What’s the Best Medication for Alcohol Use Disorder (AUD)?

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If you’re familiar with treatment for addiction – which we now call substance use disorder (SUD) – you’ve probably heard of medication-assisted treatment (MAT) for opioid use disorder (OUD), but you may not know that there’s also another type of MAT: medication for alcohol use disorder.

We published an article on the topic in July 2023:

Medication-Assisted Treatment for Alcohol Use Disorder (MAT for AUD)

In that article, we identified three medications approved by the Food and Drug Administration (FDA) for AUD treatment. Those medications include:

  • Naltrexone
  • Acamprosate
  • Disulfiram

All three medications are effective. Data from the Substance Abuse and Mental Health Services Administration (SAMHSA) publication “Medication-Assisted Treatment for the Treatment of Alcohol Use Disorder: A Brief Guide” confirms the following benefits of MAT for AUD:

  • Decreased alcohol consumption
  • Improved cognitive function
  • Improved ability to initiate and participate in AUD treatment
  • Decreased cravings for alcohol
  • Prevents alcohol use entirely (disulfiram)
  • Facilitates positive lifestyle changes

Of those three medications, clinicians use Naltrexone and Acamprosate as first-line pharmacotherapies and Disulfiram as a second-line pharmacotherapy. Note: pharmacotherapy is a fancy way of saying therapy/treatment with pharmaceutical medication. While Naltrexone and Acamprosate work by affecting neurotransmitters associated with alcohol and alcohol cravings, Disulfiram is different. It makes ingesting alcohol extremely unpleasant: a person who drinks alcohol with Disulfiram in their system will experience sweats, shakes, nausea, anxiety, and vomiting.

It works, but it’s not used as often as the other two medications for alcohol use disorder, which are the topic of a new study that got our attention: “Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis.” The research team organized the project around a simple question:

Which pharmacotherapies are associated with improved outcomes for people with alcohol use disorder?

Their systematic review and meta-analysis included 118 clinical trials with a total of 20,976 participants. They found compelling evidence supporting the use of oral naltrexone and acamprosate for people with alcohol use disorder (AUD).

Why Do We Need Another Study on Medication for Alcohol Use Disorder (AUD)?

This information published by the Centers for Disease Control (CDC) describes the significant need for a greater understanding of alcohol consumption and its consequences:

“Emerging evidence suggests that even drinking within the recommended limits may increase the overall risk of death from various causes, such as from several types of cancer and some forms of cardiovascular disease. Alcohol has been found to increase risk for cancer, and for some types of cancer, the risk increases even at low levels of alcohol consumption (less than 1 drink in a day).”

With regards to the common cultural trope/idea that moderate alcohol consumption has some positive outcomes, they clarify their point of view:

“Although past studies have indicated that moderate alcohol consumption has protective health benefits… it’s impossible to conclude whether these improved outcomes are due to moderate alcohol consumption or other differences in behaviors or genetics.”

We discuss this new information at length in previous articles. Please navigate to the blog section of our website and read this piece:

Moderate Drinking, Binge Drinking, and Alcohol-Related Problems

That’s one reason we need more research on alcohol: much of what we know about the health effects of alcohol needs revision, especially in the minds of the general public. Another is that alcohol causes significant harm that goes largely unrecognized and underreported. Here’s data published by the CDC, the National Institute on Alcohol Abuse and Alcoholism (NIAA), and the National Highway Traffic Safety Administration (NHTSA) that most people are unaware of:

Harm Caused by Alcohol

  • 2015-2019: 140,000 alcohol-related fatalities each year
    • Males: 97,000
    • Females: 43,000
  • That’s 75% more than the reported opioid-related fatalities in the same time
  • 2008-2017: 10,000 people alcohol-related automobile fatalities
  • 2020: 11,654 alcohol-related automobile fatalities
    • That’s 14.3% more than 2019

A study released in 2022 about problems among moderate alcohol drinkers who occasionally binge-drink revealed this surprising set of facts:

Binge Drinking Among Moderate Drinkers: Long-Term Problems

  • 85% of alcohol-related problems at 9-year follow-up appeared in moderate drinkers
  • Binge and heavy drinking at baseline predicted the presence of alcohol-related problems at 9-year follow-up.
  • Moderate drinkers who reported binge drinking episodes reported more alcohol-related problems at 9-year follow-up more than heavy drinkers who reported binge drinking episodes
  • Risk of multiple alcohol-related problems at 9-year follow-up increased by 439% for participants who reported moderate drinking with binge drinking episodes at baseline

Next, the 2021 National Survey on Drug Use and Health (2021 NSDUH) contains the most up-to-date information on alcohol use available.

Alcohol Use: Past Month, Binge, and Heavy Drinking, Age 12+

  • 133.1 million people reported drinking in the past month
  • 60.0 million (45.1%) reported binge drinking
  • Binge drinking by age group:
    • 18-25: ~10 million
    • 26+: ~50 million
    • 12-17: ~1 million
  • Binge drinking among underage people: ~3 million
  • Heavy drinkers: ~16.3 million
  • Heavy drinkers by age group:
    • 18-25: ~2.5 million
    • 26+: ~14 million
    • 12-17: ~100,000
  • Heavy drinkers under age 18: ~600,000

Alcohol Use Disorder: By Age Group

  • 12 + total: ~30 million
  • 12-17: ~900,000
  • 18-25: ~5 million
  • 26+: ~23.5 million

Next, evidence form studies published here and here show AUD is various negative health outcomes, including but not limited to:

  • Hypertension
  • Heart disease
  • Stroke
  • Cognitive impairment
  • Sleep problems
  • Depression
  • Anxiety
  • Peripheral neuropathy
  • gastritis and gastric ulcers
  • Liver disease including cirrhosis
  • Pancreatitis
  • Osteoporosis
  • Anemia
  • Fetal alcohol spectrum disorders
  • Several types of cancer

Finally, evidence from a study published here indicates alcohol consumption is associated with and increase in additional negative outcomes, including:

  • Homicide
  • Suicide
  • Motor vehicle crashes and deaths
  • Sexual violence
  • Domestic violence
  • Drownings

Taken as a whole, that’s a compelling set of facts that leads to one conclusion: alcohol causes more problems than most people realize. That conclusion leads to this realization: we need to know more about how to support people with alcohol use disorder (AUD).

Therefore, scientists conduct more research, and we report it to you here. With all that in mind, let’s take a look at the results of the study we introduce above, “Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis.”

Naltrexone or Acamprosate: Which Medication for Alcohol Use Disorder is More Effective?

The primary metric the research team used to judge the effectiveness of the medications for alcohol use disorder was alcohol use/ consumption over the 30-day study period. Secondary metrics included health and wellness factors, motor vehicle crashes, and mortality. However, the studies reviewed in the meta-analysis didn’t include data sufficient to draw any statistically significant or relevant conclusions on their secondary metrics. Therefore, we’ll report the results of their primary metric: alcohol consumption during the 30-day study period.

The metric they used to assess consumption is interesting. They assessed:

  • Return to drinking
  • Return to heavy drinking
  • Percentage of drinking days
  • Percentage of heavy drinking days

To report their findings, they used a construct called number needed to treat (NNT). What that means is the number of people they needed to treat with the medication in question to prevent one (1) person from returning to heavy drinking or drinking. The team identified the most effective dose for patients – 50 mg/d (milligrams per deciliter) – and reported results based on that dosage.

Here’s what they found.

Naltrexone or Acamprosate? The Results

The number of patients needed to treat (NNT) to prevent 1 person from returning to any drinking, at a dose of 50 mg/d:

  • Naltrexone: 18
  • Acamprosate: 11

Compared with placebo:

  • Oral naltrexone was associated with lower rates of return to heavy drinking
  • Injectable naltrexone was associated with fewer drinking days over the 30-day treatment period:
    • Average of 5 fewer drinking days
  • Injectable naltrexone was associated with greater reduction in percentage of heavy drinking days over the 30-day treatment period:
    • Percentage of heavy drinking days decreased by 5%
  • Acamprosate showed no statistically significant improvement in return to heavy drinking
  • Adverse effects included:
    • Naltrexone: nausea/vomiting
    • Acamprosate: diarrhea

We’ll summarize this data now. The meta-analysis showed naltrexone reduced:

  • Return to any drinking
  • Return to heavy drinking
  • Percentage of drinking days
  • Percentage of heavy drinking days

The meta-analysis showed acamprosate reduced:

  • Return to drinking
  • Number of drinking days
  • Acamprosate was not associated with reduced return to heavy drinking

Here’s how the research team describes their findings:

“Oral naltrexone and acamprosate were each associated with significantly improved alcohol consumption-related outcomes compared with placebo. In conjunction with psychosocial interventions, these findings support the use of oral naltrexone, 50 mg/d, and acamprosate as first-line pharmacotherapies for alcohol use disorder.”

MAT for AUD: How it Works

The most important thing to understand about medication-assisted treatment – whether for alcohol use disorder or opioid use disorder – is that it’s not just about the medication. Please note the summary from research team reads “…in conjunction with psychosocial interventions…” the results support the use of oral naltrexone and acamprosate for AUD.

SAMHSA indicates treatment plan with medication for AUD must include:

  • Therapy, counseling, lifestyle changes, peer support, and complementary treatment modes
  • Educational workshops on relapse prevention, healthy communication, healthy relationships
  • Family participation (biological or chosen family)
  • Treatment for co-occurring disorders
  • A timeline and criteria for discontinuing MAT
  • Timeline and criteria for completing treatment
  • An aftercare plan for ongoing support upon discharge from treatment

In other words, MAT programs for AUD should be integrated, comprehensive, and holistic. Integrated means clinicians plan how the various modes of treatment will reinforce one another. Comprehensive means they treat all issues simultaneously: a person with a mental health disorder and a substance use disorder needs treatment for both at the same time. Treating one without treating the other reduces chance of successful recovery from both. Finally, holistic means the program addresses the whole person: biological, social, and physical. We concur with the definition of health espoused by the World Health Organization (WHO):

“Health is a state of completer physical, mental, and social well-being and not merely the absence of disease or infirmity.”

When a patient comes to us for support for alcohol use disorder – or any substance use disorder – that’s why MAT is one option. It helps a person achieve total, holistic health, and puts them on the road to long-term sustainable recovery, and a life without alcohol or drugs.

The materials provided on the Pinnacle Blog are for information and educational purposes only. No behavioral health or any other professional services are provided through the Blog and the information obtained through the Blog is not a substitute for consultation with a qualified health professional. If you are in need of medical or behavioral health treatment, please contact a qualified health professional directly, and if you are in need of emergency help, please go to your nearest emergency room or dial 911.