Naltrexone is often a first-line medication for AUD. It works as an opioid receptor antagonist, reducing the rewarding effects of alcohol and decreasing cravings. Patients frequently report that alcohol becomes less pleasurable while taking the medication. Oral naltrexone is typically dosed at 50 mg daily, while a long-acting injectable formulation is also available. Avoid use in patients taking opioids and use caution in significant liver dysfunction.

Acamprosate helps maintain abstinence by modulating glutamate and GABA neurotransmission. Chronic alcohol use disrupts the balance between excitatory and inhibitory pathways in the brain, and acamprosate helps restore equilibrium. It is primarily eliminated renally, making it a useful option in patients with liver disease. The most common adverse effect is diarrhea.

Disulfiram works through a completely different mechanism. It inhibits aldehyde dehydrogenase, causing acetaldehyde accumulation when alcohol is consumed. This can lead to flushing, nausea, vomiting, headache, and hypotension. Because of this aversive reaction, patient motivation and adherence are critical for success.

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