How to Personalize Meds for Alcohol Use Disorder

New guidelines take a personalized approach to six approved medications 

STUDY: Caputo F et al, Alcohol and Alcoholism 2026

STUDY TYPE: Narrative review

FUNDING: Independent

Background

Six medications are now approved somewhere in the world for alcohol use disorder, but most guidelines lump them together without a clear hierarchy. This review sorts them by treatment goal: cutting down drinking versus staying completely abstinent.

The Study

• The authors reviewed meta-analyses, trials, and regulatory documents on disulfiram, acamprosate, naltrexone, nalmefene, baclofen, and sodium oxybate.
• Rankings reflect efficacy, safety, and practical factors like liver disease and patient motivation, not a formal guideline process.

Algorithm for Alcohol Reduction

For cutting down drinking, naltrexone or nalmefene come first, with baclofen reserved for non-responders.

Algorithm for Maintenance of Abstinence

For abstinence, acamprosate is the first-line drug. It is well-tolerated, reduces cravings, and helped maintain abstinence in a meta-analysis, but did not reduce binge drinking.

Disulfiram, baclofen, and sodium oxybate are second-line, as is combination. Combining acamprosate with naltrexone raised the 12-month abstinence to 55%, versus under 40% for either drug alone.

Other Pearls

Despite its reputation, naltrexone is safe in liver disease. A study of 3,285 cirrhosis patients found no drug-induced liver injury.

Baclofen helps abstinence and works in cirrhosis, but higher doses (120 mg/day and up) bring risks of seizures, suicide-related events, and hospitalizations. It also has a risk of substance misuse on its own (though rare). A new study suggests combined benefits for cravings with baclofen and naltrexone.

Sodium oxybate, used in Italy and Austria, helps protracted withdrawal symptoms, though 5% to 10% of patients develop craving for the drug itself. In the US, it is a controlled substance approved for narcolepsy, and is also diverted as a date-rate drug.

More Details

Practice Implications

1. This is an useful way to personalize the treatment.
2. Sodium oxybate carries too many risks for routine use
3. Baclofen is probably underutilized in the US. In France, where it is approved, physicians report good results. If you’re using baclofen, keep the dose under 80 mg/day and split it three times daily.