The answer is yes…in theory, at least

Americans are funny about alcohol. We have a special relationship with it. Drugs are bad; alcohol is fun! Unless you’re an alcoholic. Then…well, that’s uncomfortable.

Sometimes we talk about drinking too much. We complain that it’s making us fat and that the hangovers are no fun. We say we’re sorry for our belligerence last night–we overdid it. Maybe we should cut back, we wonder aloud. There’s probably an app for that, someone offers.

But what if cutting back turns out to be really hard? What if we need help?

That changes the conversation. Because if we need to “get help” with alcohol, that means we “have a problem.” And in that case, getting help usually means getting sober…right?

In fact, decades of research supports the fact that people can get help without getting sober. A medication called naltrexone dampens the rewarding effects of alcohol and can help people cut back their use. Specifically, it’s been used to help people reduce “heavy drinking days” (often defined as 5+ drinks in a sitting), a pattern of alcohol use that is known to cause accidents, stroke, hypertension, and a number of other health problems.

Conveniently, it can be prescribed by any primary care doctor. If your alcohol use is unhealthy, you can ask your doctor to try naltrexone and see if it helps reduce your drinking. Voila: getting help without getting sober.

The trouble is, most people don’t know about naltrexone and most doctors don’t prescribe it. For a drug with dozens of studies that support its effectiveness–in a country where 1 in 10 deaths among working age adults is caused by alcohol use–that’s weird, right?

What is Naltrexone?

Naltrexone is a long-acting opioid antagonist. That means it fully occupies the opiate receptors in the brain, preventing them from responding to alcohol or opioid use. Known by brand names like Revia, it comes in the form of a pill or an injection. Many take the pill form of naltrexone daily, although it has also been used off-label on an as-needed basis (as part of the Sinclair Method, for example). Injectable naltrexone, sold under the brand name Vivitrol, is usually administered once a month. It is more frequently used to treat addiction to opioids than it is for alcohol use disorders.

Alcohol stimulates a number of receptors in the brain, including the opiate receptors. For a person who takes naltrexone, alcohol’s typical effect on the opiate receptor is eliminated. In the absence of (some) of the rewarding effects of alcohol, some people are able to reduce their use. Because when getting drunk doesn’t feel that good, there’s less motivation to do it.

Isn’t Naltrexone Just a Way for Alcoholics to Avoid Doing What They Have To Do?

Ned Presnall wrote a very nice piece about this question over the summer. People with severe alcohol use disorders struggle to moderate their alcohol use, he said. As the Big Book of Alcoholics Anonymous says, “The idea that somehow, someday he will control and enjoy his drinking is the great obsession of every abnormal drinker. The persistence of this illusion is astonishing. Many pursue it into the gates of insanity or death.”

But Presnall points out that the Big Book has more to say about moderation. It suggests to the reader that she “Step over to the nearest barroom and try some controlled drinking. Try to drink and stop abruptly. Try it more than once.”

You’ll never know if you can drink moderately until you try, said Presnall.  Repeated unsucessful attempts at moderation may make clear that abstinence is a simpler path forward. Successful moderation can reduce health risks and other consequences of at-risk drinking. It’s win-win.

Fortunately, naltrexone can support this effort. We should use all available tools to help individuals who want to cut back, including an effective medication like naltrexone.

‘All or Nothing’ Isn’t Person-Centered

Brooke Feldman laid down some truth in the Huffington Post this week.

“With the overwhelming majority of addiction treatment programs and recovery residences in this country demanding complete abstinence as a requirement for receiving services, we are in essence operating systems that exclude an overwhelmingly large number of individuals in need of help,” she said.

Of all the staggering statistics related to addiction in this country, the one I think about every day has to do with “perceived need” for treatment. We all know that only 1 in 10 people who meet the criteria for a substance use disorder actually receive treatment. But why don’t the other 90% receive treatment? Is it because their insurance doesn’t cover it or they have to wait forever for a bed? No. It’s because they don’t want it. Of the 90% who would appear to need some sort of help but don’t get it, over 95% did not feel a need for treatment.

Naltrexone through a primary care physician may appeal to this group in a way that abstinence-based addiction treatment does not. But almost no one is offered naltrexone as a treatment option.

According to the federal Agency for Healthcare Research and Quality, “Current guidelines by the Veterans Administration, the National Institute on Alcohol Abuse and Alcoholism and SAMHSA all recommend that pharmacotherapy be offered as an adjunct to psychosocial therapies. However, estimates indicate that less than one in three patients with alcohol use disorder receives treatment, and fewer than one in 10 receives pharmacotherapy [medication] as part of their treatment. ”

Everybody Needs Help

I was explaining the problem of “perceived treatment need” to a friend of mine who works in marketing and he responded, “Nobody wants to be told what to do. But everybody needs help.”

I stared at him. “Yes, exactly. You sure put that in a nutshell.”

“It’s what I do,” he said.

Addiction treatment in America puts a strong emphasis on ceding control and being told what to do. For many, this leads to recovery. But for many more, it’s so unappealing that it discourages any help-seeking whatsoever.

Which is a shame because we could all use a little help. Alcohol can be a difficult issue. It’s ubiquitous at social occasions, it’s deep in our culture, and for many of us, it’s deep in our families. It also presents health risks and it can cause harm to relationships. Creating a healthy space for alcohol in our lives is not an easy task.

But the moment someone “needs help” with alcohol, we presume it’s an incurable addiction and that only a hard diet of 12-step meetings will do. In a country where alcohol is the fourth leading cause of preventable death, there must be room for an evidence-based medication that can help reduce heavy drinking days.

Note: IRETA is committed to non-discriminatory language about addiction. The word “alcoholic” is used here to refer to the way the public often perceives a person with an alcohol use disorder. 

Resources

Learn about Screening, Brief Intervention and Referral to Treatment (SBIRT)

Watch this outstanding video by Doctor Mike Evans

Read “Medication for the Treatment of Alcohol Use Disorder: A Pocket Guide”