In 2017, Katie Lain was blacking out several times each week from drinking alcohol. On weeknights, she would typically down at least one bottle of wine, often more, and on weekends she binged vodka. But even after suffering a pulmonary embolism in her 30s, which her doctor tied to her excessive drinking, she struggled to quit.
Later that year, a doctor prescribed naltrexone, a drug that blocks chemical activity in the brain’s reward centers. She noticed a shift immediately. “I would pour a third glass of wine and it would sort of just sit there,” she said. “I couldn’t believe it. It was life-changing.” She hasn’t had a drink in four years at the time of reporting.
Almost 12 million people in the U.S. struggle with alcohol use disorder, defined as more than four drinks per occasion for women and more than six for men, according to the Centers for Disease Control. Alcohol use disorder is the cause of 500 deaths every day from car crashes, organ failure, related cancers, and acute alcohol poisoning combined.
Although it’s not a panacea, in hundreds of studies naltrexone has been found to be a safe and effective medication for helping people reduce and stop drinking. The drug, which is classified as an opioid antagonist, was first approved by the Food and Drug Administration to treat alcohol use disorders in 1994—30 years ago.
Despite its effectiveness, though, naltrexone is hardly ever prescribed. In the U.S., approximately 1 percent of people with alcohol use disorders were prescribed naltrexone in a 2023 national survey. In a study published this spring, people with alcohol use disorder were the least likely to receive prescription naltrexone compared to people with other substance use disorders.
The reason is complex. But experts I spoke to told me they believe that it boils down to two factors: lack of knowledge about naltrexone and stigma around alcohol use disorders, which are often seen as a lack of willpower rather than a medical problem.
“Even in health care, people tend to think of alcohol addiction as ‘making bad choices,’ ” Andrew Saxon, an addiction psychiatrist and professor at University of Washington School of Medicine, told me. “They don’t see it as their job to treat substance use disorders.”
As a result, many doctors have not kept up with the latest research in addiction treatment, which has changed drastically in the past decade. “Until very recently, we believed that the only treatment for alcohol use disorder was total abstinence,” Saxon said. That is no longer the case.
Eden Bernstein, a fellow in primary care at Harvard Medical School and Mass General Hospital, told me he agrees with that assessment. “Many medical professionals still have this belief that addiction to alcohol is something that is a kind of personal moral failing, and not things that are conducive to treatment with a pill,” he said.
That focus on sobriety is part of the core philosophy of Alcoholics Anonymous, which eschews medication and views recovery as an “all or nothing” proposition, where one drink can cancel out years of sobriety. Among addiction researchers, however, any reduction in drinking is increasingly seen as a win.
In addition to naltrexone, there are two other FDA-approved medications for treating alcohol use disorder: acamprosate and disulfiram. Acamprosate works by stabilizing chemicals and pathways in your brain that can be damaged by chronic heavy drinking and has been shown to help maintain abstinence.* However, it requires patients to take several pills a day. Disulfiram, on the other hand, works by making people violently ill when they drink. But the sickness can be avoided simply by skipping a dose when one plans on drinking.
Naltrexone, by contrast, works by blocking neurotransmitters in the brain’s reward system, thus blunting the positive emotions alcohol can create. Chemically, it is related to Narcan, the overdose antidote that recently became available over the counter. But instead of delivering a massive dose directly to the brain via a nasal spray, naltrexone is a slower-acting pill that interrupts the feedback loop of addiction. It’s best for reducing cravings and heavy drinking overall, and only requires occasional injections or a pill each day.
“When I’m treating alcohol use disorder, naltrexone is almost always my first-choice medication,” Saxon said.
Despite this, finding a prescription for it can still be incredibly difficult. Lain approached five doctors before she found one willing to prescribe naltrexone, which she heard about from YouTube. The reasons they gave her reflected common misconceptions about the drug. One told her he couldn’t prescribe it until she had five days of sobriety in a row under her belt. Another recommended she attend an inpatient rehab program instead.
“There is a misconception that patients must be abstinent when taking naltrexone,” Jonathan Leung, a practitioner at the Mayo Clinic who surveyed doctors at the Mayo Clinic about naltrexone, told me. In a survey published in 2022 in Frontiers in Psychiatry, out of 150 doctors across three Mayo Clinic centers in Arizona, Minnesota, and Florida, most reported that they simply hadn’t heard of naltrexone or didn’t know enough about it to prescribe it. Doctors who didn’t prescribe the drug were more likely to report wrong information about how the drug works and about how effective and safe it is.
“In comparison to a lot of common medications, naltrexone is very efficacious,” Bernstein said—with the caveat that, as with many medications, “different patients respond differently.” For some, “the response may be life-changing,” while for others the effects may be minimal.
In studies, people with alcohol use disorders who took naltrexone drank significantly less each month in both frequency and amount compared to people taking a placebo. When prescribed at hospital discharge, naltrexone resulted in 42 percent fewer deaths and hospital readmissions after 30 days.
There is also evidence that naltrexone works best when patients continue drinking as normal, at least when beginning the medication. In a 2022 meta-analysis published in the scientific journal Addiction, on average, patients who took naltrexone drank two fewer days per month compared to patients who took a placebo. When participants were not required to be abstinent, the reductions were even larger.
Another reason doctors commonly cited for not prescribing naltrexone was that patients did not have “appropriate follow-up care” or were not enrolled in therapy. That is also a misconception, according to researchers. “Naltrexone is a pretty benign medication,” Saxon said. “There’s almost never adverse events, so the risk to people is very low and the benefits could potentially be very high.”
Because the brain’s same reward system is involved to some extent in almost all types of addiction, naltrexone has shown promise in treating other issues as well. It was originally developed and approved for treating opioid addiction. Combined with the antidepressant bupropion, it is approved as a weight loss management medication under the name Contrave.
Saxon sees other parallels between alcohol use disorder and overeating. There is a huge amount of stigma against obesity and being overweight, which, like alcohol use disorder, is seen as a failure of willpower rather than a legitimate medical condition.
As a result, when Ozempic and other GLP-1 agonists first came on the market last year as the first really effective weight loss medications, there was a wave of backlash driven at least in part by the idea that losing weight by taking a pill is a form of “cheating,” a way of avoiding the hard work required to atone for being fat it in the first place.
But despite the stigma, as well as a slew of harsh side effects, Ozempic and related weight loss medications have become hugely popular. Bernstein suggests that their success may hold lessons for increasing access to naltrexone.
The clamor for Ozempic and other weight loss medications has been driven largely by patients asking their doctors for prescriptions, having heard about it from news articles and pharmaceutical advertisements. “Advertising has contributed to the cultural awareness of these medications as treatment options for obesity, and we’re just not seeing the same thing for alcohol use disorder medications,” said Bernstein.
In contrast to Ozempic, which may not be covered by insurance, naltrexone is cheap and typically covered by insurance. But without the same advertising push, increasing patient awareness may fall to physicians.
A study published in February in the journal Academic Emergency Medicine found that naltrexone prescribing went up sixfold when a simple prompt was made part of routine checkups. Bernstein also believes that even people who are “sober curious” could be interested in the medication. “We know more people want to cut back even though they may not be ready to stop entirely.”
“Maybe I’ll drink again one day if the urge arises. I love that alcohol is not a forbidden fruit,” Lain said. “I feel like naltrexone erased the addiction. For me, it’s freedom.”
Correction, July 8, 2024: This piece originally misstated that acamprosate causes patients to feel violently ill when drinking alcohol. It works by stabilizing chemicals and pathways in your brain that can be damaged by chronic heavy drinking.
