Medication for the Treatment 

of Alcohol Use Disorder

Pocket Guide
Medications are underused in the treatment of alcohol use disorder. According to 

the National Survey on Drug Use and Health, of the estimated 17.6 million people 

who needed treatment for an alcohol use problem in 2014, only 1.6 million (8.9%) 

received any type of specialty treatment (excluding mutual-help groups).

SAMHSA and NIAAA created Medication for the Treatment of 

Alcohol Use Disorder: A Brief Guide, a 35-page booklet to 

assist clinicians in prescribing medications. This information is 

excerpted from that publication which is available for download at 

http://store.samhsa.gov/product/Medication-for-the-Treatmentof-Alcohol-Use-Disorder-A-Brief-Guide/SMA15-4907

This pocket guide offers:

• A Checklist for Prescribing Medication

• Approved Medications for Use in Treatment of Alcohol Use Disorder

• Standard Drink Sizes/Amounts and Recommended Limits
Medication for the Treatment of Alcohol Use Disorder 3

Checklist for Prescribing Medication for the Treatment of Alcohol Use Disorder

 Screen for risky alcohol use

 Use 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)

 Assess the need for medication-assisted treatment

 Consider prescribing medications for patients who are dependent on alcohol or have stopped 

 drinking but are experiencing cravings or relapses. Patients who have moderate or severe 

 alcohol use disorder and have not improved with psychosocial approaches alone are 

 particularly strong candidates. (See table for more information about candidates). 

 Your assessment should include:

 • A patient history

 ¡ Ensure that the assessment includes a medical and psychiatric history, a 

 substance use history, and an evaluation of family and psychosocial supports.

 ¡ Access the patient’s prescription drug use history through the state’s prescription 

 drug monitoring program (PDMP), where available, to detect unreported use of 

 other medications, such as opioid analgesics or sedative-hypnotics, that may interact 

 negatively with alcohol or with alcohol treatment medications.
Medication for the Treatment of Alcohol Use Disorder 4

 • A physical examination that measures neurocognitive function, identifies the sequelae 

 of alcohol use and looks for evidence of hepatitis dysfunction. 

 • Laboratory testing to confirm the presence of alcohol related drinking and identify 

 alcohol related damage.

 Educate the patient about how the medication works and the associated risks and 

 benefits; obtain informed consent.

 Evaluate the need for medically managed withdrawal from alcohol

 • Note that withdrawal generally begins within 24 to 48 hours after the blood alcohol 

 level drops and can persist for 5 to 7 days. 

 • Use 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

 Address co-occurring disorders

 • Have a unified treatment approach to meet the substance use, mental health, and 

 related needs of a patient

 
Medication for the Treatment of Alcohol Use Disorder 5

 Integrate pharmacologic and nonpharmacologic therapies

 • Recognize that medications for moderate or severe alcohol use disorder, professional 

 counseling, and mutual-help groups can be combined in a comprehensive, 

 complementary approach.

 Refer patients for higher levels of care, if necessary

 • Refer the patient for more intensive or specialized services if office-based treatment 

 is not effective or the clinician does not have the resources to meet a particular 

 patient’s needs, Providers can find programs in their areas or throughout the 

 United States by using SAMHSA’s Behavioral Health Treatment Services Locator at 

 http://www.findtreatment.samhsa.gov.
Medication for the Treatment of Alcohol Use Disorder 6

Medications Approved in the Treatment of Alcohol Use Disorder*

DOSAGE AND FREQUENCY OF ADMINISTRATION

Disulfiram Naltrexone oral and extended 

release injectable formulations

Acamprosate delayed-release tablets

Oral: 250 to 500 mg per day- Daily Oral: 50 to 100mg per day –Daily

Extended-release injectable: 380mg per 

month - Monthly

Oral: 666 mg- Three times per day

PRINCIPAL ACTION

Disulfiram Naltrexone oral and extended 

release injectable formulations

Acamprosate delayed-release tablets

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 reduce symptoms of 

protracted abstinence by counteracting 

the imbalance between the glutamatergic 

and GABAergic systems associated with 

chronic alcohol exposure and alcohol 

withdrawal. 
Medication for the Treatment of Alcohol Use Disorder 7

CLINICAL USES/IDEAL CANDIDATES 

Disulfiram Naltrexone oral and extended 

release injectable formulations

Acamprosate delayed-release tablets

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 is indicated for the 

maintenance of abstinence in patients who 

are dependent on alcohol and are abstinent 

at treatment initiation. The efficacy of 

acamprosate in promoting abstinence has 

not been demonstrated in subjects who have 

not completed detoxification or who have not 

achieved alcohol abstinence before beginning 

treatment. 
Medication for the Treatment of Alcohol Use Disorder 8

CONTRAINDICATIONS

Disulfiram Naltrexone oral and extended 

release injectable formulations

Acamprosate delayed-release tablets

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. 

Acamprosate is indicated for the 

maintenance of abstinence in patients who 

are dependent on alcohol and are abstinent 

at treatment initiation. The efficacy of 

acamprosate in promoting abstinence has 

not been demonstrated in subjects who have 

not completed detoxification or who have not 

achieved alcohol abstinence before beginning 

treatment. 
Medication for the Treatment of Alcohol Use Disorder 9

WARNINGS 

Disulfiram Naltrexone oral and extended 

release injectable formulations

Acamprosate delayed-release tablets

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 opioid-containing 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 initiating treatment with acamprosate, 

evaluate the patient’s renal function through 

a standard panel for urea, electrolytes, and 

serum creatinine to rule out severe renal 

impairment. For patients with moderate renal 

impairment (creatinine clearance of 30–50 

mL/min), a reduced dose of acamprosate (one 

333 mg tablet 3 times a day) is recommended. 

Because of elevated risk of diminished renal 

function in people ages 65 or older, baseline 

and frequent renal function tests are 

important in this population. 
Medication for the Treatment of Alcohol Use Disorder 10

USE IN PREGNANT AND POSTPARTUM WOMEN 

Disulfiram Naltrexone oral and extended 

release injectable formulations

Acamprosate delayed-release tablets

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: FDA Pregnancy Category C‡ 

Nursing: It is not known whether acamprosate is excreted in human milk. 

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

the package inserts or other drug reference sources 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 Library of Medicine’s MedlinePlus (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 her health care provider. 

The 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 responsibility for use of the information in the care of individual patients.
Medication for the Treatment of Alcohol Use Disorder 11

Standard Drink Sizes/Amounts and Recommendations
Medication for the Treatment of Alcohol Use Disorder 12

According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the following are 

recommended limits. People, with exceptions noted below, are advised to stay within these limits.

• For healthy men up to age 65

¡ No more than 4 drinks a day AND

¡ No more than 14 drinks in a week

• For healthy women (and healthy men over age 65)

¡ No more than 3 drinks in a day AND

¡ No more than 7 drinks in a week

• Abstinence should be advised to individuals who:

¡ Take prescriptions or over-the-counter medications that may interact with alcohol

¡ Try cutting down but cannot stay within limits they have set

¡ Have had an alcohol use disorder or now have symptoms

¡ Have a physical or mental health condition that may be exacerbated by alcohol

¡ Are or may become pregnant

¡ Are younger than age 21
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.

Electronic Access and Printed Copies

This publication may be downloaded or ordered at store.samhsa.gov.

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

SMA15-4907POCKETGUID
For more information visit: http://www.samhsa.gov/