For many people, the idea of doing something about an alcohol problem brings to mind 12-step programs and meetings where strangers holding paper coffee cups say, "Hello, my name is John, and I'm an alcoholic." Fewer people know that medications are also available to treat alcohol use disorder, the term for the condition that's been called alcoholism and alcohol abuse.
While some of these medications have been around for decades, fewer than 10% of the people who could benefit from them use them. "You don't have commercials talking about [these drugs]," says Stephen Holt, MD, who co-directs the Addiction Recovery Clinic at Yale-New Haven Hospital St. Raphael Campus in Connecticut. "And primary care doctors tend to shy away from these meds because they weren't trained to use them in med school."
Yet medications for alcohol use disorder can work well for people who want to stop drinking or drink a lot less.
"Medications are the beginning of how you make the psychological change that needs to occur," says Gerard Schmidt, an addiction counselor and president of NAADAC, the Association for Addiction Professionals.
Three drugs have FDA approval for alcohol use disorder, and each works differently.
In 1951, this was the first drug that the FDA approved for alcohol use disorder. Disulfiram (Antabuse) changes the way your body breaks down alcohol. If you drink while taking it, you get sick. And because you do, you're probably not going to drink as much.
Disulfiram isn't for everyone, though. Many people have a hard time sticking to it.
"If you start to associate a drug with nausea, vomiting, headaches, sweating, and basically a really bad hangover, you'll wake up one morning and decide, 'I'm not sure I'm going to take my Antabuse today,'" Holt says. "It gets hard to compel somebody to take a drug that's only associated with unpleasantness." But it can work well for people who are very motivated to stop drinking.
This drug may be a good choice when someone has gotten an ultimatum from their family, an employer, or the legal system about their alcohol misuse. "You can commit to taking Antabuse every day while the other person watches," he says.
Other people might only need to take the medication at times when they know they'll feel triggered to drink. For example, if someone usually relapses at the holidays or the anniversary of the death of a loved one, they might decide with their doctor to take it just around that time, Schmidt says.
When you drink alcohol while taking naltrexone, you can feel drunk, but you won't feel the pleasure that usually comes with it. "You're trying to make that relationship with alcohol have no rewards," Holt says.
The medication can help ward off cravings, too, he says. When you have alcohol use disorder, just thinking about alcohol triggers a pleasurable response in the brain. "Naltrexone can help uncouple alcohol and pleasure."
Research shows that naltrexone works best for people who have already stopped drinking for at least 4 days when they begin treatment. You take it daily as a pill or get a monthly injection at your doctor's office. The medication can help you have fewer days when you drink heavily (more than five drinks) as well as drink less overall.
"Complete abstinence is not the only goal," Holt says. "It can be 30- to 60-day abstinence rates, fewer heavy-drinking days, cutting back on total number of drinks, or even fewer [alcohol-related] ER visits."
Acamprosate (Campral) eases withdrawal symptoms -- such as insomnia, anxiety, restlessness, and feeling blue -- that can last for months after you stop drinking.
Acamprosate works by interacting with two chemical messengers in the brain: GABA (short for gamma-aminobutyric acid) and glutamate. GABA, when it works correctly, stifles certain nerve cells and may help control the fear or anxiety you feel when those cells are overexcited. Glutamate, on the other hand, stimulates nerve cells.
The balance of these systems in the brain of a person who has been drinking heavily for a long time gets thrown off, Holt says. "Acamprosate is designed to level out those abnormalities and provide some stability."
One drawback is that you must take two pills three times every day. "If you don't like taking pills, you already take too many pills, or you aren't good at remembering to take pills, then this would be a tricky one," he says.
Like naltrexone, acamprosate seems to work best for people who are able to stop drinking before starting treatment.
Two other drugs, gabapentin and topiramate, also interact with GABA and glutamate. The FDA approved them to treat seizures, but doctors sometimes prescribe them "off-label" for alcohol use disorder.
Researchers think they work in the same way as acamprosate to help people avoid drinking. Several recent clinical trials have looked at the benefits of these drugs with people who have alcohol use disorder.
"Gabapentin is a fairly new kid on the block in alcohol use disorder, but it's getting very promising results," Holt says. "I anticipate it will get FDA approval. It's already being used for this in other countries."
Most research shows the effects of taking medications for 6-12 months. The benefit of longer-term use is less clear.
But the more important question may be: Is medication alone enough to stop a person from drinking? "You can take medication, but if you don't change your behaviors, nothing else really changes," Schmidt says. "Medication is, in my opinion, only as good as an individual's motivation for recovery."
How you achieve that behavior change can vary from one person to another. Counseling or psychotherapy might help some people. For others, regular follow-up with their primary doctor should be enough and can work, Holt says.
"My hope," Schmidt says, "is that after a while the behavioral changes are such that the medication isn't going to be necessary."
Researchers haven't compared medication alone to psychotherapy alone, and results are mixed as to whether combining the two provides greater benefits than either one alone. Some studies suggest that simply getting help -- whether through medication, counseling, or both -- is what matters for successful management of this addiction.