More than 14 million adults in the U.S. live with alcohol use disorder. Yet, only about 1 in 10 get any kind of medication to help them stay sober. That’s not because the drugs don’t work. It’s because most people don’t know how they work - or what they can and can’t do.
What the Medications Actually Do
There are three FDA-approved medications for alcohol use disorder: naltrexone, acamprosate, and disulfiram. Each works differently. None cure AUD. But when used right, they cut relapse risk by about 20%. Naltrexone blocks the brain’s opioid receptors. That means when you drink, you don’t get the same rush. It doesn’t make you sick - it just takes the pleasure out of drinking. Studies show it reduces heavy drinking days by nearly 5 days a month. It’s especially helpful for people who drink to cope with stress or crave alcohol after a long day. Acamprosate is the opposite. It doesn’t touch cravings. Instead, it steadies your brain after you stop drinking. Heavy drinking messes up your neurotransmitters - especially GABA and glutamate. Acamprosate helps rebalance them. It’s best for people who want total abstinence and have already gone through detox. If you’re still drinking when you start it, it won’t help. Disulfiram is the oldest. It makes your body react badly to alcohol. If you drink, you get flushed, nauseous, dizzy, maybe even have a heart palpitation. It’s like a chemical alarm clock. But here’s the catch: it only works if you take it every day and never drink. Most people can’t stick with it. The side effects are scary, and one slip-up can land you in the ER.Which One Works Best for You?
There’s no single best drug. It depends on your history, your goals, and your body. If you’re trying to cut back - not quit entirely - naltrexone is your best bet. You don’t need to be sober to start it. Just wait 7-10 days after your last opioid use. It’s taken as a daily pill or a monthly shot (Vivitrol). The shot helps with adherence, but it doesn’t work better than the pill. One study found it didn’t reduce the chance of returning to any drinking at all - but it did cut the number of heavy drinking days. If you’re all-in on quitting, acamprosate gives you the best shot at staying clean. But you have to wait 3-5 days after your last drink before starting. It’s taken three times a day (though now there’s a new compacted tablet that cuts that to two). Side effects? Mostly diarrhea and stomach upset. About 1 in 10 people drop out because of it. Disulfiram? Only consider it if you’re highly motivated, have a strong support system, and can commit to total avoidance. It’s cheap - under $50 a month - but the risk of accidental exposure is real. One study showed 29% of people quit because of side effects like metallic taste and drowsiness. It’s also dangerous if you have liver disease.What About Gabapentin? And Other New Options?
Gabapentin isn’t FDA-approved for AUD, but doctors use it often - especially if you have liver damage or a history of severe withdrawal. It’s not a magic bullet. But in people with high withdrawal symptoms, it doubled the chance of staying sober compared to placebo. For those with mild withdrawal? Almost no difference. Newer options are coming. Ketamine infusions showed a 41% drop in relapse in a small trial. Lactobacillus probiotics and N-acetylcysteine combinations reduced heavy drinking days by 37% in early studies. There’s even a 6-month naltrexone implant in testing - with 78% adherence, compared to 42% for monthly shots. But here’s the thing: none of these work without behavioral support. Medications are tools. Therapy, counseling, peer groups - those are the foundation. The COMBINE study proved that combining medication with counseling worked better than either alone. Yet, only 8.6% of people with AUD get any medication at all.
Why Do So Many People Stop Taking Their Meds?
Cost isn’t the main issue. Most of these drugs are generic. Acamprosate runs $200-$300 a month. Naltrexone is $250-$400. Disulfiram? $20-$50. Insurance usually covers them. The real problem is expectations. People think the pill will magically make them stop wanting to drink. It doesn’t. Naltrexone doesn’t stop you from drinking - it just makes it less satisfying. Acamprosate doesn’t erase cravings - it helps your brain recover so cravings fade over time. Many quit because they don’t feel immediate results. They start acamprosate, still feel anxious, and think it’s not working. But it takes weeks to build up. Others stop naltrexone because they still drink - and feel guilty. They don’t realize the goal isn’t perfection. It’s reducing harm. And then there’s the stigma. Some patients feel ashamed taking medication for addiction. They think they should just “have willpower.” But addiction is a brain disorder. You wouldn’t tell someone with diabetes to stop taking insulin.What You Need to Know Before Starting
Before you take any of these, your doctor should check your liver and kidneys. - Naltrexone: Avoid if you have active hepatitis or liver failure. Get liver tests monthly. - Acamprosate: Needs kidney function check. Dose must be lowered if your creatinine clearance is below 50 mL/min. - Disulfiram: Never use if you have severe liver disease. Avoid if you’re on certain antidepressants or anticoagulants. Also, don’t mix any of these with alcohol - especially disulfiram. Even a sip of beer, a drop of wine in cooking, or hand sanitizer can trigger a reaction.
Real People, Real Results
One patient in a 2023 study started naltrexone after two relapses in six months. He didn’t stop drinking entirely - but he went from 12 heavy drinking days a month to 3. He kept his job. His marriage improved. He didn’t feel like a failure. Another woman took acamprosate for a year after detox. She didn’t have a single drink. But she still struggled with anxiety. She added therapy. After 18 months, she stayed sober. Disulfiram? One man took it for 14 months. He never drank. But he hated the metallic taste. He quit. He relapsed within a month. There’s no one-size-fits-all. But there is a right fit - for you.What’s Holding Back Treatment?
Doctors don’t prescribe these drugs often. Only 28% of primary care physicians feel trained to do it. Many think AUD is a moral failing, not a medical condition. They don’t know the guidelines. They don’t know the data. Insurance companies don’t always cover the monthly naltrexone shot. Some require prior authorization. Others limit refills. And patients? They don’t know these drugs exist. They go to AA. They try to quit cold turkey. They suffer in silence. We have effective tools. We’ve had them for decades. The problem isn’t science. It’s access. It’s awareness. It’s stigma.What to Do Next
If you or someone you know is struggling with alcohol: - Talk to your doctor. Ask: “Do I qualify for naltrexone or acamprosate?” - Don’t wait until you’ve hit rock bottom. Medications work best early. - Combine medication with counseling. Even one session a week helps. - Track your progress. Use an app. Write down triggers. Notice patterns. - Give it time. These aren’t quick fixes. They’re long-term supports. You don’t have to do this alone. And you don’t have to be perfect. Just show up. The medication will do the rest.Can I drink alcohol while taking naltrexone?
Yes, you can drink alcohol while on naltrexone - but you won’t feel the same pleasure from it. That’s the point. Naltrexone doesn’t make you sick. It reduces the reward your brain gets from drinking. This helps lower cravings and heavy drinking over time. But it doesn’t stop you from drinking entirely. If you’re trying to quit, you still need to make the choice not to drink.
Why is acamprosate only for people who are already sober?
Acamprosate works by restoring balance in your brain after alcohol withdrawal. If you’re still drinking, your brain chemistry is still disrupted, and the drug can’t do its job. You need at least 3-5 days of complete abstinence before starting. Taking it while still drinking won’t help - and might make side effects like diarrhea worse.
Does disulfiram really stop people from drinking?
It can - but only if taken consistently and if alcohol is completely avoided. The reaction - flushing, nausea, rapid heartbeat - is intense and scary. That fear keeps some people sober. But many stop taking it because of side effects like metallic taste or drowsiness. Studies show most people on disulfiram quit within months. It’s not a sustainable solution for most.
Are these medications addictive?
No. None of the FDA-approved medications for alcohol use disorder - naltrexone, acamprosate, or disulfiram - are addictive. They don’t produce euphoria or cause physical dependence. You can stop them safely under medical supervision. This is different from medications like buprenorphine used for opioid addiction, which do carry dependency risks.
How long should I stay on these medications?
Most guidelines recommend at least 6-12 months. For some people, especially those with long-term or severe AUD, treatment may need to continue for years or even lifelong. Stopping too soon increases relapse risk. Think of it like blood pressure medication - you don’t stop just because you feel better. You stop because your doctor says it’s safe to.
Can I take these with other medications?
It depends. Naltrexone shouldn’t be taken with opioids - you need a 7-10 day washout. Acamprosate is generally safe with most drugs, but kidney function must be monitored. Disulfiram interacts with many medications, including antidepressants and blood thinners. Always tell your doctor everything you’re taking - including supplements and over-the-counter drugs.
