Alcohol & Substance Use Disorder

The short version

●Substance use disorder (including alcohol use disorder) is a treatable medical condition defined by impaired control over use, continued use despite harm, craving, tolerance, and withdrawal — not a moral failing.
●First-line treatment combines evidence-based medications (for alcohol: naltrexone, acamprosate, disulfiram; for opioids: buprenorphine, methadone, naltrexone) with behavioral treatment and recovery support.
●It very commonly co-occurs with depression, anxiety, PTSD, and trauma, and treating both together improves outcomes.
●Ketamine is one of the more genuinely promising emerging treatments here: controlled trials (Dakwar 2020; the KARE trial, Grabski 2022) show ketamine combined with psychotherapy can increase abstinence in alcohol use disorder.
●The mechanism is thought to involve disrupting reward and craving circuitry and enhancing the neuroplasticity that makes behavioral change "stick," paired with therapy.
●It is not a standalone cure or a substitute for established addiction treatment — and ketamine itself has misuse potential, so it is used carefully, with screening, within a structured program.

Clinical definition

Substance use disorders, including alcohol use disorder, are defined in DSM-5 by a problematic pattern of use leading to clinically significant impairment or distress, with criteria spanning impaired control (using more or longer than intended, unsuccessful efforts to cut down, craving), social impairment (failure to fulfill roles, giving up activities), risky use (use in hazardous situations, continued use despite harm), and pharmacological features (tolerance, withdrawal). Severity is graded by the number of criteria met. These are chronic, relapsing-remitting medical conditions involving changes in the brain's reward, motivation, and self-control circuitry — not simply a lack of willpower. They are highly comorbid with mood, anxiety, and trauma disorders (the "self-medication" pattern is common, and each worsens the other), and integrated treatment of co-occurring psychiatric conditions improves outcomes. A separate but important point: ketamine itself is a substance with misuse potential, which shapes how cautiously it is used in this population.

How it differs from related conditions

vs. Depression

An extremely common comorbidity, often in a bidirectional, self-medicating relationship; both must be screened and treated alongside the substance use.

vs. Alcohol use disorder

The alcohol-specific disorder within this broader category — with its own FDA-approved medications and an emerging, investigational ketamine research literature.

vs. PTSD

Trauma frequently underlies substance use; integrated trauma-and-addiction treatment is more effective than treating either alone.

vs. Anxiety

Commonly drives self-medication with alcohol or sedatives; treating the anxiety supports recovery.

vs. Physical dependence (without a use disorder)

Tolerance and withdrawal can occur with prescribed medications without the compulsive, harmful pattern that defines a use disorder.

First-line treatments

Medications for the specific substance

Alcohol — naltrexone, acamprosate, disulfiram; opioids — buprenorphine, methadone, naltrexone. Strong evidence, and badly under-prescribed.

Behavioral treatment

CBT, motivational enhancement, contingency management, and relapse-prevention therapy.

Recovery support

Mutual-help groups (AA, SMART Recovery), peer support, and recovery management.

Treating co-occurring psychiatric conditions

Integrated treatment of depression, anxiety, and PTSD improves substance outcomes.

When standard treatments fail

When standard treatment doesn't hold, the steps are to ensure evidence-based medications were actually offered (they are widely under-prescribed), intensify behavioral treatment and recovery support, treat co-occurring psychiatric conditions, and consider higher levels of care. This refractory, high-relapse space — particularly alcohol use disorder with co-occurring depression — is exactly where ketamine-assisted approaches are being studied, always combined with psychotherapy rather than as a standalone intervention.

Where ketamine fits

Substance use disorder, and alcohol use disorder specifically, is one of the areas where ketamine has more than hand-waving evidence. In controlled trials, a single ketamine infusion combined with motivational enhancement therapy increased abstinence in alcohol use disorder (Dakwar 2020), and the KARE trial found adjunctive ketamine with relapse-prevention psychotherapy improved abstinence outcomes (Grabski 2022). The proposed mechanisms — disrupting reward and craving circuitry, weakening maladaptive drinking-related memories, and opening a neuroplastic window that makes behavioral change more durable — are why ketamine is always paired with psychotherapy in these protocols, not given alone. Two honest caveats: the evidence, while encouraging, is still emerging and these are specialized protocols; and ketamine itself has misuse potential, so its use in people with addiction requires careful screening, structure, and monitoring. Where alcohol or substance use co-occurs with treatment-resistant depression, ketamine's dual relevance is greater.

Where this fits with Tovani

Tovani approaches substance use disorder cautiously and within its scope. Ketamine is most appropriate when a treatment-resistant depression co-occurs with alcohol use, with the substance use managed in an appropriate addiction-treatment setting, because ketamine's own misuse potential requires careful screening and structure. Eligibility screening specifically captures substance-use history, and active, unmanaged substance use disorder is a contraindication to at-home ketamine. Patients are directed to evidence-based addiction treatment (medications, behavioral therapy, recovery support); ketamine for a co-occurring depression is considered when the substance use is being appropriately addressed. If you need help, SAMHSA's National Helpline is 1-800-662-4357.

Check eligibility Find treatment options The science behind ketamine

Frequently asked

Can ketamine help me stop drinking?

There's genuinely promising evidence here. Controlled trials found ketamine, combined with psychotherapy, increased abstinence in alcohol use disorder. But it's always paired with therapy (not given alone), the evidence is still emerging, and ketamine has its own misuse potential — so it's used carefully within a structured program, not as a quick fix.

Is addiction a disease or a choice?

It's a treatable medical condition involving real changes in the brain's reward, motivation, and self-control circuitry — not simply a lack of willpower. That's why evidence-based medications and behavioral treatments work, and why blame and shame don't. Effective treatment exists and recovery is common.

Isn't it risky to use ketamine in someone with addiction?

It's a real and important consideration. Ketamine has misuse potential, so in people with substance use disorders it's used cautiously, with careful screening, structure, and monitoring — and active, unmanaged substance use is a contraindication to at-home ketamine. The clearest role is for a co-occurring depression while the substance use is managed in proper addiction care.

What's the first-line treatment for alcohol use disorder?

Evidence-based medications (naltrexone, acamprosate, disulfiram) combined with behavioral therapy and recovery support — and these medications are badly under-used. Treating co-occurring depression, anxiety, or PTSD improves outcomes too.

References

Dakwar E et al. 2020, American Journal of Psychiatry — RCT: a single ketamine infusion combined with motivational enhancement therapy increased abstinence in alcohol use disorder. (PMID 31786934)
Grabski M et al. 2022, American Journal of Psychiatry — The KARE trial: adjunctive ketamine with relapse-prevention psychotherapy improved abstinence outcomes in alcohol use disorder. (PMID 35012326)
Murrough JW et al. 2013, American Journal of Psychiatry — Ketamine RCT in treatment-resistant depression, the comorbidity most relevant to substance use. (PMID 23982301)

Last reviewed by Dr. Ben Soffer, DO on May 31, 2026. This page is educational and not a substitute for clinical evaluation. A physician determines whether ketamine therapy is appropriate for your specific situation.