Characterized by compulsive drinking, loss of control, and negative emotional states when not using, alcohol use disorder (AUD) was recently linked to dementia. Despite advances in neuroscience and genetics, relapses approach 60-70 percent within a year of treatment cessation. Medications like naltrexone, acamprosate, and disulfiram were FDA-approved decades ago, and demonstrate consistent benefits—yet are rarely utilized.

Psychedelics like psilocybin, LSD, and MDMA have been considered potential breakthrough treatments for major depression, eating disorders, generalized anxiety disorder (GAD), end-of-life anxiety, and substance use disorders.

“The bad news is, this enthusiasm, particularly around psilocybin, sometimes outpaced the data—raising critical questions about whether psychedelics are suited for treating AUD and if the field could be succumbing to a wave of therapeutic hype,” said A. Benjamin Srivastava, M.D., Assistant Professor of Psychiatry at Columbia University and lead author with me of a November 2025 paper.

He added, “The evidence for their role in treating AUD is limited and much of it is quite flawed. Meanwhile, we have extensive, high-quality evidence supporting the efficacy and safety of already-existing AUD treatments, especially when paired with structured behavioral support such as Alcoholics Anonymous (AA). As addiction psychiatrists, our immediate priority should be advocating wider use of treatments we already know work, rather than being swept away by incomplete and largely uninterpretable data on psychedelics. The last thing we want is for patients to self-administer psilocybin for AUD when existing treatments are much safer and more effective.”

Canadian psychiatrists Humphry Osmond and Abram Hoffer experimented with LSD to treat alcoholism in the 1960s. Osmond sought to reproduce “spiritual bottoming out” described by Alcoholics Anonymous (AA), which many recovered individuals cited as a turning point in recovery. In small studies, Osmond and Hoffer reported higher rates of abstinence among patients receiving LSD versus traditional therapy—sparking curiosity from an AA founder, Bill Wilson. But early studies were methodologically weak, without randomization, blinding, or standardized measures, and Wilson also abandoned his advocacy.

As Srivastava and Gold emphasize today, enthusiasm around psychedelics is high, but shouldn’t substitute for quality evidence. Nor do we want people trying psilocybin on their own for AUD.

JAMA recently noted nonclinical psilocybin use has sharply increased in the US, particularly among adults 19-50 years, with more than 7 million individuals reporting past-year use.

In a phase 2 trial by Bogenschutz and colleagues, psilocybin combined with psychotherapy reduced heavy drinking days—but only in the final four weeks of a 36-week study, and after most assessments showed no difference between psilocybin and diphenhydramine placebos. Up to 90 percent of study participants accurately guessed if they were given a psychedelic or a placebo, due to the unmistakable effects of psilocybin and LSD.

Psychedelic-assisted therapy may find a role in severe/refractory AUD cases. Some studies hypothesize that psychedelics exert effects by promoting neuroplasticity or facilitating mystical experiences. Its potential lies in disrupting rigid network activity, potentially allowing for greater emotional and cognitive flexibility, and addressing identity in ways conventional treatments do not. But current evidence is insufficient to recommend psychedelics over or even alongside standard care.

Existing medications for AUD remain under-prescribed, although the National Institute on Drug Abuse’s Dr. Nora Volkow and the National Institute on Alcohol Abuse and Alcoholism’s Dr. George Koob emphasize the need to use these medications.

Oral naltrexone reduces relapse risk and heavy drinking days. Acamprosate supports abstinence maintenance after detox, and disulfiram is highly effective under supervision—especially when abstinence is the goal.

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The AUD treatment medication naltrexone can be administered orally or as an extended-release injection, Vivitrol (monthly). The injectable form addresses a major treatment barrier: adherence. Patients struggling with taking a daily medication may benefit from long-acting once-a-month injectable Naltrexone instead.

Approved in the United States in 2004, acamprosate modulates glutamate and GABA receptors, helping stabilize the neurochemical imbalance created by chronic alcohol use. It is particularly effective at supporting abstinence after detoxification.

Disulfiram (Antabuse) is often underused. While it doesn’t reduce cravings, it acts powerfully through aversive conditioning. Anyone who drinks alcohol becomes severely nauseous because disulfiram blocks the ability to process alcohol. Open-label and supervised trials demonstrate disulfiram has among the highest abstinence rates.

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Innovations in Access: Direct-to-Consumer Models

So, we have 3 FDA-approved medications, decades of data, and validated models for combining them with behavioral supports. Yet <2 percent of people with AUD take them. I previously discussed this underutilization.

Recent efforts have increased access to Naltrexone using a Viagra-like direct-to-patient sales model, delivering naltrexone via telehealth, shipping medications to homes. Normalizing medication through direct-to-consumer marketing and flexible, patient-controlled paths may bring evidence-based treatments to public consciousness.

In a November 2025 JAMA article, Mass General Hospital’s Harvard psychiatrists advocate for making oral naltrexone available over-the-counter (OTC) to address unhealthy alcohol use and AUDs. Both are under-treated in the U.S. Naltrexone reduces alcohol cravings and heavy drinking, but is underutilized primarily due to stigma, shame, and lack of awareness that Naltrexone works. OTC availability is a logical idea that could reduce harm, high-intensity drinking, and mirror successful public health strategies like OTC nicotine replacement products for smokers.

Not everyone wants to quit drinking—and that’s okay. Research supports a stepped-care, harm-reduction model where reduced or controlled drinking goals are valid. Naltrexone works in this model by reducing the “buzz” of alcohol, allowing patients to regain control before they are ready for abstinence.

A large Cochrane review confirmed that AA and 12-step facilitation were more effective in maintaining abstinence than other psychological treatments. That makes AA a great addition to Naltrexone treatment. AA, after all, is one of the most cost-effective tools for promoting abstinence and reducing alcohol-related harm, especially with pharmacotherapy.

Psychedelics may not deserve the therapeutic spotlight in AUD, but with depression, treatment-resistant anxiety, eating disorders, post-traumatic stress disorder (PTSD), and existential distress in terminal illnesses, there is compelling data for psilocybin, LSD, and others.

Randomized controlled trials at Johns Hopkins, Imperial College London, and other leading institutions have shown that one to two sessions of psilocybin-assisted therapy can rapidly and dramatically reduce depressive symptoms. In some cases, effects last months. On November 4, 2025, psychedelic drug developer Compass Pathways said it’s accelerating the FDA process to move its experimental psilocybin-based depression therapy up 9-12 months. The decision follows completion of enrollment for a late-stage study for the psychedelic-based therapy, COMP360, as well as a positive meeting with the FDA.

Studies in GAD and obsessive-compulsive disorder reinforce the idea that psychedelics may “reset” entrenched cognitive patterns. Given that these conditions often involve repetitive thought loops and maladaptive rumination, psychedelics may hold a unique role where antidepressants and anxiolytics fail.

In terminally ill patients facing anxiety and depression, psychedelics have demonstrated rapid, enduring reductions in distress, decreases in death anxiety, and greater spiritual well-being persisting six months or longer. These outcomes are compelling because conventional medications offer modest relief and don’t address existential suffering.

Conclusion

Psychedelic use grew sixfold among U.S. adults 35–50 years old from 2014 to 2024, based, in part, on positive controlled research clinical trials. Clinical trials are highly controlled medical procedures designed for scientific rigor and patient safety, while self-medication occurs in uncontrolled, non-medical settings, with unapproved “street drugs”, and carries significant immediate and long-term risks.

The path forward isn’t about choosing between psychedelics and standard medications — it’s about prioritizing treatments, comparing to existing treatments, saving lives while supporting innovative research. The utility of psychedelics in depression, end-of-life distress, GAD, eating disorders, and trauma is compelling. But with AUD, hype runs ahead of science. Clinicians seek to reduce harm, save lives, and restore function. For AUD, we have the tools. The next step is ensuring they are actually used.