Alcohol Use Disorder (AUD)
What is it? How does treatment work? What should I expect?
AUD is among the most common chronic conditions in the US. It’s also one of the most under-identified and under-treated. Many people don’t even know that effective medications exist, whether your goal is to stop drinking entirely or to better control drinking. It does, and it’s accessible through telemedicine.
TL;DR
What you need to know if you’re short on time:
Alcohol Use Disorder (AUD) is a medical diagnosis defined by a pattern of alcohol use that causes significant harm or loss of control
The goal of treatment is resolution of harm, and restoration of control. Whether that means stopping alcohol entirely or reducing your use to a level that no longer causes harm is up to you. Both are valid treatment goals, and the medications we use support either approach.
Alcohol withdrawal can be medically serious. Before stopping alcohol use, it's important to assess withdrawal risk. If the risk of severe withdrawal is high, in-person medical supervision is required. OURera will be direct with you about when telemedicine is and isn't the right setting for your care.
Effective FDA-approved medications for AUD exist and are underused. The right medication, or combination, depends on your goals, history, and preferences. We'll find what works for you.
What is Alcohol Use Disorder?
Alcohol Use Disorder is the medical term for what most people would recognize as alcohol addiction or alcoholism, but the popular terms can carry connotations that aren't always accurate or fair. The clinical definition of AUD is straightforward: a pattern of alcohol use that causes significant impairment or distress. It doesn't require drinking every day, or drinking in the morning, or losing your job. Those are stereotypes. AUD has an estimated lifetime prevalence of nearly 30% in the United States. It affects people across every demographic, profession, and income level.
Diagnosis is based on 11 criteria, evaluated over the past 12 months. The presence of any two or more qualifies as AUD:
Drinking more, or for longer, than you intended to
Persistent desire or repeated unsuccessful efforts to cut down or control drinking
Spending a significant amount of time obtaining alcohol, drinking, or recovering from its effects
Craving: a strong urge or compulsion to drink
Repeated failure to meet obligations at work, school, or home because of drinking
Continuing to drink despite ongoing social or relationship problems it causes or worsens
Giving up or cutting back on activities you care about because of drinking
Drinking in situations that are physically hazardous (e.g., driving, operating machinery)
Continuing to drink despite knowing it's causing or worsening a physical or psychological problem
Tolerance: needing significantly more alcohol to feel the same effect
Withdrawal: experiencing physical symptoms when you stop or cut back, or drinking to avoid them
Mild
2 - 3 Criteria Present
Moderate
4 - 5 Criteria Present
Severe
6+ Criteria Present
Severity does affect treatment recommendations, but it doesn't determine whether someone is “ready” or needs treatment. Even mild AUD causes real harm, and treatment works across the full spectrum.
Why AUD goes untreated so often
Despite being extraordinarily common and treatable, AUD is one of the most under-treated conditions in medicine. Stigma is at least partly to blame, both the internal reluctance many people feel about acknowledging the problem, and the external stigma that keeps some medical professionals from asking about it or engaging with it. Also to blame, is a widespread unawareness that effective medical treatments exist at all. Many people assume the only options are willpower, AA, or rehab. That belief leaves a lot of people without truly effective care they could be receiving today.
The Goal of Treatment
Let’s be direct about something that often goes unsaid in addiction medicine: complete, permanent abstinence from alcohol is not the only valid treatment goal. For many people, it is the right goal. For others, the goal is to reduce drinking to a level that no longer causes harm, interferes with relationships, affects health, or takes up an outsized amount of mental and emotional energy. That is also a legitimate, clinically meaningful outcome.
The goal of treatment is remission: the resolution of the symptoms that make up AUD. What that means specifically for you is not an assumption I impose before we start.
Importantly, every maintenance medication we use for AUD — naltrexone, acamprosate, topiramate, gabapentin — supports the brain in reducing the compulsive drive to drink in different ways. We’ll select the approach that best meets your goals.
How Treatment Progresses
First, addressing withdrawal
Alcohol acts on the brain by stimulating inhibitory signals (GABA receptors), suppressing excitatory signals (via NMDA receptors), and also stimulating the dopamine reward system (involving opioid receptors). The net effects is sedation. With chronic, heavy use, the brain adapts by setting a new baseline, hyper-aroused state that depends on the effects of alcohol to maintain balance. When alcohol is removed abruptly, that baseline hyperarousal is suddenly unmasked. The result is alcohol withdrawal syndrome.
About half of people with AUD who abruptly stop or significantly reduce drinking will develop some signs of withdrawal. Most experience mild symptoms. But in a subset of people, withdrawal can escalate to something medically serious, and in a smaller subset still, to something life-threatening.
Fortunately, we have validated tools that help predict the expected severity of withdrawal. If your assessment supports risk of severe or complicated withdrawal (considerations include a prior history of withdrawal seizures or delirium tremens, heavy daily consumption, blackouts, treatment history, intoxication, or lack of a supportive home environment) then I will be direct with you: telemedicine is not the right setting to manage your withdrawal, and I'll help you find a safe in-person setting to get started. In these cases, we can resume telemedicine care after withdrawal has safely passed.
For patients whose assessment indicates risk of only mild to moderate withdrawal, outpatient management is usually preferred.
For mild withdrawal, gabapentin and carbamazepine are appropriate options to reduce symptoms. Both can be tapered over 5–7 days. For moderate withdrawal, a short course of a benzodiazepine may be needed. All of this can be managed through telemedicine with close daily follow-up, appropriate check-ins, and a clear plan for escalation to in-person care if symptoms worsen.
Next, achieving long-term control
Once withdrawal is safely managed, or if withdrawal isn't a concern to begin with, long-term treatment begins.
The evidence base for AUD pharmacotherapy is strong, and yet these medications are dramatically underutilized. A large meta-analysis found that naltrexone and acamprosate are significantly more effective than placebo in supporting remission, with no consistent evidence that either is superior to the other, meaning the choice between them (or the decision to combine them, or to use other agents) should be driven by your individual situation, not by a fixed protocol. We also have two second line, or supportive medications demonstrated to be effective in certain situations: topiramate, and gabapentin.
Naltrexone
Vivitrol (extended-release injectable) · ReVia (oral tablet) · Generic oral
Naltrexone is an opioid receptor blocker. Alcohol's rewarding effects are mediated in part through the brain's endogenous opioid system, and naltrexone attenuates this reward signal. The result is that drinking produces less of the dopamine-driven pleasure response that reinforces continued use. Over time, the drive to drink weakens.
Naltrexone is available in two forms, each suited to different goals and preferences. Extended-release injectable naltrexone (Vivitrol) is a once-monthly injection administered in a clinical setting or at some pharmacies. It removes the need for daily dosing and provides consistent effects.
Naltrexone can also be taken once daily as a pill. This approach is not as well studied as the monthly injection and may not be as effective. There’s a unique advantage of the pill, however, for occasional excessive or “binge” drinking; it can be taken as needed 1 hour before a situation where drinking is anticipated. This approach, sometimes called the Sinclair Method, may be useful for patients whose goal is controlled drinking rather than abstinence. However when the goal is to stop drinking, injectable naltrexone has the strongest evidence.
Naltrexone should not be used by anyone with acute hepatitis or liver failure, or by anyone currently using opioids; it will cause opioid withdrawal.
Acamprosate
Campral
Acamprosate works differently from naltrexone. Rather than targeting the reward system, it addresses the hyperactivity that develops in the brain after chronic alcohol exposure, the same mechanism underlying withdrawal. Even after withdrawal has passed, this neurological imbalance can persist for months, producing a pervasive sense of discomfort, anxiety, and restlessness that makes staying sober difficult and drives relapse. Acamprosate reduces that background noise.
It is most effective in patients who have already achieved abstinence and want to maintain it. It requires three doses daily, which is its main practical drawback. Acamprosate is cleared by the kidneys (not the liver), making it a good choice for patients with liver disease.
Topiramate
Topamax · Generic
Topiramate is an anticonvulsant that helps reduce alcohol use through several overlapping mechanisms, including inhibiting dopamine release. It is not FDA-approved specifically for AUD, but the clinical evidence supporting its use is substantial enough to be recommended as a second-line treatment.
Topiramate can be a good addition particularly for patients who haven't responded well to naltrexone or acamprosate alone, and for patients who have both AUD and another condition topiramate addresses (such as migraines or binge eating).
Gabapentin
Neurontin · Generic
Gabapentin is primarily used in AUD for its role in withdrawal management, and there is growing evidence for its effectiveness in long-term maintenance as well. A randomized controlled trial found that patients starting gabapentin after short-term abstinence had fewer heavy drinking days and greater rates of continued abstinence than those receiving placebo, with the effect most pronounced in patients who had experienced more severe withdrawal.
Gabapentin is also useful in patients who have co-occurring anxiety, insomnia, or pain, conditions that commonly coincide with AUD and can drive relapse if unaddressed. It is generally well-tolerated. Gabapenting can be used as a twice-daily or three-times-daily medication. Gabapentin can be sedating, so it should not be taken at the same as a drink containing alcohol; for this reason, we usually prefer bedtime and morning dosing only for patients who intent to continue light or moderate drinking in the afternoons or evenings.
These medications are not mutually exclusive. For some patients, a combination, naltrexone plus gabapentin, for example, may provide better effect than either alone. The decision to combine medications is individualized and based on your symptoms, your goals, any co-ocurring conditions, and how you respond to initial treatment. There's no single correct answer, and we'll adjust as we learn what works for you.
A note on disulfiram
You may have heard of disulfiram (Antabuse), a medication that causes an unpleasant physical reaction if you drink while taking it. It is FDA-approved for AUD and can be effective for some patients who strongly prefer it. We can offer it when appropriate, but it requires careful decision-making because it’s both less effective and higher risk than other available treatments. It is unsuitable for patients with certain cardiac or liver conditions, and is not compatible with a goal of moderation rather than abstinence
Support
Medications work best alongside some form of meaningful support, but I want to be clear about what that does and doesn't mean. It does not mean mandatory therapy, or group meetings, or a treatment program you don't like. What the evidence actually supports is broader than that.
What matters is regular engagement in something purposeful that involves other people. That could be a peer support group like SmartRecovery or AA, individual therapy, a structured exercise routine you share with someone, or a job or hobby that gives you a sense of accomplishment and accountability. The common ingredients are meaning and connection, not any specific format.
What's also worth acknowledging: some people do well with medication alone, especially early in treatment, and adding behavioral requirements that create friction or feel coercive can actually limit effectiveness. We'll talk honestly about what support looks like for you, and we won't make one a prerequisite for the other.
If and When Treatment Stops
Medication for AUD is safe and effective for long-term treatment, and there is no clinical requirement to stop. Treatment should continue for as long as it continues to be helpful.
Gabapentin and topiramate can cause rebound symptoms if stopped abruptly and need to be tapered over 2 - 6 weeks. Naltrexone and acamprosate can be stopped promptly without tapering if desired. Treatment can and should be resumed promptly if symptoms of AUD recur after stopping treatment.
Conclusion
What This Means If You're Thinking About Treatment
AUD affects nearly one in three Americans at some point in their lifetime. Most of them don't receive treatment. Of those who do seek help, many encounter programs that focus on willpower, identity, and abstinence as prerequisites.
That's not the approach here. The approach here is to assess where you are, be honest with you about what your options are and what the risks are, start effective treatment, and follow up closely. Your goal, whether that's stopping alcohol entirely or simply improving your control over it, is valid. Both are achievable with the right support.
If you're unsure whether what you're experiencing qualifies as AUD, that's okay. Schedule a visit, tell me what's going on, and we'll figure it out together. You don't need a crisis to receive care.
If you have questions about whether telemedicine is the right fit for your situation, particularly around withdrawal, I'd rather you ask than wait. We can have that conversation at an initial visit, and if in-person care is what you need first, I'll help you understand how to access it and what to expect.
OURera and Dr. Brian Clear provide reliable telemedicine-based care for alcohol use disorder anywhere in California. New patients are welcome. No prior experience with treatment is required. Or if you’ve tried before without success, we’ll take that experience and build on it to do better.