Q: I remember a long time ago my uncle used to take a medication that would keep him from drinking alcohol, he said it would make him really sick if he drank while on it. Is something like that still available?
The medication you’re thinking of was likely Antabuse (disulfiram). Although it’s no longer commercially produced in Canada, it can still be accessed through certain compounding pharmacies. Antabuse works as a form of alcohol-aversion therapy where if you drink alcohol while the medication is in your system, it triggers what’s called a disulfiram reaction, which can cause intense flushing, headache, nausea, and vomiting. It is not considered to be a first-line treatment option for alcohol use disorder (AUD) today.
AUD is more common than many people realize. A 2021 Canadian Community Health Survey found that roughly 18% of Canadians aged 15 years or older will meet the criteria for AUD at some point in their lives. The condition generally involves patterns of heavy drinking and a loss of control over alcohol use, despite being aware of the harm it’s causing. It is understood to be a potentially chronic medical condition where in many cases, there will be periods of relapse and remission.
Current Canadian guidelines for the clinical management of high-risk drinking and alcohol use disorder recommend naltrexone or acamprosate as the preferred first-line medications for adults with moderate to severe AUD. These medications are most effective when paired with counselling, support groups, and when possible, family or friends who can be involved in the treatment plan. Medication is one tool, but a supportive environment and on-going follow-up can make an enormous difference.
Naltrexone helps reduce the pleasurable, reinforcing effect of alcohol and can also decrease cravings. It’s useful both for people whose goal is to quit drinking and for those aiming to reduce heavy drinking in an effort to improve their well being and to minimize alcohol-related harms. Naltrexone is taken once daily, with or without food, and importantly, you do not need to be alcohol-free before starting treatment.
Acamprosate, on the other hand, is specifically used when the goal is complete abstinence. It works by reducing cravings and helping people stay alcohol-free. Unlike naltrexone, acamprosate treatment is more effective when a person has already been alcohol-free for several days before starting treatment. The standard dose is taken three times daily with meals.
Many people often wonder how effective these medications truly are. The guidelines use a calculation called the number needed to treat (NNT), which tells us how many people need to receive treatment for one person to benefit from it. For example, a NNT of 10 means that for every 10 people treated, one person will achieve the desired outcome because of the treatment alone- the lower the number, the more effective the therapy.
For naltrexone, the NNT is 20 for supporting complete abstinence and 12 for reducing heavy drinking. This means that out of 20 people taking naltrexone to quit drinking, one person will successfully avoid returning to alcohol because of the medication. Out of 12 people using it to reduce heavy drinking, one will avoid heavy-drinking episodes due to the treatment. Acamprosate, which is only used for abstinence, has a NNT of 12. These numbers might seem modest, but given how complex and challenging addiction can be, they represent meaningful improvements and can significantly support long-term recovery. Typical treatment duration ranges from 6 to 12 months.
Although no direct link has been established, I would like to mention that clinical trials for acamprosate did report adverse events of suicidal nature, including thoughts, attempts, and, rarely, completed suicides. These occurred in 2.4% of people taking acamprosate, compared with 0.8% in the placebo group. These findings do not show that acamprosate causes suicidal behaviour, but they do highlight the importance of open communication, close monitoring, and regular follow-up with your healthcare team- something that is already recommended for anyone undergoing treatment for AUD. Support is essential.
In practice, medications for AUD are not commonly used. Alcohol intake if often not assessed, and when it is, many people feel pressure to downplay how much they drink. Yet when Canadians were anonymously surveyed, 57% of adults reported drinking above low-risk levels for AUD. If you feel your drinking may be affecting your life, don’t hesitate to talk to your health-care provider.