Medications for Alcohol Use Disorder and the Hidden Risk of Relapse

When someone is trying to stop drinking, the right medication can make all the difference. But here’s the thing: even with proven treatments like naltrexone, acamprosate, or disulfiram, many people still end up back in old patterns. Why? Because medication alone doesn’t fix the problem. And when you mix these drugs with alcohol-even a little-it can undo months of progress, or worse.

How AUD Medications Actually Work

Not all medications for alcohol use disorder work the same way. That’s why choosing the right one matters.

Naltrexone blocks the brain’s opioid receptors. When you drink, alcohol usually triggers a dopamine rush that feels rewarding. Naltrexone dulls that high. It doesn’t make you sick-it just makes drinking feel less satisfying. Studies show it reduces heavy drinking days by about 5% compared to placebo. It’s especially helpful if you’re trying to cut back, not necessarily quit cold turkey.

Acamprosate works differently. After quitting alcohol, your brain chemistry gets scrambled. Glutamate and GABA systems go haywire, causing anxiety, insomnia, and cravings. Acamprosate helps rebalance those signals. It’s not a quick fix. You need to be alcohol-free for at least 3-5 days before starting it. People who stick with it for a year are more likely to stay sober.

Disulfiram is the old-school option. It doesn’t reduce cravings. Instead, it punishes drinking. If you take it and then drink alcohol, your body can’t break it down properly. You get a nasty reaction: flushing, vomiting, racing heart, even low blood pressure. It’s designed to scare you off alcohol. But here’s the catch: if you don’t take it every day, or if you think you can outsmart it, the risk of relapse goes up. Many people stop taking it because they can’t handle the fear-or because they don’t want to be constantly watching what they drink.

Why Relapse Still Happens-Even With Medication

Let’s be real: taking a pill every day is hard. Especially when life gets messy.

A 2023 study tracked 1,200 people on AUD medications for six months. Only 35% were still taking their meds after 90 days. Why? Side effects. For acamprosate, diarrhea and nausea pushed some people out. For naltrexone, a few felt dizzy or had stomach upset. But the biggest reason? Cost. Even though most of these drugs are generic, monthly prices still range from $20 to $400. Insurance doesn’t always cover them fully. If you’re juggling rent, food, and bills, medication becomes a luxury you can’t afford.

Then there’s the psychological trap. People think, “I’ve been sober for three months-I’m fine now.” So they stop the meds. But AUD is a chronic condition, like diabetes or high blood pressure. Stopping treatment doesn’t mean you’re cured. It means you’re going back to square one. One study found that people who quit naltrexone after six months had a 60% higher chance of returning to heavy drinking within the next year.

And here’s something no one talks about enough: some people start drinking again because they think the medication will protect them. “I’m on naltrexone, so I can have a beer.” But naltrexone doesn’t block all the effects of alcohol. It just reduces the reward. You can still get drunk. You can still lose control. And when you do, your brain remembers: alcohol = relief. That’s how relapse starts.

What Happens When You Drink While on These Medications

Drinking while on medication isn’t just risky-it can be dangerous.

If you’re on disulfiram and drink even a sip of alcohol, you’re risking a medical emergency. Symptoms can start within 10 minutes and last hours. In rare cases, it can cause heart rhythm problems or seizures. Emergency rooms see this more often than you’d think-especially among people who thought they could handle “just one drink.”

With naltrexone, drinking won’t make you sick, but it won’t help either. The drug is designed to reduce cravings and heavy drinking. If you’re drinking regularly, the medication isn’t working. You’re just wasting time and money. Worse, you’re training your brain to associate drinking with normalcy again.

Acamprosate is safer in this regard. It doesn’t interact dangerously with alcohol. But if you drink while taking it, you’re defeating the whole point. The drug helps your brain recover after quitting. If you keep drinking, your brain never gets the chance to heal. And the longer you delay healing, the harder it is to quit later.

And then there’s gabapentin, which isn’t FDA-approved for AUD but is commonly prescribed off-label. It’s especially helpful for people with a history of severe withdrawal. But if you drink while on gabapentin, you increase your risk of dizziness, confusion, and respiratory depression-especially if you’re also taking opioids or benzodiazepines.

Who Benefits Most From Each Medication?

There’s no one-size-fits-all solution. Your history, your body, and your goals matter.

• If you want total abstinence and have already detoxed, acamprosate is your best bet. It’s the most effective for long-term sobriety.
• If you’re trying to cut down on heavy drinking but aren’t ready to quit completely, naltrexone gives you more control. It reduces the urge to binge.
• If you’re highly motivated, have a strong support system, and can commit to daily dosing, disulfiram might work. But only if you’re willing to live with the fear of a reaction.
• If you have liver disease from years of drinking, gabapentin is often preferred. It’s easier on the liver than naltrexone and doesn’t require detox before starting.

A 2022 trial found that patients with high withdrawal symptoms during detox were nearly twice as likely to stay sober on gabapentin than on placebo. But for those with mild symptoms, gabapentin offered no real advantage. That’s why personalized treatment matters. One size doesn’t fit all.

The Big Problem: Underuse and Misunderstanding

Over 14 million Americans have alcohol use disorder. Only about 8% get any medication for it.

Why? Doctors don’t prescribe it. Many primary care providers don’t feel trained to handle AUD. They don’t know the differences between naltrexone and acamprosate. They don’t know how to monitor liver enzymes or adjust doses for kidney problems. And patients? They think medication is a crutch. Or they’ve heard horror stories about disulfiram reactions. Or they believe recovery means “going it alone.”

But here’s the truth: medication isn’t replacing willpower. It’s supporting it. Think of it like insulin for diabetes. You still have to manage your diet and lifestyle. But the drug gives your body a fighting chance.

And the cost of not treating AUD? It’s staggering. A 2021 study estimated that if just half of eligible patients got medication, the U.S. would save $12.7 billion a year in emergency visits, liver transplants, and lost productivity.

What You Can Do Right Now

If you’re on AUD medication:

1. Don’t skip doses-even if you feel fine. Consistency is what keeps your brain stable.
2. Avoid alcohol completely. Even one drink can trigger a relapse cycle.
3. Track your cravings. Use a journal or app. Notice patterns: stress? loneliness? certain places?
4. Get liver and kidney tests done every 3-6 months, especially if you’re on naltrexone or acamprosate.
5. Ask your doctor about extended-release options. The monthly naltrexone shot (Vivitrol) improves adherence. New 6-month implants are coming soon.
6. If cost is an issue, ask about generic versions or patient assistance programs. Most insurers cover these drugs now.

If you’re thinking about starting medication:

• Be honest with your doctor about your drinking habits. No judgment. Just facts.
• Ask: “Which medication fits my goals?” Not “Which one is best?”
• Plan for support. Medication works best with counseling, AA, or peer groups.
• Don’t wait until you’ve hit rock bottom. Early intervention saves lives.

What’s Next for AUD Treatment

The future is personalization.

Researchers are now using brain scans to predict who will respond to acamprosate. They’re testing blood markers and genetic profiles to match patients with the right drug. One machine learning model got it right 82% of the time.

New drugs are on the horizon. Ketamine infusions showed a 41% drop in relapse in a small 2022 trial. Microbiome treatments-like probiotics and NAC-are showing promise in early studies. And digital tools? Apps that track cravings and send real-time coping tips reduced relapse by 33% in a 2023 Lancet study.

But none of this matters if people don’t get access to the treatments we already have.

The best medication in the world won’t help if you’re afraid to take it. Or if you can’t afford it. Or if no one explained how it works.

Recovery isn’t about being perfect. It’s about staying connected-to your treatment, your support system, and your reason for wanting to change.

Medication isn’t the end of the journey. It’s the first step.