What factors into your choice to use craving-related medications (e.g., baclofen, naltrexone, acamprosate, etc.) in the management of alcohol use disorder?

When I discuss starting medications of alcohol use disorder (MAUD), we discuss reducing alcohol cravings, thereby reducing overall intake with the ultimate goal of abstinence with adjunctive psychotherapy if necessary. The options currently available in the market are naltrexone oral and intramuscular formulations, acamprosate, baclofen, and disulfiram. I discuss that disulfiram should not be considered due to hepatotoxicity. By going through the formulations, frequency of intake, and safety profile, the patient and I often land on naltrexone, either oral or intramuscular, as the best therapy for them. Thereafter, we recommend baclofen and acamprosate for our patients with decompensated cirrhosis. Patients who find benefit with MAUD should ...

I favor naltrexone over ease of use, especially if the patient has cravings. If the patient has anxiety that seems to be driving their alcohol use, I choose gabapentin 300 mg BID. If they don’t have anxiety or have a contraindication to naltrexone, I would go with acamprosate. If the patient doesn’t think they need a daily drug or want to be on a daily drug, I will sometimes prescribe Naltrexone PRN for them to take during the holidays or before an event or party with alcohol for an extra layer of support. I also discuss the drugs, frequency of dosing, their benefits/side effect profiles and let the patient decide alongside my guidance. I also let them know that if this medication doesn’t seem to help, we have others that we can try.