Naltrexone, an opioid antagonist, is the first-line medication for alcohol use disorder (AUD)—though it is also approved for opioid use disorder (OUD).

Naltrexone, an opioid antagonist, is the first-line medication for alcohol use disorder (AUD)—though it is also approved for opioid use disorder (OUD).

Gabapentin is effective as an off-label medication to ease alcohol withdrawal symptoms and to reduce cravings over the long term in patients with alcohol use disorder (AUD).

Disulfiram is an aversive treatment, causing a buildup of ethanol’s metabolite acetaldehyde in the serum, which in turn causes symptoms such as flushing, dizziness, nausea, and vomiting if patient consumes alcohol.

Acamprosate is best for maintaining abstinence in patients who have already quit drinking, but it can be helpful even after patients relapse. Naltrexone is the better choice for patients who are still drinking, since it is better at helping patients quit. Acamprosate is preferred over naltrexone in patients with hepatic impairment.

Prazosin is an alpha-1 antagonist (FDA approved for hypertension) that has become popular as a treatment for insomnia/nightmares associated with post-traumatic stress disorder (PTSD). 

NAC is a glutamate modulator derived from the amino acid cysteine. It’s been tested in many psychiatric conditions, but shows the most promise as an adjunctive treatment to selective serotonin reuptake inhibitors for compulsive behaviors like obsessive-compulsive disorder (OCD), trichotillomania, nail biting, and skin picking. Evidence is modest but encouraging.

When a benzodiazepine is appropriate for use (short term; minimal risk of abuse), we consider lorazepam to be a first-line agent.

Flurazepam is an older benzodiazepine that has fallen out of favor due to its very long half-life and its active metabolites.

Diazepam is a long-acting benzodiazepine useful for anxiety, alcohol withdrawal, muscle spasms, and seizures.