Last month a client reached out to me because he wanted a prescription for Naltrexone, an FDA-approved medication for addiction to alcohol and opiates, but his doctor wouldn’t give it to him. Was it because his alcoholism wasn’t severe enough for medication, that he had health problems that made him a bad fit for it, or because he was taking another prescription that could dangerously interact with it?
No. None of the above was relevant. Instead, the doctor said that the client needed to show proof of at least 6 months of Alcoholics Anonymous (AA) attendance before she’d even consider Naltrexone as an option. Essentially the client needed to admit he was powerless over alcohol, turn himself over to God, and then pray that God remove his character defects before he could get a prescription for a potentially life-threatening health condition. Not only could this be considered medical malpractice, but it is also symbolic of a troublesome theme in the addiction treatment world.
How Does Naltrexone Work?
Naltrexone is an opioid antagonist medication that works by inhibiting the “euphoria” that alcohol, opiates and potentially other rewards create. It blocks opioid receptors in the brain, thereby inhibiting the release of endorphins that cause the pleasure one associates with these substances. Over time, one no longer experiences the desirable effects of them and cravings gradually cease. While an alcoholic drink may, much like a can of your favorite soda, continue to taste good, it does not create any pleasure or euphoria beyond that.
Naltrexone itself is not addictive and it does not adversely interact with alcohol. Furthermore, the safety and efficacy of Naltrexone for alcoholism have been upheld by a large body of research since the time of its acceptance by the FDA in 1984. Unfortunately, Naltrexone still faces some barriers in becoming a more commonplace choice of treatment.
Strong Evidence, Weak Implementation
A recent national study of addiction treatment centers found that, depending on the type of Naltrexone, only 9 to 17 percent of centers offered it (U.S. Department of Health and Human Services, 2016). Furthermore, while an estimated 16.3 million adults in the U.S. have an alcohol use disorder, in 2010 only 658,000 people received prescriptions for medications like Naltrexone—that’s only 5 percent!
Why has the rollout of Naltrexone been so limited? Abraham et al (2015) found that counselors at addiction treatment centers with a 12-Step ideology, meaning they require clients to follow the 12 Steps of AA (much like the doctor above), were significantly less likely to consider Naltrexone effective. Also, Roman et al (2011) found that addiction programs that place a greater emphasis on the 12 Steps were less likely to adopt any form of medication-assisted therapy (MAT). When you consider that 80% of addiction treatment centers in this country incorporate the 12 Steps, the low uptake of Naltrexone makes a whole lot of sense.
Addiction counselors with a Master’s degree or higher were more likely to view Naltrexone as a viable treatment compared to counselors with less education. Altogether, these results suggest that the misconception that Naltrexone is just another “narcotic” that can be addictive, a commonly-held view in the 12 Step community, and a widespread lack of knowledge regarding its effectiveness are major barriers to its adoption.
So what’s to be done? Abraham et al (2015) have suggested integrating medication-specific training and practice guidelines into coursework for students seeking certification in addiction counseling. Such strategies may contribute to a faster, more efficient adoption of the medication by treatment programs. However, given AA’s stronghold on the treatment community, it may take a while before Naltrexone is widely available enough to meet the need for it. Luckily, there are options out there.
My thoughts on naltrexone
I make it my goal to be one of the most forward-thinking recovery resources available, and that includes embracing Naltrexone. I offer support services for the “Sinclair Method,” a controlled drinking program that incorporates Naltrexone to individuals with prescriptions for it. Double-blind clinical trials conducted by creator Dr. JD Sinclair (Sinclair, 2001) have demonstrated the benefits of Naltrexone are most evident when individuals continued consuming alcohol during treatment while taking it (the “Sinclair Method”), whereas individuals who practiced abstinence while taking it did not receive such benefits, suggesting the medication may be better suited for people who wish to control their drinking.
The Sinclair Method takes advantage of “extinction”, a learning mechanism that gradually reduces the positive reinforcement of alcohol use. Individuals with AUDs have been “conditioned” to positively associate benefits with drinking alcohol. Pairing Naltrexone with alcohol consumption helps to break this association. However, this extinction mechanism is not put into action when the original problem stimuli (alcohol) is not presented, supporting the efficacy of the Sinclair Method in the goal of treating AUDs.
Finally, it is important to note that Naltrexone is part of medication-assisted therapy, meaning it is a supplement to a comprehensive program that must include a behavioral component. It is not a magic bullet. That’s why I offer a complete behavioral education and coaching program to support clients through The Sinclair Method experience
Abraham, A. J., Rieckmann, T., McNulty, T., Kovas, A. E., & Roman, P. M. (2011). Counselor attitudes toward the use of naltrexone in substance abuse treatment: A multi-level modeling approach. Addictive behaviors, 36(6), 576-583.
Anderson, K., M.A. (2013, July 20). Drink Your Way Sober with Naltrexone.
Litten, R. Z. (2016), Nociceptin Receptor as a Target to Treat Alcohol Use Disorder: Challenges in Advancing Medications Development. Alcohol Clin Exp Res, 40: 2299–2304. doi:10.1111/acer.13222
Roman, P. M., Abraham, A. J., & Knudsen, H. K. (2011). Using medication-assisted treatment for substance use disorders: Evidence of barriers and facilitators of implementation. Addictive behaviors, 36(6), 584-589.
Sinclair, J. D. (2001). Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism. Alcohol and Alcoholism, 36(1), 2-10.
Thomas, C., Wallack, S., Swift, R., Bishop, C., McCarty, D., & Simoni-Wastila, L. (2001, January). Adoption of naltrexone in alcoholism treatment. In Journal of Addictive Diseases (Vol. 20, No. 2, pp. 180-180).
Thomas, S. E., Miller, P. M., Randall, P. K., & Book, S. W. (2008). Improving acceptance of naltrexone in community addiction treatment centers: A pilot study. Journal of substance abuse treatment, 35(3), 260-268.
U.S. Department of Health and Human Services (2016). The Surgeon General’s Report on Alcohol, Drugs, and Health. Office of the Surgeon General, 6-29.
NIAAA Alcohol Facts & Statistics
One response to “Naltrexone works for Alcohol Problems – Why Is It So Poorly Adopted?”
Thank you Dr Jaffe for your work and writing this piece. I know people that Naltrexone helped. This Dr who told the person to go to AA should be sued and removed from practice.