Last month a client reached out to us 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?
None of the above. No, the doctor said that the 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. So 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 “high” that alcohol and opiates 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 1994. 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 (Litten, 2016).
Why has the rollout of Naltrexone been so limited? Abraham et al (2011) 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 treatment (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.
So what’s to be done? Abraham et al (2011) have suggested integrating MAT 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.
The Alternatives Approach
We at Alternatives are one of the few forward-thinking treatment programs that embrace Naltrexone. We offer support services for the “Sinclair Method,” a controlled drinking program that incorporates Naltrexone, to individuals with prescriptions for it. With the Sinclair Method, one takes a dose of Naltrexone only one hour before consumption of alcohol and never otherwise. Double-blind clinical trials conducted by creator Dr. David 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. For those who want to try the Sinclair Method but have not yet received a prescription for Naltrexone, we provide referrals to physicians who can prescribe it.
Finally, it is important to note that Naltrexone is part of medication-assisted treatment, meaning it is a supplement to a comprehensive program that must include a behavioral component. It is not a magic bullet. If you are interested in trying it for alcohol addiction, talk to a doctor first about your health and treatment goals to see if you are a good candidate for it.
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.
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.
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. https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf
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