Disulfiram vs. Naltrexone for Alcohol Use Disorder: 5 Differences You Need to Know
Key takeaways:
Disulfiram and naltrexone (Vivitrol) are prescription medications that can help treat alcohol use disorder (AUD). But they work in different ways and have different side effects.
Naltrexone is usually considered a first-choice medication for AUD. Disulfiram may be a second-choice option. But it usually works best if it’s taken under supervision.
Disulfiram is a tablet that’s taken daily. Naltrexone is available as a tablet and brand-name intramuscular injection (Vivitrol). The tablet is usually taken daily. In some cases, it can be taken on an as-needed basis before situations where heavy drinking may be involved. The injection is given every 4 weeks by a healthcare provider.
Disulfiram and naltrexone are both available as lower-cost generic tablets. GoodRx can help you save over 70% off the average retail price at certain pharmacies. And if you’re eligible, a manufacturer savings card can help you save up to $500 a month on Vivitrol.
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Table of contents
If you or a loved one has alcohol use disorder (AUD), you may know that medications are available to help treat this condition. Disulfiram (formerly known as Antabuse) and naltrexone (Vivitrol) are two medication options that can help treat AUD. But they’re different in many ways, including how they work and their side effects. If you’re considering disulfiram or naltrexone, knowing about these differences can help you make the best decision for yourself.
1. Naltrexone is a first-choice option for treating AUD, and disulfiram usually isn’t
Disulfiram and naltrexone are both FDA approved to treat AUD. Naltrexone is considered a first-choice medication. Another medication called acamprosate is also considered a first-choice option. If naltrexone or acamprosate doesn't work for you, disulfiram may be a good second-choice option.
Research shows that disulfiram and naltrexone can both be effective. But deciding which medication to take for AUD is a highly personal decision. For example, disulfiram may work best if it’s taken under supervision (even from a family member).
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No matter which medication you take, treating AUD should also include nonpharmacologic therapies like therapy and support groups.
2. Disulfiram and naltrexone work in different ways
Disulfiram stops alcohol from being broken down (metabolized) in the body. This means that alcohol can’t leave your body as quickly as it usually would. This causes a reaction in the body that can make you feel sick. It may cause you to throw up. It can also cause sweating, a racing heart, and flushing of the face or chest.
Knowing that this “disulfiram-alcohol reaction” can occur is what makes disulfiram effective for some people. The knowledge that you’ll get sick if you drink may be enough to stop you from drinking alcohol. But it’s important to know that disulfiram doesn’t lower cravings for alcohol. However, naltrexone can.
When you drink alcohol, your body releases chemicals called natural (endogenous) opioids and dopamine. These chemicals make you feel good, which makes you want to drink more alcohol. Naltrexone works by blocking endogenous opioids from working. This lowers the amount of opioids and dopamine released in the brain. Cravings for alcohol decrease and drinking becomes less enjoyable. This can make it easier for you to avoid alcohol.
3. Disulfiram and naltrexone come in different forms and are dosed differently
Disulfiram comes as a generic tablet in 250 mg and 500 mg strengths. The usual dose is 250 mg daily, but up to 500 mg may be recommended.
Naltrexone comes as a generic 50 mg tablet. It’s usually given once a day. It also comes as a brand-only intramuscular (IM) injection called Vivitrol. The 380 mg injection is given into the buttock muscle by a healthcare provider every 4 weeks.
What’s unique about oral naltrexone is that some people may not need to take it every day. This is a dosing method called “targeted naltrexone,” where you take naltrexone before an event or situation where you’re at risk of heavy drinking. Though this dosing method isn’t FDA approved, it has been shown to be successful for some people, particularly heavy drinkers.
4. You shouldn’t drink alcohol while taking disulfiram, but it may be OK to take naltrexone, even if you relapse
You shouldn’t take disulfiram within 12 hours of drinking alcohol. If you do, you may experience the disulfiram-alcohol reaction discussed earlier. If you’re taking disulfiram and decide to stop, avoid alcohol and alcohol-containing products for at least 2 weeks. This includes products like some cough syrups and mouthwashes.
If you relapse while taking naltrexone, it might be OK to continue taking it. But make sure to talk to your healthcare provider about this. Although naltrexone reduces alcohol cravings, it doesn’t stop alcohol from having negative effects on your body if you continue to drink.
5. Disulfiram and naltrexone have different side effects
Both disulfiram and naltrexone have side effects to be aware of. Some are mild but commonly occur, while others are more serious but rare.
Disulfiram side effects
The most common side effects of disulfiram include numbness or tingling in the arms and legs, and skin irritation. Headache, tiredness, and an unusual aftertaste may also occur.
More seriously, disulfiram may rarely cause severe liver problems. Signs of liver damage include yellowing of the skin or eyes or abdominal pain. You may also experience nausea and vomiting, dark urine, or tiredness. If you notice signs of liver problems, contact your healthcare provider right away.
Naltrexone side effects
Both forms of naltrexone are generally well tolerated. Some of the common side effects include nausea, headache, and dizziness. It can also cause restlessness and increased liver enzymes.
Reactions at the injection site can happen with IM naltrexone. This includes redness and swelling. If you notice a skin reaction after your injection, contact your healthcare provider.
More serious naltrexone side effects include:
Opioid withdrawal: If you start naltrexone while taking opioids, you may experience opioid withdrawal. The signs of opioid withdrawal include muscle aches, nausea, and vomiting. You may also experience diarrhea, stomach cramping, or a runny nose. To prevent opioid withdrawal symptoms, avoid opioid medications for at least 7 to 10 days before starting naltrexone.
Increased opioid sensitivity: If you start taking opioids after you’ve been taking naltrexone, you may be more sensitive to opioids. This can make an opioid overdose more likely, even with lower opioid doses than what you’ve tolerated in the past.
Liver problems, especially at high doses of naltrexone: Your healthcare provider may order lab tests to check your liver function before you start taking naltrexone and throughout treatment.
Depression and suicidal thoughts: If you notice a change in your mood while taking naltrexone, talk to your provider.
If you or someone you know struggles with substance use, help is available. Call SAMHSA’s National Helpline at 1-800-662-4357 to learn about resources in your area.
And if you or someone you know is having thoughts of suicide, help is also available. Call the National Suicide Prevention Lifeline at 988, or text HOME to 741-741 to reach the Crisis Text Line.
Who should avoid naltrexone or disulfiram?
People who have taken a medication called metronidazole (Flagyl) in the last 2 weeks should avoid disulfiram. And if you’ve had any alcohol or alcohol-containing products in the last 12 hours, you should avoid disulfiram as well. Some people who have severe heart problems or psychotic conditions should also avoid disulfiram.
People who are taking opioids, or who are experiencing opioid withdrawal, shouldn’t take any form of naltrexone. And if you have severe liver problems, it’s best to avoid naltrexone as well.
How to save on disulfiram and naltrexone
There are ways to save on disulfiram and naltrexone. Both are both available as lower-cost generics. GoodRx can help you navigate ways to save on your prescription.
Save with GoodRx. GoodRx can help you save over 70% off the average retail price of the generic versions of disulfiram and naltrexone. Generic disulfiram at certain pharmacies is as low as $33.59 with a free GoodRx discount. Generic oral naltrexone at certain pharmacies is as low as $39.47 with a free GoodRx discount.
Save with a copay savings card. If you have commercial insurance, you may be eligible to save up to $500 a month on out-of-pocket costs for brand-name IM Vivitrol using a savings card from the manufacturer.
The bottom line
Disulfiram and naltrexone can both help treat alcohol use disorder (AUD). When comparing disulfiram and naltrexone, naltrexone is a first-choice medication option for AUD. Disulfiram is usually a second-choice option if naltrexone doesn’t work.
Naltrexone works by decreasing alcohol cravings and reducing your desire to drink. Disulfiram works by causing an unpleasant reaction in your body if you drink alcohol. This may involve throwing up and feeling sick. The knowledge of this reaction is enough to keep some people from drinking.
Another difference between disulfiram and naltrexone is that disulfiram is only available as a tablet. Naltrexone is available as a tablet and monthly injection. If you’ve been diagnosed with AUD, your healthcare provider can help you choose the best medication option for your situation.
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References
Alkermes, Inc. (2022). Vivitrol- naltrexone [package insert].
American Psychiatric Association. (n.d.). Practice guideline for the pharmacological treatment of patients with alcohol use disorder.
Bold, K. W., et al. (2016). Daily relations among affect, urge, targeted naltrexone, and alcohol use in young adults. Experimental and Clinical Psychopharmacology.
Bryant Ranch Prepack. (2023). Naltrexone hydrochloride- naltrexone hydrochloride tablet, film coated [package insert].
Chartwell RX, LLC. (2022). Disulfiram- disulfiram tablet [package insert].
Gianoulakis, C. (2001). Influence of the endogenous opioid system on high alcohol consumption and genetic predisposition to alcoholism. Journal of Psychiatry and Neuroscience.
Kranzler, H. R., et al. (2011). Targeted naltrexone for problem drinkers. Journal of Clinical Psychopharmacology.
Laaksonen, E., et al. (2007). A randomized, multicentre, open-label, comparative trial of disulfiram, naltrexone and acamprosate in the treatment of alcohol dependence. Alcohol and Alcoholism.
If you or someone you know struggles with substance use, help is available. Call SAMHSA’s National Helpline at 1-800-662-4357 to learn about resources in your area.
