Medication-Assisted Treatment for Alcohol Use Disorder: How Does It Work?

Alcohol use disorder (AUD) is a diagnosable medical condition in which a person has trouble stopping or controlling their alcohol use despite negative consequences from drinking. ¹

AUD is diagnosed as mild, moderate, or severe. Although medications exist to treat AUD, and medication-assisted treatment (MAT) is a well-established, evidence-based method of helping people cut down on drinking or quit alcohol, many still aren’t aware medications exist, or how MAT works.

When Is Medication Prescribed for AUD?

Before prescribing medication to help you manage your drinking, a healthcare provider first determines whether you have AUD. If you do, your healthcare provider will diagnose your AUD  as mild, moderate, or severe. This screening consists of questions about your alcohol use and how drinking affects your health and personal life.

“When we ask the questions to determine how severe the disorder is, it’s based on looking back over the past 12 months,” says Kerri Weinstein, FNP, a family nurse practitioner with the Ascension Medical Group in Binghamton, New York, and an Oar provider.

Along with screening, the provider discusses your goals. For example, are you aiming to cut down on the amount you drink, or looking to quit alcohol entirely?

The clinician also determines whether a medication is safe and appropriate for you.

“There are several considerations, such as a patient’s kidney function, liver function, prior experience with medication treatment, and family history,” says George Cameron Coleman Jr., MD, an addiction medicine physician at the University of Michigan Addiction Center — a leading treatment, prevention, and research clinic — and a clinical assistant professor at Michigan Medicine.

Is Medication-Assisted Treatment for AUD Effective?

The Food and Drug Administration (FDA) has approved three drugs to treat alcohol use disorder: naltrexone, disulfiram, and acamprosate. Each was approved based on evidence of its effectiveness. Naltrexone received FDA approval in 1994; disulfiram in 1951; and acamprosate in 2004.¹

More recently, numerous studies and reviews have found that MAT can be effective in treating alcohol use disorder.

The authors of a 2018 review published in the Journal of the American Medical Association (JAMA) concluded that giving people with AUD an alcohol treatment medication alongside brief therapy can help them reduce and manage their drinking. ¹

Another review published in 2018, this time on the effectiveness of approved AUD medications on alcohol cravings and published in the journal Neuropsychopharmacology Reports, stated that the “potential benefit of each drug…is viewed as far‐outweighing the possible side effects of anti-craving drugs or the harms of continued use of alcohol.” ¹

And in 2015, a joint panel of the U.S. government’s National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) published “Medication for the Treatment of Alcohol Use Disorder: A Brief Guide.”

After reviewing evidence of the effectiveness of the three AUD medications, the expert panel recommended clinicians consider prescribing an AUD medication for people with alcohol dependence as well as those who have stopped drinking but are experiencing issues, like cravings and relapse. ¹

What Medications Are Used to Treat AUD?

Currently, three FDA-approved medications can treat AUD: naltrexone, acamprosate, and disulfiram. Any healthcare provider licensed to write prescriptions may prescribe these medications.

Each medication works a little differently.

“Naltrexone works in the brain to make alcohol use less pleasurable,” says Coleman. “Many patients who take naltrexone will report that they ‘lose the taste’ for alcohol, and it reduces cravings.

“We think acamprosate works in the brain to restore the normal balance from the ‘depressant’ effects of alcohol. Many patients report that acamprosate reduces cravings and reduces relapse.

“Disulfiram works a little differently, and its effects are actually not in the brain. It works as a deterrent. If a patient consumes alcohol while taking disulfiram, they can get really sick: nausea, vomiting, flushing, sweating, shortness of breath, dizziness, etc.

“In general, naltrexone is considered to be the first-line medication option for most patients,” Coleman says.

Why Haven't I Heard More About Medication-Assisted Treatment?

“Believe it or not, physicians actually don’t get much training in medical school and residency on these medications,” says Coleman.

“This is changing, fortunately, but physicians in many fields, like primary care, OB-GYN, hepatology, etc., feel less experienced and less knowledgeable about these medications than treatments for other common conditions,” he says.

Indeed, many studies have found that medication is underutilized in treating AUD. ¹ A study published in June 2021 in JAMA Psychiatry analyzing the use of FDA-approved AUD medications highlights the current situation.

In the study, researchers from the National Institute on Drug Abuse (NIDA), the Centers for Disease Control and Prevention (CDC), and the NIAAA analyzed data from the 2019 National Survey on Drug Use and Health.

The survey found that of the roughly 14 million people who in 2019 had AUD within the past year, just 1.6% of them were treated with an FDA-approved medication. ¹

Summing up the JAMA Psychiatry study’s findings, NIAAA deputy director Patricia A. Powell, PhD, a study co-author, said after its release: “The limited use of medications for treating AUD is a troubling aspect of a ‘treatment gap’ across all modalities for screening and treating AUD. Far too few people with AUD receive treatment of any type, including medications.”

The study’s senior author, NIDA deputy director Wilson Compton, MD, MPE, commented: “We need to find a way to make these medications a more routine part of clinical care. To increase uptake of these medications, we must educate people with alcohol use disorder that effective medications do exist, and help them recognize their symptoms and engage with evidence-based treatments.” ¹

There are several reasons medications to treat AUD aren’t used more, says Joshua Lee, MD, MSc, a clinician and researcher focused on MAT for alcohol and opioid use disorders and Oar’s chief clinical adviser.

Lee describes the infrequency with which medication is prescribed as “one of the great modern tragedies of alcohol treatment.”

Also an associate professor in the departments of population health and medicine at the NYU Grossman School of Medicine in New York City, director of the NYU Fellowship in Addiction Medicine, and chief of the Lee Lab at NYU, Lee points out that alcohol problems, like addiction disorders in general, struggle to get the same attention as other health issues.

“In part it’s because of stigma,” he says. “Many people who have the problem don’t want to talk about it and don’t advocate for themselves. They’re kind of left in the dark as opposed to with other common disorders that are easier to talk about, like heart disease.”

Even when someone is willing to discuss their concerns about their drinking with their doctor, “they may or may not have a primary care physician that’s able and skilled to talk to them about alcohol or ready to prescribe them medication,” Lee says. “We know a lot of the primary care workforce doesn’t address alcohol adequately and doesn’t prescribe medication in adequate rates.”

Another factor that’s stifled MAT is that for decades, alcohol treatment has largely been led by people outside the medical field.

Many drug and alcohol rehab facilities are not staffed by physicians, Lee says.

“They’re typically minimally staffed in terms of licensed medical personnel. They more or less depend on drug and alcohol counselors, who are essentially laypeople who have lived experience. These people can be great at their job, but it’s not close to someone who can prescribe any of these medications.”

For these reasons, Lee says, “If you were going to get treatment for alcohol in the last 50 years or so, you’re very unlikely to have been told about medication.”

Today, the underutilization of medication to treat AUD persists even though major medical organizations, such as the American Medical Association ¹ , American Psychiatric Association¹ , American Academy of Family Physicians¹ , and Veterans Affairs¹ , recommend MAT for qualified patients in tandem with other therapeutic interventions.

Naltrexone for AUD: A Deeper Dive

In addition to treating people with alcohol and opioid use disorders,  Lee is a leading researcher on naltrexone.

“Slowly but surely,” he says, “the clinical trial evidence and observational evidence has stacked up that shows very clearly that naltrexone works.”

“There have been some really well-designed studies that suggest that naltrexone can lead to a 36% reduction in the rate of relapse to heavy drinking,” says the University of Michigan’s Coleman “It is true that naltrexone won’t work for all patients,” Coleman continues. “But it is actually one of the more effective medicines that we have in modern medicine.”

Naltrexone is unique among AUD medications in that it assists both people looking to moderate their drinking and those intending to quit alcohol entirely.

“People can use it to be a much more moderate drinker,” Lee says. “And I would argue, although you could debate me on this, that that is equally important as getting people to quit. Both for the individual and for public health, it would be great if we can get people to just drink far less.”

Most adults with moderate or severe AUD will benefit from treatment, Lee says.

“And pretty much 9 out of 10 people with an alcohol use disorder can successfully stop drinking and start naltrexone at home. They’re not so sick that they need to be in a hospital just to not drink, which is one popular misconception — that you can’t start alcohol treatment unless you have wraparound medical services, like a hospital-based detox episode.”

Most people don’t need a lot of monitoring or hand-holding, he continues. “And if they do, it’s usually fairly obvious, both to the person and to any medical provider helping them.”

Some people who take naltrexone do need extra assistance beyond just taking the medication to help them cut down or quit.

“People can get a lot out of 12-step programs or individual professional counseling, especially people with more complex mental health comorbidities,” Lee says.

However, a problem in the alcohol treatment field, Lee says, has been that many providers believe that if a patient is not doing counseling or 12-step work, then they’re not being adequately treated. There are many alternatives to 12-step programs, many of which will include medication-assisted treatment, such as Oar Health, which offers an assessment to see if medication-assisted treatment for alcohol use is right for you.

“I prescribe a lot of naltrexone in primary care for alcohol use disorder,” Lee says. “We call it medical management, where you really are getting counseling. It’s just not from a licensed MSW or a psychologist or a psychoanalyst. But it is from a primary care doctor saying, ‘Hey, you’ve got a real problem and I want to work on it with you, and no judgments, and here’s a medication. Let’s follow up with this. It’s important to your health and your other medical problems that you address your heavy drinking.’ And then we will see over time if naltrexone is a good choice for them to stay on longer term.”