The alcohol medication gap: what 2024 Medicaid prescription data shows

In 2024, Medicaid filled about three prescriptions for opioid addiction for every one it filled for alcohol addiction — 3,225,806 versus 1,049,808, a ratio of 3.07 to 1. That is the opposite of what the size of the two problems would predict: an estimated 27.9 million Americans 12 and older had alcohol use disorder in 2024, compared with 4.8 million with opioid use disorder — nearly six times as many people.

Adjust for how common each condition is and the gap stretches to roughly eighteen to one: per person affected, opioid use disorder received approximately eighteen times more medication fills than alcohol use disorder did. Treat that as an estimate — the prescription counts and the survey counts come from different systems — but the direction is not in doubt. Same insurance program, same year, and both conditions have FDA-approved medications.

We pulled these numbers from the federal government's own records of what Medicaid paid for, drug by drug. The full state-by-state table is downloadable below, along with everything you'd need to check our math.

The gap, drug by drug

Three medications are FDA-approved for alcohol use disorder: naltrexone, acamprosate, and disulfiram. Across all fifty states, D.C., and Puerto Rico, Medicaid's 2024 records show the following fills — a "fill" meaning one prescription dispensed at a pharmacy, one bottle or one injection, not one person:

Medication	2024 Medicaid fills
Naltrexone, oral tablets	675,977
Naltrexone, monthly injection (Vivitrol)	228,797
Acamprosate	108,236
Disulfiram	36,798
Total	1,049,808

Two things stand out.

First, the total leans almost entirely on naltrexone — 904,774 of the 1,049,808 fills. And naltrexone is approved for both alcohol and opioid addiction, with no way to tell from pharmacy data which condition a given fill treated. We counted every naltrexone fill toward the alcohol side anyway, which means 1,049,808 is a ceiling and the 3.07-to-1 ratio is a floor. The two medications that treat only alcohol — acamprosate and disulfiram — add up to 145,034 fills nationally for the entire year. That works out to roughly one fill for every 192 Americans with alcohol use disorder.

Second, disulfiram, the oldest alcohol medication of the three, has nearly vanished: fewer than 37,000 fills across the whole country.

Three places where the numbers all but disappear

In Mississippi, Wyoming, and Puerto Rico, the 2024 file contains not one visible acamprosate or disulfiram number. Every single one of those data cells was hidden for low volume, all four quarters of the year.

Hidden does not mean zero, and the distinction matters. Federal privacy rules suppress any cell where a drug was filled between 1 and 10 times in a state in a quarter, because counts that small could risk identifying the people behind them. So the accurate way to say it is this: in those three places, so few alcohol-only prescriptions were filled that federal privacy rules hide the numbers — no acamprosate or disulfiram product reached even eleven fills in any quarter of 2024. Suppression happens everywhere in this dataset, but only in these three places does it swallow the alcohol-only medications entirely. Whatever the exact counts behind the privacy screen, they are small enough to hide.

How the gap compares with the harm

Deaths are harder to compare than prescriptions, and it is worth being precise, because the sloppy version of this comparison gets stories killed. The CDC attributes roughly 178,000 deaths a year to excessive alcohol use — a deliberately broad measure, averaged over 2020–2021, that counts chronic diseases such as liver disease and cancer as well as injuries in which alcohol played a causal role. Opioid-involved overdoses killed an estimated 54,743 people in 2024, by the CDC's provisional count. Those figures use different definitions and different years, so they do not support a tidy "alcohol kills more" headline. What they do support is plainer: both are among the country's leading causes of preventable death, and only one of them gets medication at anything like scale.

And to be clear about the direction of the argument — nothing here says the opioid numbers are too high. Expanding medication for opioid addiction was a hard-won answer to an emergency, and those prescriptions save lives. The question this data raises is why the alcohol side stayed so small. Part of the answer may be clinical: buprenorphine relieves opioid withdrawal and treats the disorder at the same time, so it can be started right away, while the alcohol medications are generally started after someone has stopped or cut back — and alcohol withdrawal, unlike opioid withdrawal, can be life-threatening, so reaching that starting point sometimes needs medical supervision of its own. The paths to a first prescription are not equally smooth. We have written before about the other prescribing barriers — training, habit, stigma — in why won't doctors prescribe naltrexone.

What the three medications actually are

None of what follows ranks them. Which one fits, if any of them does, depends on health history and goals — that is a clinician conversation, not a chart.

Naltrexone blunts the reward. Part of what makes drinking feel good runs through the brain's opioid receptors — the same circuitry the body's own endorphins use — and naltrexone blocks those receptors, so a drink delivers less of its usual lift. It comes as a daily tablet or a monthly injection, and it is discussed around both cutting down and quitting. It is also, as noted, used for opioid addiction — the very thing that muddies this count. More in our naltrexone explainer.

Acamprosate works on the other side of the problem. After someone stops drinking, brain signaling can stay over-revved for months — restlessness, poor sleep, unease — and acamprosate helps resettle it. It is approved for staying stopped rather than for cutting down. More in our acamprosate explainer.

Disulfiram is the old tripwire. It blocks the second step of alcohol breakdown, so a toxic byproduct called acetaldehyde builds up and drinking makes you feel promptly, memorably ill — a deterrent some people committed to full abstinence choose on purpose. At 36,798 fills, it is the closest of the three to disappearing from practice. More in our disulfiram explainer.

The backdrop to all three is the same: most people with alcohol use disorder never receive any of them. Federal survey data shows fewer than one in ten people with past-year alcohol use disorder received any alcohol treatment in 2024, and a 2024 American Family Physician review reports that in 2019 just 1.6 percent were prescribed medication for it.

How we counted — and how to check us

The numbers come from the Medicaid State Drug Utilization Data, the public record of outpatient prescriptions that state Medicaid programs paid for, reported drug by drug, quarter by quarter. We took every calendar-2024 row for the three alcohol medications in all their forms, and compared them with fills of opioid-addiction medications — buprenorphine combination products and their brand versions.

Four honest limits:

• Medicaid only. Nothing here covers commercial insurance, Medicare, the VA, or people paying cash. This is one large insurance program, not a picture of all American prescribing.
• A fill is not a person. Prescriptions on both sides are often refilled monthly, and nothing in this data counts unique people.
• Naltrexone cuts both ways. Because it treats both conditions and we credited all of it to alcohol, the alcohol total is an upper bound — the real gap is understated here, not overstated.
• Small numbers are hidden. 2,880 alcohol-medication cells were suppressed for low volume. Each hides at most 10 fills, so the true national total is at most 1,078,608 — the headline ratio barely moves either way. On the opioid side we excluded plain single-ingredient buprenorphine, since some of it is prescribed for pain; counting any of it would only widen the ratio.

The full state-by-state table — fills by drug, suppressed-cell counts, and observed opioid-medication fills — is downloadable as a CSV: aud-medication-access-2024.csv. One caution if you dig in: states differ in how completely their managed-care plans report into this file, which is why we have deliberately drawn no state-versus-state rankings in this article. And if you re-derive the numbers from the federal file and get something different, tell us — being checkable is the point of publishing the file.

If some of this is you

If those 27.9 million include you or someone you share a table with, the useful takeaway is smaller than the ratio: medication for alcohol use disorder is a normal, unremarkable thing to raise with a doctor — the same register as asking about blood-pressure pills — and that the question has three concrete, FDA-approved answers worth discussing, whether the goal is stopping entirely or drinking less. If raising it feels easier said than done, that conversation is what Clero is being built for — educational today, not a clinic; join the waitlist to hear when that changes.

The gap in this data took decades to build, and no article closes it. But it narrows one ordinary conversation at a time, and most of those start with someone learning the medications exist.

This article is general education, not medical advice or a prescription; whether any medication fits you is a decision for a licensed clinician who knows your history and your goals. For confidential treatment referrals, SAMHSA's National Helpline is 1-800-662-HELP (4357).

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