family: 

Family members may feel ashamed, be in 

denial, ignore the problem, believe the 

problem is not serious, or feel that their older 

relatives have a right to drink or use drugs. 

	 Misdiagnosis: Health care practitioners often 

mistake alcohol or drug problems for 

symptoms of other conditions that are 

common among older adults, such as 

depression or dementia. 

Pharmacotherapies for alcohol use disorder 

appear to be as effective and safe for older 

adults as for younger adults. However, because 

older adults are more likely than their younger 

counterparts to have comorbid medical problems 

and thus to be using multiple medications and 

have decreased ability to eliminate medications, 

care must be taken to avoid adverse drug 

events.45 

12 
The FDA has approved three oral 

medications and one injectable medication 

for treatment of alcohol dependence or 

prevention of relapse to alcohol use. 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

As a result, the following factors need to be 

considered when prescribing pharmacotherapy to 

older adults:45,46 

 Dose reductions and frequent renal function 

tests may be necessary when prescribing 

acamprosate to individuals in whom 

decreased renal function (creatinine clearance 

rate <70 mL/min/1.73 m2

) is evident. 

 In patients ages 61 and older, disulfiram 

doses may need to be reduced. Disulfiram 

interacts with multiple drugs, so caution 

should be exercised in prescribing it to older 

adults at risk for polypharmacy. 

Selecting a Medication 

The FDA has approved three oral medications 

(disulfiram, acamprosate, and naltrexone) and 

one injectable medication (extended-release 

injectable naltrexone) for the treatment of alcohol 

dependence or the prevention of relapse to 

alcohol use.7,24 In addition to factors specific to 

each medication, the clinician should consider 

the patient’s past experience with particular 

medication-assisted treatment medications; 

beliefs and opinions about which 

pharmacotherapy may be most helpful; level of 

motivation for abstinence; medical status and 

contraindications for each medication; and 

history of medication adherence.2 

Although further research with large patient 

samples is required before definitive advice can 

be offered on which medication to select for a 

particular patient, information for matching 

patients to particular pharmacotherapies is 

summarized below.24,40,47,48,49 Medications are 

listed in the approximate order in which the FDA 

approved them for the treatment of alcohol 

dependence. 

Disulfiram. Approved by the FDA as an alcohol 

abuse deterrent in 1951, disulfiram disrupts the 

metabolism of alcohol, resulting in an unpleasant 

reaction, which can be severe whenever an 

individual taking disulfiram consumes 

alcohol.50,51,52,53,54 

Mechanism of Action. The disulfiram reaction 

is caused by a blockade of aldehyde 

dehydrogenase, which causes an accumulation 

of acetaldehyde when alcohol is ingested. When 

this occurs, the physical reaction can include 

nausea, flushing, and heart palpitations.40 Unlike 

other medications approved to treat alcohol use 

disorder, disulfiram does not directly affect 

opiate, gaba-aminobutyric acid, or glutamate 

receptors in the brain. Disulfiram blocks 

dopamine-beta-hydroxylase in the brain, thereby 

increasing dopamine levels and reducing 

noradrenaline levels.51 

Formulation. Disulfiram is manufactured as a 

white to off-white odorless and almost tasteless 

powder. It is supplied in 250 mg and 500 mg 

tablets for oral administration.50 

Dosing and Administration. The initial and 

average maintenance dose is 250 mg per day 

(doses range from 125 mg to a maximum dose of 

500 mg per day). The disulfiram tablet is taken by 

mouth once a day; it may be crushed and mixed 

with water, coffee, tea, milk, soft drink, or fruit 

juice.50 Faulty bioactivation in some patients can 

yield too low a concentration of the active 

metabolite needed to inhibit aldehyde 

dehydrogenase, and the 500 mg dose may be 

more effective in these patients.52 Patients who 

experience mild side effects (as described later in 

this section) may obtain relief by reducing the 

dose to 125 mg daily.51 

Efficacy. The effectiveness of disulfiram in the 

prevention and limitation of relapse to alcohol 

use is supported by multiple studies.47,48 It should 

be noted that disulfiram was approved prior to 

the requirement that drugs be shown to be 

effective before being marketed was enacted. An 

evidence report from the Agency for Healthcare 

Research and Quality concluded that four 

placebo-controlled randomized clinical trials of 

oral disulfiram produced mixed results.49 

Although disulfiram was shown to reduce the 

frequency of drinking days in two trials, in neither 

study did it improve relapse rates compared with 

placebo. Two studies that examined patient 

adherence with oral disulfiram found it to be 

low,53,54 and a third study had a 46 percent 

dropout rate.55 

Investigators who argue that disulfiram is 

effective in preventing relapse to alcohol use 

frequently emphasize the importance of the 

13 
The actual neurobiological mechanisms by 

which naltrexone induces the reduction in 

alcohol consumption observed in alcoholdependent patients is not entirely understood. 

Preclinical data suggest the involvement of the 

endogenous opioid system. 

 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

circumstances in which it is administered. In 

particular, the level and quality of supervision a 

patient receives while taking disulfiram are 

believed to be important components of its 

success.55,56 Some studies have found that courtordered disulfiram therapy promotes efficacy by 

increasing adherence to the disulfiram regimen.57 

Use of incentives, patient contracts, the 

cooperation of a significant other in fostering 

adherence, the use of regular reminders to the 

patient, and patient behavioral counseling and 

social support may enhance disulfiram efficacy 

by improving adherence. Overall, methodologic 

limitations and mixed results make it difficult to 

state with certainty what percentage of patients 

benefit from disulfiram.1 However, disulfiram is a 

medication that should be considered for patients 

with no contraindications and who might have 

major consequences should they use alcohol. 

Safety. The severity of a disulfiram–alcohol 

interaction is proportional to the dose of 

disulfiram and the amount of alcohol consumed. 

A reaction lasts 30 to 60 minutes in mild cases. 

In more severe cases, the reaction can continue 

for several hours or until the alcohol is 

metabolized. When effects are severe, palliative 

and supportive measures may be needed to 

restore blood pressure and treat shock.50 

Other safety issues include both minor side 

effects and more serious adverse reactions. 

Minor side effects, which typically occur during 

the first 2 weeks of therapy, include 

skin/acneiform eruptions, headache, allergic 

dermatitis, impotence, mild drowsiness, fatigue, 

and metallic or garlic-like aftertaste.2,50 

Serious adverse reactions, although rare,51 

include the following conditions:2,50 

 Optic neuritis: Usually diagnosed after a 

patient complains of visual disturbances, 

optic neuritis is addressed by discontinuing 

disulfiram and conducting (or referring the 

patient for) an ophthalmologic examination. 

 Peripheral neuritis, polyneuritis, peripheral 

neuropathy: Usually diagnosed after a patient 

complains of paresthesias (numbness or 

tingling), these conditions require that 

disulfiram be discontinued. A neurological 

evaluation should be conducted. 

 Hepatitis, including cholestatic and fulminant 

hepatitis, as well as hepatic failure: When 

symptoms of hepatic dysfunction are reported 

or observed, liver function tests should be 

obtained. When clinical or laboratory 

evidence of hepatic dysfunction is found, 

disulfiram should be discontinued 

immediately and liver function and other 

symptoms monitored closely. 

Drug Interactions. There is evidence that 

disulfiram interacts with a number of drugs, 

including benzodiazepines, isoniazid, rifadin 

(Rifampin®), metronidazole, oral anticoagulants 

such as warfarin, oral hypoglycemics, phenytoin, 

and theophylline. The potential severity of some 

drug interactions makes it essential that patients 

be cautioned to report all medications they are 

taking and not to start any new medication 

without checking with the disulfiram 

prescriber.14,53 

Clinical Recommendations. Patients who are 

good candidates for treatment with disulfiram 

include those who are motivated for treatment 

and want to achieve abstinence, who are 

medically appropriate, who can receive 

supervised dosing, and who understand the 

consequences of drinking alcohol while taking 

disulfiram. It may be an appropriate short-term 

therapy for a patient in recovery who anticipates 

being in a situation that may trigger craving for 

alcohol (e.g., a family holiday visit) and who 

requests an additional incentive to remain 

abstinent.2,53,54,55,56,57 

Naltrexone. Naltrexone hydrochloride is a longacting opioid antagonist. The FDA approved oral 

naltrexone for the treatment of alcohol 

dependence or alcoholism in 1994. The low rate 

of retention and adherence encountered with oral 

naltrexone led to the development of the 

extended-release injectable formulation, which 

the FDA approved for the treatment of alcohol 

use disorder in 2006.2,24 

Mechanism of Action. Naltrexone has affinity 

for the mu, kappa, and delta opiate receptors. 

The actual neurobiological mechanisms by which 

14 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

naltrexone induces the reduction in alcohol 

consumption observed in alcohol-dependent 

patients is not entirely understood. Preclinical 

data suggest the involvement of the endogenous 

opioid system.58 

As an antagonist at the mu receptor, naltrexone 

may reduce the urge to consume alcohol through 

two mechanisms: 

1. Suppression of alcohol-mediated betaendorphin stimulation of dopamine neurons in 

the nucleus accumbens 

2. Reduction of beta-endorphin disinhibition of 

the tonic inhibition of dopamine cells by 

gamma-aminobutyric acid neurons in the 

ventral tegmental area47,59,60 

Extended-release injectable naltrexone is 

metabolized in the liver to the opioid antagonist 

6ß-naltrexol.61 Two peak blood levels occur after 

injection: a transient initial peak occurs 

approximately 2 hours after injection and a 

second peak occurs approximately 2 days later. 

About 14 days after injection, the blood level 

slowly begins to decline in a linear fashion. The 

absorption of extended-release naltrexone is 

mediated by its gradual and prolonged release 

for 2 to 4 weeks after injection through hydrolysis 

of copolymer microspheres.7,24 

Formulation. Oral naltrexone is marketed in 50 

mg tablets.7,24 

Extended-release injectable naltrexone was 

developed by embedding the drug molecule 

within microspheres composed of a 

biodegradable copolymer, resulting in release 

of the active ingredient over a period of 

approximately 4 weeks.62,63 It is packaged in a kit 

containing a vial of naltrexone as a dry powder, 

which must be suspended in a liquid diluent 

immediately before use. Each kit contains a 

syringe and five needles: one for mixing the 

microspheres with the diluent and four needles 

(two 1.5-inch needles and two 2-inch needles) for 

injecting the suspension into the upper outer 

quadrant of the gluteal muscle.63 

Kits must be refrigerated during storage but 

should be brought to room temperature 

approximately 45 minutes before an injection is 

given. The suspended microspheres in solution 

must be mixed vigorously to prevent clumping, 

which can clog the needle during injection.63 

Dosing and Administration. The oral 

naltrexone tablet is taken by mouth once a day. 

The dose recommended for most patients is 50 

mg per day, given in a single dose.2,7 GI side 

effects are common and dose dependent, so 

patients with GI side effects should have a trial of 

therapy at a lower dose. 

The approved dose of extended-release 

naltrexone is 380 mg, given approximately once 

a month. Clinical trial data confirm earlier studies 

indicating that there is no need to adjust the dose 

for the patient’s body weight.63 

Extended-release injectable naltrexone is 

administered by intramuscular (IM) gluteal 

injection. It is retained at the site of injection so 

that its active compound is released consistently 

over approximately 4 weeks,63 and measurable 

levels may be observed for longer than 1 month. 

Efficacy. Oral naltrexone has been shown to 

reduce relapse to heavy drinking, which is 

defined as three or more drinks per day for 

women and four or more for men.59,60,64 In a 

systematic review of 11 double-blind, placebocontrolled trials, researchers found that oral 

naltrexone, when combined with psychosocial 

treatments, reduced relapse rates at 3 months in 

patients with alcohol dependence.59 (Almost all 

studies were done in patients who were abstinent 

at baseline.) Short-term outcomes in favor of 

naltrexone included fewer patients relapsing to 

alcohol dependence (38% with naltrexone versus 

60% with placebo), fewer patients returning to 

drinking (61% versus 69%), reduced craving for 

alcohol, and fewer drinking days. Thus, it is 

especially useful in patients who have a history of 

drinking relapses.65 

Extended-release injectable naltrexone is 

approved for use only in patients who can refrain 

from drinking for several days before treatment 

begins—a subgroup of the patient population in 

whom efficacy has been demonstrated. For 

example, in a 6-month, randomized, doubleblind, placebo-controlled trial involving 624 

individuals, patients who received a 380 mg dose 

of extended-release injectable naltrexone had a 

25 percent reduction in heavy drinking days 

compared with those receiving placebo. The 

effect was greater in males.66 A secondary 

analysis found that patients who had 4 or more 

days of abstinence before beginning treatment 

with extended-release injectable naltrexone 

15 
A side effect unique to extended-release 

injectable naltrexone is injection-site 

reaction, which involves pain or tenderness 

at the injection site. 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

experienced particularly good treatment 

outcomes.67 

Safety. Naltrexone generally is well tolerated, 

although it has the potential to precipitate severe 

opioid withdrawal in patients who are opioid 

dependent.2

 Common side effects include 

nausea, vomiting, headaches, dizziness, 

fatigue, anxiety, and somnolence, with 

nausea and vomiting the most frequently 

reported.59,60,64,65,66,67,68 Less common side effects 

include diarrhea, constipation, chest pains, 

joint/muscle pain, rash, insomnia, excessive 

thirst, loss of appetite, perspiration, mild 

depression, increased tears, and delayed 

ejaculation.2,24 

More serious adverse reactions, with suggestions 

for management, include the following:59,60 

	 Precipitated opioid withdrawal: To mitigate 

withdrawal symptoms, discontinue 

naltrexone, provide supportive treatments 

(i.e., hydration and antispasmodic and 

antidiarrheal medications) until the symptoms 

resolve, and provide a ß2-agonist such as 

clonidine. Watch for clonidine side effects, 

including dizziness, hypotension, fatigue, and 

headache. 

	 Hepatic toxicity: Discontinue naltrexone. 

	 Naltrexone overdose: Treat the patient 

symptomatically under close supervision. 

Contact a poison control center for current 

information. 

A side effect unique to extended-release 

injectable naltrexone is injection-site reaction, 

which involves pain or tenderness at the injection 

site, usually resolving in 2 to 5 days. Swelling, 

erythema, bruising, and pruritus may occur, 

generally as the result of an inadvertent 

subcutaneous injection. Serious reactions include 

induration, cellulitis, hematoma, abscess, sterile 

abscess, and necrosis. Rarely, these reactions 

require surgical intervention, such as 

debridement of necrotic tissue, which can result 

in significant scarring. To prevent problems, 

providers should be trained in proper techniques 

for IM injections.63 

Drug Interactions. Potential drug interactions 

involve cough and cold preparations, 

antidiarrheal medications, thioridazine, 

yohimbine, and nonsteroidal anti-inflammatory 

drugs (which can elevate liver enzymes). 

As noted earlier, naltrexone blocks the effects of 

opioid analgesics.13 For more information, see 

the discussion of Special Considerations in Pain 

Management on page 18.13,14,68,69 

Clinical Recommendations: Oral Naltrexone. 

Oral naltrexone is most effective when prescribed 

for patients who are highly motivated and/or 

supported with observed daily dosing and who 

are abstinent at the time treatment is initiated.70,71 

Naltrexone also appears to be effective in the 

following patient populations: 

 Patients who have a history of opioid use 

disorder and who are seeking treatment for an 

alcohol use disorder. Naltrexone reduces the 

reinforcing effects of and curbs cravings for 

both opioids and alcohol. 

	 Patients with intense craving for alcohol 

during treatment. These individual may 

experience greater medication benefit than 

patients with low levels of craving for 

alcohol.72 

	 Patients who have a family history of alcohol 

use disorder. Both laboratory studies and 

clinical trials suggest that patients with a 

family history of alcohol problems may benefit 

more from treatment with naltrexone than 

patients who do not have such a history.73 

Clinical Recommendations: ExtendedRelease Injectable Naltrexone. Extendedrelease injectable naltrexone benefits people 

appropriate for treatment with oral naltrexone, as 

well as the following:1,68,69,74 

	 Patients who are abstinent at initiation of 

treatment. Extended-release injectable 

naltrexone has not been shown to be effective 

in patients who are drinking at the time 

treatment is initiated. 

	 Patients who are seeking treatment for 

moderate or severe alcohol use disorder while 

in recovery from co-occurring opioid use 

disorder. The FDA approved extendedrelease injectable naltrexone in 2010 for the 

16 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

prevention of relapse to opioid dependence, 

following opioid detoxification. 

Acamprosate. Acamprosate is a delayedrelease synthetic compound that is indicated for 

maintaining abstinence in patients who are 

alcohol dependent and are abstinent at the time 

treatment is initiated.75 The FDA approved the 

medication for the treatment of alcohol use 

disorder in 2004.7 

Mechanisms of Action. Although the precise 

mechanisms of action of acamprosate are not yet 

known, they appear to involve beneficial 

modulation of the glutamatergic neurotransmitter 

system (including antagonism of the mGlu5 

metabotropic glutamate receptor) to counteract 

the imbalance between the glutamatergic and 

GABAergic systems associated with chronic 

alcohol exposure and alcohol withdrawal.75 

Formulation. Acamprosate is supplied as 

enteric-coated 333 mg tablets.7 

Dosing and Administration. Two 333 mg 

delayed-release tablets are taken by mouth three 

times a day, with or without food (a lower dose 

may be effective with some patients and must be 

used with those with impaired renal function). 

Pills must be swallowed whole, not crushed or 

broken.7,76 

Efficacy. Acamprosate has been shown to be an 

effective treatment for dependence on alcohol, 

with no abuse potential and no significant 

interaction with medications commonly used to 

treat substance use and mental disorders.76 

Acamprosate’s efficacy is primarily due to its 

ability to reduce the negative symptoms 

associated with the period immediately following 

alcohol withdrawal.77 

Safety. Acamprosate has a good safety profile: 

no development of tolerance has been reported, 

there appears to be no risk of overdose, and 

there is no clinically significant interaction 

between acamprosate and other medications. 

The most common side effect is diarrhea, which 

usually is mild and transient, typically 

disappearing within the first few weeks of 

treatment.78 Less common side effects include 

intestinal cramps and flatulence, headache, 

increased or decreased libido, insomnia, anxiety, 

muscle weakness, and dizziness. 

Rare but serious side effects include suicidal 

ideation and suicide attempts. In such patients, 

acamprosate should be discontinued and the 

patient monitored for worsening of depression.76 

A psychiatric consultation should be obtained 

and/or an antidepressant medication prescribed 

as needed. 

Drug Interactions. There are no known drug 

interactions with acamprosate.14,24 

Clinical Recommendations. Research on 

patient characteristics has not definitively 

identified particular characteristics that would 

predict which patients would benefit most from 

acamprosate.77 However, evidence suggests that 

acamprosate may be most effective for the 

following types of patients:59,79 

	 Patients who are abstinent from alcohol at the 

time treatment is initiated and who are 

motivated to maintain abstinence. A study 

found that these patients had better outcomes 

with acamprosate than did patients who 

wanted only to reduce their drinking.78 

	 Patients with hepatic disease or those who 

are being treated with opioids for pain or 

addiction. Acamprosate is eliminated renally 

and does not affect endogenous or 

exogenous opioids. 

	 Patients who are coping with multiple medical 

issues and who are taking many other 

medications. There are no clinically significant 

drug interactions with acamprosate, so it can 

be a safe medication for many patients taking 

other medications. 

17 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

MEDICATION-ASSISTED TREATMENT 

A patient who is being considered for medicationassisted treatment must be free of the 

contraindications listed in Table 1, including 

severe medical or psychiatric problems that 

would make the individual a poor candidate for 

treatment with a medication.1,2 

The following steps are recommended for 

initiating treatment with any of the medications 

approved for the management of moderate or 

severe alcohol use disorder or the prevention of 

relapse to alcohol use:1,2,7 

	 Educate the patient about medication-assisted 

treatment and the specific medication being 

recommended. 

	 Obtain informed consent for medicationassisted treatment. 

	 Complete a medical, psychiatric, and 

substance use history, including history of 

cardiovascular disease, diabetes, thyroid 

disease, seizure disorder, central nervous 

system impairment, and kidney or liver 

disease. 

	 Determine which prescription and over-thecounter medications the patient is taking, 

including herbal preparations. 

	 Perform a physical examination, baseline liver 

and kidney function tests, urine toxicology 

screen, and (in women) a pregnancy test. 

	 Assess the patient for allergies to the 

proposed medication and to other 

medications. 

	 For women, assess reproductive status, 

including current pregnancy or plans to 

become pregnant or to breastfeed. 

Initiating Treatment with 

Disulfiram 

Steps in initiating treatment with disulfiram are as 

follows:2,55,56 

	 Wait until the patient has abstained from 

alcohol for at least 12 hours and/or until the 

breath or blood alcohol level is zero. 

	 Perform an electrocardiogram if clinically 

indicated (e.g., in a patient with a history of 

heart disease). 

	 Confirm the absence of allergy to disulfiram. 

	 Perform the following tests to confirm 

abstinence and determine baselines after 

stabilization: 

a. Breath or blood alcohol tests, if clinically 

indicated to confirm abstinence 

b. Liver function tests: alanine 

aminotransferase, aspartate 

aminotransferase, gamma glutamyltransferase, alkaline phosphatase, 

lactate dehydrogenase, bilirubin, total 

protein, albumin, prothrombin time 

c. Complete blood count and routine 

chemistries, if clinically indicated 

d. Kidney function tests: routine blood urea 

nitrogen, creatinine 

Initiating Treatment with 

Naltrexone 

Naltrexone has not been shown to be effective in 

patients who are drinking at treatment initiation. 

The clinician should consider how best to induct 

a prospective patient into treatment with 

extended-release injectable naltrexone. 

Advise all patients being treated for alcohol use 

disorder that it is imperative to notify health care 

providers of any recent use of opioids or any 

history of opioid use disorder before starting 

extended-release injectable naltrexone, to avoid 

precipitation of opioid withdrawal. A urine drug 

screen should be conducted to verify abstinence 

before beginning induction.80 If patients are to be 

treated for both alcohol and opioid substance 

use disorder, they should be off all opioids, 

including prescription opioid analgesics, for a 

minimum of 7 to 10 days before starting 

naltrexone.81 Patients transitioning from opioid 

agonist therapy to extended-release injectable 

naltrexone may be vulnerable to precipitation of 

withdrawal symptoms for as long as 2 weeks. 

Ensure that patients understand that withdrawal 

precipitated by administration of an opioid 

antagonist is different from the experience of 

spontaneous withdrawal that occurs with 

discontinuation of opioids in a dependent 

individual. Withdrawal precipitated by an opioid 

antagonist may be severe enough to require 

hospitalization. 

18 
Pain management for patients using extendedrelease injectable naltrexone can be even 

more complicated than for those taking oral 

naltrexone, because of the long-acting nature 

of the injectable formulation. 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

When discontinuing naltrexone for patients with a 

history of co-occurring opioid use disorder, 

advice on opioid overdose prevention should be 

provided. After a period of abstinence from 

opioids, tolerance is greatly reduced. This means 

a previously tolerated amount of opioid could 

result in opioid overdose. Patients discontinuing 

opioid antagonist therapy in order to receive pain 

management with opioid analgesics should also 

be advised of this risk. Consider providing 

patients at risk of opioid overdose with a 

prescription for naloxone. SAMHSA’s Opioid 

Overdose Toolkit includes strategies for 

developing such a plan to address emergency 

reversal of actual or suspected opioid 

overdose.82 

Pretreatment with oral naltrexone is not required 

before induction onto extended-release injectable 

naltrexone.63,68 

Dosing and Administration. For appropriate 

candidates, the recommended dose of extendedrelease injectable naltrexone is 380 mg, 

delivered intramuscularly approximately every 30 

days, alternating buttocks for each subsequent 

injection. The following cautions should be 

observed:24,63,68 

	 Injectable naltrexone should be administered 

only by a medical professional (a physician, 

nurse, physician assistant or nurse 

practitioner) who knows how to administer IM 

gluteal injections. 

 Injectable naltrexone is packaged in a kit 

containing a vial of naltrexone as a dry 

powder that must be reconstituted with a liquid 

diluent immediately before use. Kits must be 

refrigerated during storage but should be 

brought to room temperature approximately 

45 minutes before an injection is given. The 

reconstituted microspheres in solution must 

be mixed vigorously to prevent clumping, 

which can clog the needle during injection. 

	 A syringe and five needles are provided: one 

for mixing the microspheres with the diluent 

and four needles (two 1.5-inch needles and 

two 2-inch needles) for injecting the 

suspension into the upper outer quadrant of 

the gluteal muscle. Body habitus should be 

assessed before each injection for each 

patient to ensure that needle length is 

adequate for IM administration. Injectable 

naltrexone must be administered only with 

one of the administration needles supplied in 

the carton. A spare administration needle of 

each size is provided in case of clogging. 

	 Proper IM injection technique is essential. 

Serious injection-site reactions, sometimes 

requiring extensive surgical debridement, 

have been observed with extended-release 

injectable naltrexone. It has been reported 

that these severe reactions may be more 

common if the product is inadvertently 

administered subcutaneously rather than 

intramuscularly. 

	 The medication should be administered every 

4 weeks. If a dose is delayed or missed, the 

next injection should be administered as soon 

as possible. However, it is not recommended 

that the medication be readministered at less 

than 4-week intervals. 

	 It is not recommended that the medication be 

administered at a dose higher than 380 mg. 

Clinicians are advised to download prescribing 

information on extended-release naltrexone at 

http://dailymed.nlm.nih.gov/dailymed/index.cfm. 

Special Considerations in Pain 

Management. As discussed earlier, both oral 

and extended-release naltrexone block the 

effects of opioid analgesics. However, pain 

management for patients using extended-release 

injectable naltrexone can be even more 

complicated than for those taking oral naltrexone, 

because of the long-acting nature of the 

injectable formulation. In an emergency, regional 

analgesia, conscious sedation, use of non-opioid 

analgesics, or general anesthesia may be 

needed for pain management.2,63 

If regional anesthesia is not used, then a larger 

amount of the opioid analgesic may be needed to 

override the opioid blockade. This may result in 

respiratory depression that is deeper and more 

prolonged than usual. For this reason, a rapidonset, short-acting opioid analgesic that 

minimizes the duration of respiratory depression 

is preferred. The amount administered should be 

19 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

titrated to the needs of the patient, who should be 

monitored closely by trained medical 

personnel.1,2 

Initiating Treatment with 

Acamprosate 

Acamprosate typically is initiated 5 days after the 

cessation of alcohol use. The drug typically 

reaches full effectiveness in 5 to 8 days.2,75,76 

Acamprosate therapy should be continued even 

if a patient relapses to alcohol use.1 

Treating People with Co-Occurring 

Disorders 

Co-Occurring Psychiatric Disorders. The 

use of pharmacotherapy in people with cooccurring psychiatric disorders typically involves 

the following considerations:30,31,83,84,85 

	 Naltrexone and acamprosate may be used in 

combination with psychiatric medications. 

There are no known drug interactions 

between those classes of medication and 

either drug. 

	 If a patient exhibits chronic psychiatric 

symptoms (e.g., depression, mood lability, 

psychosis, anxiety), concurrent pharmacologic 

treatment of the alcohol use disorder and the 

psychiatric comorbidity should be considered. 

	 If the patient exhibits symptoms of chronic 

depression or substance-induced depression 

that limits recovery potential, antidepressant 

therapy in the absence of contraindications 

(e.g., a history of mania or hypomania) should 

be considered. 

	 Disulfiram is contraindicated in the presence 

of psychosis because of the risk that it will 

exacerbate psychotic symptoms. 

	 Disulfiram may increase blood levels of 

tricyclic antidepressants and long-acting 

hepatically metabolized benzodiazepines, 

thereby increasing the effects of those 

medications. 

Co-Occurring Medical Conditions and 

Complications. Individuals with alcohol use 

disorder are at high risk for co-occurring medical 

conditions as a result of their heavy drinking and 

greater risk of concurrent drug use (which is 

particularly problematic if it involves injection 

drug use), behavioral and social factors such as 

unprotected sex and homelessness, or lack of 

regular medical care.85,86,87 Alcohol can also 

interfere with balance and coordination, thus 

predisposing individuals to falls and other 

injuries. Patients who present to emergency 

departments and trauma centers with serious 

injuries are far more likely than members of the 

general population to have engaged in recent 

use of alcohol.88 

Moreover, alcohol affects virtually every organ 

system. Women are more susceptible to many of 

the effects of alcohol at lower doses than men 

because of reduced first-pass metabolism of 

alcohol and lower average body weights.89 

MONITORING PATIENT PROGRESS 

As is the case with other chronic relapsing 

disorders, patients diagnosed with an alcohol use 

disorder require long-term monitoring and 

support, as well as periodic adjustment of the 

treatment regimen. 

Monitoring 

Monitoring patient progress is an ongoing 

process, during which the patient is assessed on 

three dimensions: (1) adherence to the treatment 

plan; (2) ability to maintain abstinence or reduced 

drinking, duration of periods of abstinence or 

reduced drinking, and levels of craving; and (3) 

overall health status and social functioning.1,3,7 

With this information, the clinician can modify the 

treatment plan, decide whether to continue 

pharmacotherapy, and address co-occurring 

medical, psychiatric, and substance use issues. 

Sources of Information. Patient self-reports 

can be useful indicators of treatment progress. In 

seeking information on treatment progress, it is 

important for the clinician to avoid conveying a 

judgmental attitude toward the patient’s behavior. 

Patients should be asked about the quantity and 

frequency of their drinking, especially during 

stressful periods (e.g., holidays, celebrations, 

major life changes). They should be asked about 

current craving and how they felt over the 

preceding week (by assigning a rating between 1 

and 10, with 1 indicating no craving and 10 the 

20 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

most intense craving the patient has ever 

experienced). In addition, patients may be asked 

whether any episodes have caused particular 

problems. Identifying patterns of craving over 

time helps both the patient and the caregiver 

understand that the pattern of craving fluctuates 

throughout the day and even over longer periods, 

indicating the need to continue, adjust, 

supplement, or discontinue use of a particular 

medication. Other information that is useful in 

patient monitoring includes the following:1,2,13 

	 Instruments such as the eight-question 

Alcohol Urge Questionnaire 

(https://www.phenxtoolkit.org/index.php?page 

Link=browse.protocoldetails&id=520301) 

 Laboratory tests such as the AST, GGT, CDT, 

EtG, and urine drug screens 

	 The patient’s record of keeping (or not 

keeping) appointments for medication 

monitoring 

	 The frequency of prescription refills, as 

monitored through the state PDMP90 or direct 

contact with the dispensing pharmacy 

	 Periodic reports from family members (with a 

signed release of information form) 

	 Periodic status reports from specialty 

substance abuse treatment programs, 

psychiatric referrals, and other psychosocial 

therapy or support 

	 Any information about other drugs being used 

In addition to securing the patient’s PDMP 

record, obtaining information from family 

members and significant others can provide 

useful perspectives on the patient’s behavior and 

level of function, as does contact with or records 

from clinicians who have treated the patient in 

the past and information from the prescription 

benefit provider.91 Ultimately, the goal of 

treatment is to improve the patient’s quality of 

life. Specific areas of patient progress for which 

the patient should be monitored are described in 

Table 2. 

Adjusting the Treatment Plan 

Alcohol use disorder is a chronic illness that, 

despite treatment, may change in intensity over 

time.2,7,13 If a patient begins to experience 

problems with adherence, the clinician should 

assess the patient for underlying medical, 

psychiatric, or social factors and revisit the 

treatment plan to determine whether different 

strategies or treatment modalities (pharmacologic 

and nonpharmacologic) may be useful. For 

example, increasing the frequency of monitoring 

visits or counseling may enhance the patient’s 

ability to manage relapse risks or stressors that 

are contributing to nonadherence, and switching 

the patient from oral naltrexone to extendedrelease injectable naltrexone may enhance 

adherence to the treatment regimen. 

A patient’s goals may change over time, and the 

clinician must adapt to new objectives. Also, as 

with patients who receive treatment for other 

chronic diseases, patients receiving treatment for 

alcohol use disorder may relapse. If this occurs, 

the provider should consider several options:2,24 

	 Examine social, medical, or behavioral factors 

that contribute to the patient’s alcohol 

consumption 

 Increase monitoring 

 Adjust the dose of medication 

 Increase or change the intensity of 

psychosocial services 

 Refer the patient for specialty care 

Determining the Duration of Treatment. 

Although the optimal duration of treatment is not 

known, some evidence suggests that treatment 

should continue for at least 6 months to 1 

2,24 year.

Because alcohol use disorder is a chronic 

medical problem, patients may need to use 

medications for long periods of time or may 

require multiple episodes of pharmacotherapy. In 

addition, some patients may benefit from 

treatment with medication over short periods to 

help them through particularly stressful situations 

that may elicit cravings for alcohol (e.g., a patient 

may ask for disulfiram or naltrexone to use when 

visiting family members who drink excessively).2,7 

21 
§

 

                                                                

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

TABLE 2: Monitoring Health Status and Social Functioning 

Areas for 

Monitoring Indicators of Progress 

Health  Stabilization of medical problems the patient was experiencing before beginning 

treatment (e.g., lowered blood pressure; improved liver function; control of blood 

glucose; and stabilization of asthma, cardiomyopathy, encephalopathy, gastritis, ascites, 

edema) 

 Signs of increased attention to personal health, such as seeing physicians or other 

health care professionals regularly, increased adherence with prescribed medication 

regimens not related to alcohol treatment (e.g., asthma or blood pressure medications), 

and healthful lifestyle changes 

Mental Status§  Reduced irritability and anxiety 

 Improved mood 

 Improved sleep 

 Obtaining appropriate treatment for anxiety disorders, suicidal ideation, depression, or 

schizophrenia rather than self-medicating with alcohol 

Family/Social 

Activities 

 Increases in positive time spent with loved ones 

 Reduced interpersonal conflict 

 Engagement in leisure and recreational activities that do not involve alcohol 

Work/School/ 

Vocational 

Status 

 Resumption of meaningful activities 

 Gaining employment if previously unemployed 

 Engagement in school or other employment preparation 

 Stabilized housing 

 Improved work or school performance 

Legal Status  Absence of parole or probation violations (in a patient with legal problems) 

 Absence of new or other legal problems (e.g., driving under the influence charges) 

SOURCE: SAMHSA and NIAAA. (2012, September). Report of the SAMHSA-NIAAA Consensus Panel on New and Emerging 

Pharmacotherapies for Alcohol Use Disorders and Related Comorbidities. Rockville, MD: SAMHSA. 

Ideally, a decision to discontinue 

pharmacotherapy will be based on one of the 

following reasons:2,13 

	 The patient has maintained stable abstinence 

over a sustained period and reports 

substantially diminished craving for alcohol. 

	 The patient feels ready to discontinue the 

medication. 

	 The patient is engaged in ongoing recovery 

activities involving community supports (e.g., 

attendance at mutual-help group meetings). 

Some patients simply stop taking their 

medication without consulting the prescriber. Or 

a patient may ask to discontinue medication use 

because of side effects or other reasons. Still 

§ It is recommended that the health care professional administer 

the PHQ-9 screening tool to objectively assess and monitor the 

patient’s mental status over time. http://www.drugabuse.gov 

/sites/default/files/files/PatientHealthQuestionnaire9.pdf 

other patients must discontinue medication use 

because of a significant negative laboratory 

finding or a problem with their physical health 

status.2,13 In each situation, the provider should 

help the patient withdraw from the medication at 

an appropriate pace and, as indicated, 

encourage the patient to continue with 

psychosocial therapies and participation in 

mutual-help groups. 

Referring a Patient for Higher Levels of 

Care. If office-based treatment is not effective or 

the clinician does not have the resources to meet 

a particular patient’s needs, the patient should be 

referred for more intensive or specialized 

services.2,7 Many specialty treatment programs 

provide services that address not only immediate 

withdrawal and craving, but also management of 

long-term abstinence through pharmacotherapy; 

case monitoring; individual, group, and 

22 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

family/couples counseling and therapy; other 

psychosocial services including vocational 

counseling; and referral to mutual-help groups.2,24 

A provider who is planning to treat a patient with 

an alcohol use disorder should become familiar 

with local treatment resources. Developing 

relationships with treatment staff members 

facilitates consultation and referral. In addition, 

understanding something about a program’s 

treatment duration, modality, philosophy, and 

continuing-care options helps the provider match 

a particular patient to an appropriate treatment 

program.13 It also helps the provider prepare the 

patient for what to expect, thus enhancing 

adherence with a referral.2 

Providers can find programs in their areas or 

throughout the United States by using the 

Behavioral Health Treatment Services 

Locator on the SAMHSA Web site at 

http://www.findtreatment.samhsa.gov. 

SUMMARY 

Medication-assisted treatment has shown much 

promise in reducing alcohol use and promoting 

abstinence in patients diagnosed with alcohol 

use disorder. Considerable research evidence 

and consensus among experts support the use of 

pharmacologic treatments in primary care 

settings. 

A number of FDA-approved medications have 

been shown to be important elements of such 

treatment. Although some patients do not benefit 

from medication-assisted treatment, most do. For 

each patient deemed an appropriate candidate 

for medication-assisted treatment, multiple 

pharmacologic agents offer a variety of options 

so that treatment can be tailored to each patient’s 

needs and circumstances. 

As new patient care models are encouraged by 

the Patient Protection and Affordable Care Act 

(ACA) and the accompanying improvements in 

the quality and quantity of treatment options that 

are anticipated as the ACA is implemented, there 

is considerable potential for expanding the use of 

medication-assisted treatment as clinicians 

recognize their safety, efficacy, and costeffectiveness. 

23 
                                                                

 

 

 

 

 

 

 

 

 

 

 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

APPENDIX A: MEMBERS OF THE CONSENSUS 

PANEL, STAFF, AND CONSULTANTS**

** Affiliations listed are positions held at the time of the consensus panel in July 2012. 


 

Members of the Consensus Panel 

PANEL CHAIR 

Bankole A. Johnson, D.Sc., M.D., 

M.Phil. 

Professor and Chair 

Department of Psychiatry and Brain 

Science Research Consortium 

Unit 

University of Maryland School of 

Medicine 

Baltimore, Maryland 

PANEL MEMBERS 

Amanda Abraham, Ph.D. 

Assistant Professor 

Department of Health Policy and 

Management 

University of Georgia 

Athens, Georgia 

Peter R. Cohen, M.D. 

Medical Director 

Maryland Alcohol and Drug Abuse 

Administration 

Catonsville, Maryland 

Marc J. Fishman, M.D. 

Assistant Professor 

Department of Psychiatry 

Johns Hopkins University School of 

Medicine and 

Medical Director 

Maryland Treatment Centers 

Baltimore, Maryland 

J. C. Garbutt, M.D. 

Professor of Psychiatry 

Bowles Center for Alcohol Studies 

University of North Carolina at 

Chapel Hill 

Chapel Hill, North Carolina 

Constance Horgan, Sc.D. 

Professor and Associate Dean for 

Research 

Director 

Institute for Behavioral Health 

Heller School for Social Policy and 

Management 

Brandeis University 

Waltham, Massachusetts 

Andrea King, Ph.D. 

Professor 

Department of Psychiatry and 

Behavioral Neuroscience 

University of Chicago 

Chicago, Illinois 

Henry R. Kranzler, M.D. 

Professor of Psychiatry 

Director, Center for Studies of 

Addiction 

Perelman School of Medicine 

University of Pennsylvania 

Philadelphia, Pennsylvania 

Joseph Liberto, M.D. 

Associate Professor of Psychiatry 

University of Maryland School of 

Medicine and 

Baltimore VA Medical Center 

Baltimore, Maryland 

Paolo Mannelli, M.D. 

Associate Professor of Psychiatry 

Duke University Medical Center 

Chapel Hill, North Carolina 

Tami L. Mark, Ph.D., M.B.A. 

Senior Director 

Analytic Consulting and Research 

Services 

Truven Health Analytics 

Washington, D.C. 

Percy Menzies, M.Pharm. 

President 

Assisted Recovery Centers of 

America 

St. Louis, Missouri 

Charles P. O’Brien, M.D., Ph.D. 

Kenneth Appel Professor of 

Psychiatry 

Treatment Research Center 

University of Pennsylvania 

Philadelphia, Pennsylvania 

Stephanie S. O’Malley, Ph.D. 

Professor of Psychiatry 

Director, Division of Substance 

Abuse Research in Psychiatry 

Yale School of Medicine 

New Haven, Connecticut 

Ismene Petrakis, M.D. 

Professor 

Department of Psychiatry 

Yale School of Medicine 

New Haven, Connecticut 

Helen M. Pettinati, Ph.D. 

Professor 

Department of Psychiatry 

Perelman School of Medicine 

Treatment Research Center 

University of Pennsylvania 

Philadelphia, Pennsylvania 

Lara Ray, Ph.D. 

Assistant Professor 

Department of Psychology and 

Brain Research Institute 

University of California, Los 

Angeles 

Los Angeles, California 

Robert Swift, M.D., Ph.D. 

Professor of Psychiatry and Human 

Behavior 

Brown University 

Providence, Rhode Island 

George Woody, M.D. 

Professor of Psychiatry 

Treatment Research Institute 

University of Pennsylvania 

Philadelphia, Pennsylvania 

24 
  

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

Staff and Consultants†† 

†† Affiliations listed are positions held at the time of the project work. 

CMS STAFF 

Stephen Cha, M.D. 

Chief Medical Officer 

Center on Medicaid and CHIP 

Services 

Centers for Medicare and Medicaid 

Services 

Baltimore, Maryland 

John P. O’Brien 

Senior Policy Advisor 

Centers for Medicare and Medicaid 

Services 

Baltimore, Maryland 

HRSA STAFF 

Seiji Hayashi, M.D., M.P.H. 

Chief Medical Officer 

Bureau of Primary Health Care 

Health Resources and Services 

Administration 

Rockville, Maryland 

Rita Vandivort-Warren, M.S.W. 

Office of Special Health Affairs 

Health Resources and Services 

Administration 

Rockville, Maryland 

NIAAA STAFF 

Joanne Fertig, Ph.D. 

Division of Treatment and Recovery 

Research 

National Institute on Alcohol Abuse 

and Alcoholism/NIH 

Rockville, Maryland 

Bob Huebner, Ph.D. 

Deputy Director 

Division of Treatment and Recovery 

Research 

National Institute on Alcohol Abuse 

and Alcoholism/NIH 

Rockville, Maryland 

Raye Z. Litten, Ph.D. 

Associate Director 

Division of Treatment and Recovery 

Research 

National Institute on Alcohol Abuse 

and Alcoholism/NIH 

Rockville, Maryland 

Kenneth R. Warren, Ph.D. 

Acting Director 

National Institute on Alcohol Abuse 

and Alcoholism/NIH 

Rockville, Maryland 

NIDA STAFF 

Ivan Montoya, M.D., M.P.H. 

Deputy Director 

Division of Pharmacotherapies and 

Medical Consequences of Drug 

Abuse 

National Institute on Drug 

Abuse/NIH 

Bethesda, Maryland 

SAMHSA STAFF 

Melinda Campopiano von Klimo, 

M.D. 

Medical Advisor 

Division of Pharmacologic Therapies 

Center for Substance Abuse 

Treatment/SAMHSA 

Rockville, Maryland 

H. Westley Clark, M.D., J.D., 

M.P.H., CAS 

Director 

Center for Substance Abuse 

Treatment/SAMHSA 

Rockville, Maryland 

Peter Delany, Ph.D., LCSW-C 

Director 

Center for Behavioral Health 

Statistics and Quality/SAMHSA 

Rockville, Maryland 

LCDR Brandon T. Johnson, 

M.B.A. 

Public Health Advisor 

Division of Pharmacologic Therapies 

Center for Substance Abuse 

Treatment/SAMHSA 

Rockville, Maryland 

CDR Erich Kleinschmidt, M.S.W. 

Public Health Advisor 

Division of Pharmacologic Therapies 

Center for Substance Abuse 

Treatment/SAMHSA 

Rockville, Maryland 

Elinore McCance-Katz, M.D., Ph.D. 

Chief Medical Officer 

SAMHSA 

Rockville, Maryland 

Sandrine Pirard, M.D., Ph.D., 

M.P.H. 

Medical Advisor 

Division of Pharmacologic Therapies 

Center for Substance Abuse 

Treatment/SAMHSA 

Rockville, Maryland 

CDR Alina Salvatore, R.Ph., M.S. 

Public Health Advisor 

Division of Pharmacologic Therapies 

Center for Substance Abuse 

Treatment/SAMHSA 

Rockville, Maryland 

PROJECT CONSULTANTS 

Anton C. Bizzell, M.D. 

President 

The Bizzell Group, LLC 

Silver Spring, Maryland 

Krystyna Isaacs, Ph.D. 

Project Director 

JBS International, Inc. 

North Bethesda, Maryland 

Jane Carlisle Maxwell, Ph.D. 

Senior Research Scientist 

School of Social Work 

University of Texas at Austin 

Austin, Texas 

Joseph Perpich, M.D., J.D. 

Principal & Senior Medical Advisor 

JBS International, Inc. 

North Bethesda, Maryland 

PROJECT DIRECTORS 

Susan Hayashi, Ph.D. 

Vice-President 

JBS International, Inc. 

North Bethesda, Maryland 

Bonnie B. Wilford, M.S. 

Director
 

Center for Health Services & 

Outcomes Research 

Senior Principal 

JBS International, Inc. 

North Bethesda, Maryland 

25 
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide

APPENDIX B: SOURCES OF HELPFUL 

INFORMATION

SAMHSA PUBLICATIONS AND WEB

SITES

Detoxification and Substance Abuse Treatment,

Treatment Improvement Protocol 45

http://www.store.samhsa.gov/product/TIP-45-

Detoxification-and-Substance-AbuseTreatment/SMA13-4131

General Principles for the Use of 

Pharmacological Agents to Treat Individuals with 

Co-Occurring Mental and Substance Use 

Disorders

http://www.ncdsv.org/images/SAMHSA_General

PrinciplesUsePharmacologicalAgentsTreatIndivid

ualsCo-OccuringMentalSubstanceUseDisorders_

2012.pdf 

Incorporating Alcohol Pharmacotherapies Into 

Medical Practice, Treatment Improvement 

Protocol 49

http://www.store.samhsa.gov/product/TIP-49-

Incorporating-Alcohol-Pharmacotherapies-IntoMedical-Practice/SMA13-4380 

Naltrexone for Extended-Release Injectable 

Suspension for Treatment of Alcohol 

Dependence, Substance Abuse Treatment 

Advisory

http://www.store.samhsa.gov/product/Naltrexonefor-Extended-Release-Injectable-Suspension-forTreatment-of-Alcohol-Dependence/SMA07-4267

Opioid Overdose Toolkit 

http://www.store.samhsa.gov/shin/content/SMA1

3-4742/Overdose_Toolkit_2014_Jan.pdf

The Role of Biomarkers in the Treatment of 

Alcohol Use Disorders, SAMHSA Advisory

http://www.store.samhsa.gov/product/The-Roleof-Biomarkers-in-the-Treatment-of-Alcohol-UseDisorders-2012-Revision/SMA12-4686 

SAMHSA’s National Registry of Evidence-based 

Programs and Practices 

http://nrepp.samhsa.gov 

SAMHSA's Screening, Brief Intervention, and 

Referral to Treatment (SBIRT)

http://www.samhsa.gov/sbirt

SAMHSA’s Treatment Locator

http://www.samhsa.gov/treatment

NIAAA PUBLICATIONS AND WEB SITES 

Alcohol Screening and Brief Intervention for 

Youth: A Practitioner’s Guide

http://www.niaaa.nih.gov/publications/clinicalguides-and-manuals/alcohol-screening-and-briefintervention-youth/resources

Assessing Alcohol Problems: A Guide for 

Clinicians and Researchers, Second Edition

http://www.pubs.niaaa.nih.gov/publications/Asses

singAlcohol

Clinical Protocols to Reduce High Risk Drinking 

in College Students: The College Drinking 

Prevention Curriculum for Health Care Providers

http://www.collegedrinkingprevention.gov/media/

FlemingManual.pdf

Exploring Treatment Options for Alcohol Use 

Disorders, Alcohol Alert, No. 81

http://www.pubs.niaaa.nih.gov/publications/AA81/

AA81.htm

Helping Patients Who Drink Too Much: A 

Clinician’s Guide, Updated 2005 Edition

http://www.pubs.niaaa.nih.gov/publications/Practi

tioner/CliniciansGuide2005/clinicians_guide.htm

Prescribing Medications for Alcohol Dependence

http://www.pubs.niaaa.nih.gov/publications/Practi

tioner/CliniciansGuide2005/PrescribingMeds.pdf 

Rethinking Drinking: Alcohol and Your Health

(available in English and Spanish) 

http://www.pubs.niaaa.nih.gov/publications/Rethi

nkingDrinking/OrderPage.htm

26
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

MENTORING NETWORK 

Providers’ Clinical Support System for Medication 

Assisted Treatment 

http://www.pcssmat.org 

MUTUAL-HELP GROUPS 

Al-Anon Family Groups 

http://www.al-anon.alateen.org 

Alcoholics Anonymous 

http://www.aa.org 

Self-Management and Recovery Training 

http://www.smartrecovery.org 

Women for Sobriety, Inc. 

http://www.womenforsobriety.org 

WEB-BASED COURSES 

ASAM e-Live Learning Center 

http://www.softconference.com/asam/default.asp 

ASAM From Assessment to Service Planning 

and Level of Care Course 

https://www.changecompanies.net/products/prod 

uct.php?id=ASE2 

ASAM Multidimensional Assessment eLearning 

http://www.changecompanies.net/asamcriteria 

/elearning.php 

ASAM SBIRT Core Training Program 

http://www.sbirttraining.com 

NIAAA Clinician’s Guide Online Training 

http://www.niaaa.nih.gov/publications/clinicalguides-and-manuals/niaaa-clinicians-guideonline-training 

NIAAA Presentations and Videocasts 

http://www.niaaa.nih.gov/publications/presentatio 

ns-and-videocasts 

OTHER WEB SITES 

American Society of Addiction Medicine 

http://www.asam.org 

Georgetown University Medical Center’s 

Ensuring Solutions to Alcohol Problems 

http://www.ensuringsolutions.org 

Gold MS, Aronson, MD. Psychosocial treatment 

of alcohol use disorder. Up-to-date online 

medical education service, 2013. 

http://www.uptodate.com/contents/psychosocialtreatment-of-alcohol-use-disorder 

National Association of State Controlled 

Substances Authorities 

http://www.nascsa.org 

U.S. Department of Justice, Drug Enforcement 

Administration, Office of Diversion Control, State 

Prescription Drug Monitoring Programs 

http://www.deadiversion.usdoj.gov/faq/rx_monitor 

.htm 

SUGGESTED INSTRUMENTS FOR 

SCREENING AND MONITORING 

Alcohol Misuse: Screening and Behavioral 

Counseling Interventions in Primary Care 

http://www.uspreventiveservicestaskforce.org/us 

pstf/uspsdrin.htm 

Alcohol, Smoking and Substance Involvement 

Screening Test (ASSIST) 

http://www.who.int/substance_abuse/activities/as 

sist/en/index.html 

Alcohol Urge Questionnaire (AUQ) 

https://www.phenxtoolkit.org/index.php?pageLink 

=browse.protocoldetails&id=520301 

Alcohol Use Disorders Identification Test 

(AUDIT) 

http://www.whqlibdoc.who.int/hq/2001/WHO_MS 

D_MSB_01.6a.pdf 

Clinical Institute Withdrawal Assessment for 

Alcohol Scale, Revised (CIWA-Ar) 

https://umem.org/files/uploads/1104212257_CIW 

A-Ar.pdf 

Oregon SBIRT Comprehensive Screening and 

Brief Intervention Resources 

http://www.sbirtoregon.org 

Problem Oriented Screening Instrument for 

Teenagers (POSIT) 

http://www.emcdda.europa.eu/html.cfm/index443 

9EN.html 

27 
 

 

 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

PUBLISHED GUIDELINES AND 

REFERENCE TEXTS 

American Psychiatric Association (APA). 

Diagnostic and Statistical Manual of Mental 

Disorders, Fifth Edition (DSM-5). Washington, 

DC: American Psychiatric Publishing, 2013. 

American Psychological Association (APA). 

Understanding Alcohol Use Disorders and Their 

Treatment. APA Help Center, 2012. 

http://www.apa.org/helpcenter/alcoholdisorders.aspx 

American Society of Addiction Medicine (ASAM). 

ASAM Patient Placement Criteria, Third Edition 

(PPC-3). Philadelphia, PA: Lippincott, Williams & 

Wilkins, 2013. 

American Society of Addiction Medicine (ASAM). 

ASAM Patient Placement Criteria: Supplement 

on Pharmacotherapies for Alcohol Use 

Disorders. Philadelphia, PA: Lippincott, Williams 

& Wilkins, 2010. 

American Society of Addiction Medicine (ASAM). 

ASAM Principles of Addiction Medicine, Fifth 

Edition. Philadelphia, PA: Lippincott, Williams & 

Wilkins, 2014. 

Lingford-Hughes AR, Welch S, Peters L, et al., 

for the British Association of Psychiatry (BAP). 

BAP updated guidelines: Evidence-based 

guidelines for the pharmacological management 

of substance abuse, harmful use, addiction and 

comorbidity. J Psychopharm. 2012; 26(7):899­

952. 

National Clinical Guideline Centre for Acute and 

Chronic Conditions. Alcohol-Use Disorders. 

Diagnosis and Clinical Management of AlcoholRelated Physical Complications. London, UK: 

National Institute for Health and Clinical 

Excellence, 2010. 

National Clinical Guideline Centre for Acute and 

Chronic Conditions. Alcohol-Use Disorders. 

Diagnosis, Assessment and Management of 

Harmful Drinking and Alcohol Dependence. 

London, UK: National Institute for Health and 

Clinical Excellence, 2011. 

Veterans Health Administration and Department 

of Defense (DoD). VA/DoD Clinical Practice 

Guideline for the Management of Substance Use 

Disorders in the Primary Care Setting. 

http://www.healthquality.va.gov/sud/sud_fulltext 

.pdf 

28 
 

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide 

APPENDIX C: ACKNOWLEDGMENTS 

CDR Alina Salvatore, R.Ph., M.S., and LCDR Brandon T. Johnson, M.B.A., of the Division of 

Pharmacologic Therapies, Center for Substance Abuse Treatment (CSAT), Substance Abuse and 

Mental Health Services Administration (SAMHSA), served as the Contracting Officer Representatives 

for this activity. Robert A. Lubran, M.S., M.P.A., Director of SAMHSA’s Division of Pharmacologic 

Therapies, provided valuable guidance, as did Sandrine Pirard, M.D., Ph.D., M.P.H.; Melinda 

Campopiano von Klimo, M.D.; CDR Erich Kleinschmidt, M.S.W.; and other experts within SAMHSA, the 

National Institute on Alcohol Abuse and Alcoholism (NIAAA), other federal agencies, and private-sector 

organizations. 

Members of the SAMHSA-NIAAA Consensus Panel on New and Emerging Pharmacotherapies for 

Alcohol Use Disorders and Related Comorbidities graciously agreed to serve as peer reviewers of the 

document. Their many contributions are acknowledged with gratitude. 

Special appreciation is extended to Panel Chair Bankole A. Johnson, D.Sc., M.D., M.Phil., and to 

Kenneth R. Warren, Ph.D., Raye Z. Litten, Ph.D., Joanne Fertig, Ph.D., Bob Huebner, Ph.D., Daniel 

Falk, Ph.D., and Megan Ryan, M.B.A., of NIAAA. 

Susan W. Hayashi, Ph.D., and Bonnie B. Wilford, M.S., served as Project Directors, with valuable 

assistance from Joseph Perpich, M.D., J.D.; Krystyna Isaacs, Ph.D.; Gwen Solan Littman, M.D.; 

Candace A. Baker, M.S.W.; Jeffrey Vender, M.L.I.S.; Leotta Britton; and Valerie L. Vivian, M.B.A., of 

JBS International, Inc. 

29 
 

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34