Medications for Alcohol Use Disorder: How They Reduce Relapse Risk - and When They Don’t

When someone is trying to stop drinking, the hardest part isn’t always willpower - it’s the brain’s constant pull back toward alcohol. That’s where medications come in. For people with Alcohol Use Disorder (AUD), drugs like naltrexone, acamprosate, and disulfiram aren’t magic pills, but they do change the odds. Studies show they can cut relapse risk by 18% to 30%, depending on the person and the drug. Yet, only about 1 in 10 people with AUD in the U.S. even get prescribed one. Why? Because many don’t know how they work - or when they might make things worse.

How These Medications Actually Work

Naltrexone blocks the brain’s opioid receptors. When you drink, alcohol normally triggers a dopamine surge that makes you feel good. Naltrexone dulls that reward. You still drink, but it doesn’t feel as satisfying. That reduces heavy drinking episodes. A 2021 meta-analysis of nearly 3,000 people found oral naltrexone (50 mg daily) cut relapse risk by 18% compared to placebo. The monthly shot, Vivitrol, works the same way but doesn’t require daily pills.

Acamprosate works after you’ve stopped drinking. Heavy alcohol use scrambles brain chemicals like GABA and glutamate. When you quit, your brain stays out of balance, causing anxiety, restlessness, and insomnia - big triggers for relapse. Acamprosate helps stabilize those systems. It’s most effective for people who’ve already detoxed and are aiming for total abstinence. In clinical trials, it improved abstinence rates by about 15% over six months.

Disulfiram is the oldest and most dramatic. It makes your body react badly to alcohol. If you drink while taking it, you get intense flushing, nausea, vomiting, and a dangerous drop in blood pressure. It’s a deterrent - a physical warning sign that says, “Don’t even think about it.” But it only works if you take it consistently. And if you forget? The risk isn’t just a bad hangover - it’s a medical emergency.

Which Medication Is Right for You?

If you’re trying to cut back on heavy drinking - maybe you’re not ready to quit completely - naltrexone is often the first pick. It doesn’t force abstinence. It just makes drinking less rewarding. People who’ve tried to quit before and kept falling back into binge patterns tend to respond well.

If you’ve already stopped drinking and want to stay stopped, acamprosate is the go-to. It helps with the emotional chaos that follows detox: the jitteriness, the irritability, the urge to drink just to feel normal. But here’s the catch: you can’t start it until you’ve been alcohol-free for at least 3 to 5 days. If you’re still drinking, it won’t help - and might even make you sick.

Disulfiram is for a very specific type of person: highly motivated, with strong social support, and willing to live with the consequences of a slip-up. It’s not for someone who drinks occasionally or is unsure about quitting. One study showed 28% of people quit disulfiram because of side effects like metallic taste, drowsiness, or fear of accidentally drinking something with alcohol - like mouthwash or cough syrup.

There’s also gabapentin, not FDA-approved for AUD but widely used off-label. It’s especially helpful for people who’ve had severe withdrawal symptoms - seizures, hallucinations, delirium tremens. A 2020 trial found 45% of high-risk patients stayed abstinent on gabapentin, compared to 28% on placebo. It’s also safer for people with liver disease, since it’s cleared by the kidneys, not the liver.

Why So Many People Stop Taking These Drugs

In clinical trials, about 60% of people stick with naltrexone or acamprosate for 16 weeks. In the real world? Only 35% are still taking them after three months. Why?

• Side effects: Nausea is common with naltrexone. Diarrhea and dizziness happen with acamprosate. Disulfiram causes fatigue and a bad taste in the mouth.
• Cost: Even though most are available as generics, monthly costs can hit $200-$400. Insurance doesn’t always cover them, and copays add up fast.
• Timing: You can’t start acamprosate until you’ve stopped drinking. If you’re still using, you’re stuck waiting - and that waiting period is when most people slip back.
• Expectations: Many think medication will make the craving disappear. It doesn’t. It just makes drinking less appealing. If you’re expecting a miracle, you’ll be disappointed.

One patient told a recovery forum: “I took naltrexone for two months. I didn’t get drunk, but I still drank every night. It didn’t make me stop - just made me feel weird.” That’s not failure. That’s how it works. The goal isn’t to feel nothing. It’s to reduce the damage.

What Happens When You Mix Medication With Alcohol

With disulfiram, drinking even a small amount of alcohol - a sip of wine, a beer, or a dessert with alcohol - can trigger a life-threatening reaction. Blood pressure can crash. Heart rhythm can go haywire. Emergency rooms see this often.

With naltrexone, drinking isn’t physically dangerous, but it defeats the purpose. You’ll still get the physical effects of alcohol - impaired coordination, poor judgment - but you won’t feel the usual reward. That can lead to risky behavior: “I’m on naltrexone, so I’ll have more.” That increases the chance of injury or overdose.

With acamprosate, alcohol doesn’t cause a bad reaction. But if you drink while taking it, the medication doesn’t work. It’s like taking insulin and then eating a whole cake - the drug can’t fix what you’re actively breaking.

And then there’s liver damage. Naltrexone is processed by the liver. If you have cirrhosis or hepatitis, it can build up and cause toxicity. Doctors check liver enzymes before and during treatment. Acamprosate is cleared by the kidneys - so if you have kidney disease, your dose must be lowered. Gabapentin is safer here, which is why it’s becoming a top choice for people with alcohol-related liver disease.

Why So Few Doctors Prescribe These Drugs

A 2023 survey found only 28% of primary care doctors in the U.S. feel confident prescribing AUD medications. Many still think addiction treatment belongs only in rehab centers or specialty clinics. But AUD is a medical condition - like high blood pressure or diabetes. It should be treated in the same place you go for your annual checkup.

Doctors also worry about liability. If someone on disulfiram drinks and ends up in the ER, who’s responsible? If a patient on naltrexone keeps drinking and loses their job, did the doctor enable it?

But the bigger problem is stigma. Addiction is still seen as a moral failure, not a brain disease. That’s changing - slowly. More medical schools now teach addiction medicine. More insurance plans are covering AUD meds. But progress is uneven.

What’s Next: New Treatments and Personalized Care

Researchers are using brain scans to predict who will respond to which drug. One study found that people with higher white matter integrity in the frontal brain region were 68% more likely to respond to acamprosate. That means one day, we might test your brain before prescribing.

New drugs are coming. A combination of buprenorphine and samidorphan reduced heavy drinking days by 32% in a 2023 trial. Ketamine infusions showed a 41% drop in relapse. Even probiotics and anti-inflammatory agents are being tested, because gut health is linked to cravings.

Longer-acting forms are also in development. A 6-month naltrexone implant is in phase 2 trials. If it works, adherence could jump from 42% (with monthly shots) to 78%. That’s huge.

And digital tools are helping. Apps that track cravings, send reminders, and connect you to peer support have been shown to cut relapse risk by a third when used with medication.

What You Can Do Right Now

• Don’t wait for “rock bottom.” Medications work best when started early.
• Ask your doctor about naltrexone or acamprosate. They’re safer and more effective than you think.
• If you’ve had withdrawal symptoms before, ask about gabapentin.
• If you’re considering disulfiram, make sure you have strong support - and understand the risks.
• Don’t stop taking the medication just because you feel fine. Most people relapse within months of quitting.
• Combine medication with counseling. No pill works alone.

Alcohol Use Disorder isn’t a character flaw. It’s a medical condition with proven treatments. The fact that so few people get them isn’t because the treatments don’t work. It’s because we still don’t treat addiction like the disease it is.

If you’ve tried to quit drinking before and failed, don’t give up. The problem isn’t you - it’s that you haven’t found the right tool yet. Medications for AUD aren’t perfect, but they’re the most effective option we have. And they work best when you’re not alone.