Naltrexone can save millions of lives. Why don't we use it?

The usual suspects.

My ex-boyfriend’s little brother hung himself on April Fool’s day. “He always had a sense of humor,” a mutual friend said. He’d struggled with heroin for years. But it was the alcohol that got him. In a last ditch effort to help him get better, the Swedish side of the family let him move in, setting a hard limit of 10 drinks a day. But, it was too late. His kidneys were failing, his liver was on the way out. He decided, I guess, that he’d prefer to die on his own terms.

Occasionally, the fact floats around that even with fentanyl in the mix, alcohol misuse is directly and indirectly responsible for more deaths than opioids. According to the CDC the average annual number of deaths from excessive alcohol increased 29.3% between 2017 and 2020. Obviously this is pandemic related and will roll back, just as crime did when the pandemic subsided. But the CDC also observes that alcohol use and alcohol-related deaths have been steadily creeping up over the past 2 decades.

So what should we do, CDC?

Implementation of evidence-based policies that reduce the availability and accessibility of alcohol and increase its price (e.g., policies that reduce the number and concentration of places selling alcohol and increase alcohol taxes) could reduce excessive alcohol use and alcohol-related deaths.

Ugh. Higher taxes? Who likes that? If only there were a magic pill...

There is. Naltrexone, an opioid inhibitor, has been available in Europe for years. It has a 78% success rate.

The way it works is neat. The medication blocks receptors in the brain that produce pleasurable — even euphoric — feelings when some people have a drink. Cravings start to lessen almost immediately — some people take it only before, say, a work event where it would be untoward to get smashed. Other people use it longterm to scale back their drinking or stop entirely. Eventually the brain rewires so that a drink is just a drink. You could take it or leave it, and you certainly don’t have to have 10.

Meanwhile, the Sinclair method has an 80% success rate. How crazy is that? (although the group disputes the numbers, studies have found AA’s longterm success rate to be between 5 and 10 percent, reports NPR).

With the Sinclair method, invented by Dr. John David Sinclair, you take a pill an hour before you plan to drink. And then you drink. Like, you’re supposed to drink, to kickstart the process of teaching your brain to stop associating alcohol with euphoria. The timing makes the drug most effective right around when the alcohol is going to metabolize and overrun your neural receptors. Also it generally lasts about 6 hours so it’s a good idea to take it later in the day if you drink at night.

It’s the Ozymbic of booze. With one important difference: it’s been around for decades, so we know there are no side effects.

So why isn’t it widely prescribed? How many lives could be saved? I think this is one of the under-the-radar travesties of the century—when you consider the death toll, and all the other countless negative social consequences.

It’s disdained by the shady rehab industry. You want return customers, after all. AA adherents are outraged at a cure that doesn’t require complete sobriety; and is easy, instead of painstakingly difficult; and that relies on science, not higher powers and their literal tokens; the narrative of an inner prodigal son. Blah blah. You get the point (caveat: if AA worked for you, amazing. It clearly doesn’t for everyone).

I know that there are more modern versions, and atheist versions, and women only versions, and LGBTQ and hipster versions. It’s not all grizzled old men shaking from black coffee and cigarettes. But the core message that abstinence is the only way and it can only be reached through hard work and furious struggle remains, and continues to undergird popular conceptions of addiction: you see it in everything from court-mandated treatment to pop culture. Magic bullet? Well that’ll put a lot of people out of business (I will say what AA brings that a pill doesn’t is community. So there’d be a role for AA).

And Americans have a strange relationship to drugs. We either overmedicate (remember when every hyper kid was pumped with ADHD meds?) or bluster, like in the addiction discourse, that it isn’t that it shouldn’t be “easy.” It’s why harm reduction measures, from suboxone to administering low doses of alcohol to alcoholics, to safe injection sites, are met with derision and rage.

More broadly this roughly maps onto the perennial U.S. tension between the desire for instant gratification and self-flagellating Calvinism (usually for others). More precisely, it’s rooted in the fact that the pharmaceutical industry only promotes patented drugs. Naltrexone isn’t patented, it’s generic. So even though it’s legal and approved for treatment of alcohol disorder, no one knows about it because it doesn’t profit Big Pharma.

In “One Little Pill,” a 2014 documentary about naltrexone, you see doctor after doctor go, “What? I’ve never heard of that” when their patients, most of whom have gotten it off the Internet, ask them for a prescription. When the doctors dig into the research they promptly send out a script. The film follows several people whose alcohol use had like 98% destroyed their lives. These are heavy, heavy drinkers—not the annoying “My two glasses of white wine made me less present for my children!” drinker, a story the NYT runs like every week. One guy would go on three day, morning till night whiskey benders. Another woman admits to desperately driving around at 6am to buy more booze.

“I had two glasses of wine. I took the third one to bed. When I woke up, it was half full. That had never happened before,” another says with the disbelief and wonder.

The high rates of alcohol-related fatalities is a preventable mass casualty event.