by Amy Stewart
As I researched this article, I wondered what it would be like to try naltrexone, which the U.S. Food and Drug Administration approved for alcohol-abuse treatment in 1994. I asked my doctor whether he would write me a prescription. Not surprisingly, he shook his head no. I don’t have a drinking problem, and he said he couldn’t offer medication for an “experiment.” So that left the Internet, which was easy enough. I ordered some naltrexone online and received a foil-wrapped package of 10 pills about a week later. The cost was $39.
The first night, I took a pill at 6:30. An hour later, I sipped a glass of wine and felt almost nothing—no calming effect, none of the warm contentment that usually signals the end of my workday and the beginning of a relaxing evening. I finished the glass and poured a second. By the end of dinner, I looked up to see that I had barely touched it. I had never found wine so uninteresting. Was this a placebo effect? Possibly. But so it went. On the third night, at a restaurant where my husband and I split a bottle of wine, the waitress came to refill his glass twice; mine, not once. That had never happened before, except when I was pregnant. At the end of 10 days, I found I no longer looked forward to a glass of wine with dinner. (Interestingly, I also found myself feeling full much quicker than normal, and I lost two pounds. In Europe, an opioid antagonist is being tested on binge eaters.)
I was an n of one, of course. My experiment was driven by personal curiosity, not scientific inquiry. But it certainly felt as if I were unlearning something—the pleasure of that first glass? The desire for it? Both? I can’t really say.
Patients on naltrexone have to be motivated to keep taking the pill. But Sari Castrén, a psychologist at the Contral Clinic I visited in Helsinki, told me that when patients come in for treatment, they’re desperate to change the role alcohol has assumed in their lives. They’ve tried not drinking, and controlling their drinking, without success—their cravings are too strong. But with naltrexone or nalmefene, they’re able to drink less, and the benefits soon become apparent: They sleep better. They have more energy and less guilt. They feel proud. They’re able to read or watch movies or play with their children during the time they would have been drinking.
In therapy sessions, Castrén asks patients to weigh the pleasure of drinking against their enjoyment of these new activities, helping them to see the value of change. Still, the combination of naltrexone and therapy doesn’t work for everyone. Some clients opt to take Antabuse, a medication that triggers nausea, dizziness, and other uncomfortable reactions when combined with drinking. And some patients are unable to learn how to drink without losing control. In those cases (about 10 percent of patients), Castrén recommends total abstinence from alcohol, but she leaves that choice to patients. “Sobriety is their decision, based on their own discovery,” she told me.
Claudia Christian, an actress who lives in Los Angeles (she’s best known for appearing in the 1990s science-fiction TV show Babylon 5), discovered naltrexone when she came across a flier for Vivitrol, an injectable form of the drug, at a detox center in California in 2009. She had tried Alcoholics Anonymous and traditional rehab without success. She researched the medication online, got a doctor to prescribe it, and began taking a dose about an hour before she planned to drink, as Sinclair recommends. She says the effect was like flipping a switch. For the first time in many years, she was able to have a single drink and then stop. She plans to keep taking naltrexone indefinitely, and has become an advocate for Sinclair’s method: she set up a nonprofit organization for people seeking information about it and made a documentary called One Little Pill.
In the United States, doctors generally prescribe naltrexone for daily use and tell patients to avoid alcohol, instead of instructing them to take the drug anytime they plan to drink, as Sinclair would advise. There is disagreement among experts about which approach is better—Sinclair is adamant that American doctors are missing the drug’s full potential—but both seem to work: naltrexone has been found to reduce drinking in more than a dozen clinical trials, including a large-scale one funded by the National Institute on Alcohol Abuse and Alcoholism that was published in JAMA in 2006. The results have been largely overlooked. Less than 1 percent of people treated for alcohol problems in the United States are prescribed naltrexone or any other drug shown to help control drinking.
To understand why, you have to first understand the history.
The American approach to treatment for drinking problems has roots in the country’s long-standing love-hate relationship with booze. The first settlers arrived with a great thirst for whiskey and hard cider, and in the early days of the Republic, alcohol was one of the few beverages that was reliably safe from contamination. (It was also cheaper than coffee or tea.) The historian W. J. Rorabaugh has estimated that between the 1770s and 1830s the average American over age 15 consumed at least five gallons of pure alcohol a year—the rough equivalent of three shots of hard liquor a day.
Religious fervor, aided by the introduction of public water-filtration systems, helped galvanize the temperance movement, which culminated in 1920 with Prohibition. That experiment ended after 14 years, but the drinking culture it fostered—secrecy and frenzied bingeing—persists.
In 1934, just after Prohibition’s repeal, a failed stockbroker named Bill Wilson staggered into a Manhattan hospital. Wilson was known to drink two quarts of whiskey a day, a habit he’d attempted to kick many times. He was given the hallucinogen belladonna, an experimental treatment for addictions, and from his hospital bed he called out to God to loosen alcohol’s grip. He reported seeing a flash of light and feeling a serenity he had never before experienced. He quit booze for good. The next year, he cofounded Alcoholics Anonymous. He based its principles on the beliefs of the evangelical Oxford Group, which taught that people were sinners who, through confession and God’s help, could right their paths.
AA filled a vacuum in the medical world, which at the time had few answers for heavy drinkers. In 1956 the American Medical Association named alcoholism a disease, but doctors continued to offer little beyond the standard treatment that had been around for decades: detoxification in state psychiatric wards or private sanatoriums. As Alcoholics Anonymous grew, hospitals began creating “alcoholism wards,” where patients detoxed but were given no other medical treatment. Instead, AA members—who, as part of the 12 steps, pledge to help other alcoholics—appeared at bedsides and invited the newly sober to meetings.
A public relations specialist and early AA member named Marty Mann worked to disseminate the group’s main tenet: that alcoholics had an illness that rendered them powerless over booze. Their drinking was a disease, in other words, not a moral failing. Paradoxically, the prescription for this medical condition was a set of spiritual steps that required accepting a higher power, taking a “fearless moral inventory,” admitting “the exact nature of our wrongs,” and asking God to remove all character defects.
Mann helped ensure that these ideas made their way to Hollywood. In 1945’s The Lost Weekend, a struggling novelist tries to loosen his writer’s block with booze, to devastating effect. In Days of Wine and Roses, released in 1962, Jack Lemmon slides into alcoholism along with his wife, played by Lee Remick. He finds help through AA, but she rejects the group and loses her family.
Mann also collaborated with a physiologist named E. M. Jellinek. Mann was eager to bolster the scientific claims behind AA, and Jellinek wanted to make a name for himself in the growing field of alcohol research. In 1946 Jellinek published the results of a survey mailed to 1,600 AA members. Only 158 were returned. Jellinek and Mann jettisoned 45 that had been improperly completed and another 15 filled out by women, whose responses were so unlike the men’s that they risked complicating the results. From this small sample—98 men—Jellinek drew sweeping conclusions about the “phases of alcoholism,” which included an unavoidable succession of binges that led to blackouts, “indefinable fears,” and hitting bottom. Though the paper was filled with caveats about its lack of scientific rigor, it becam
e AA gospel.
Jellinek, however, later tried to distance himself from this work, and from Alcoholics Anonymous. His ideas came to be illustrated by a chart showing how alcoholics progressed from occasionally drinking for relief, to sneaking drinks, to guilt, and so on until they hit bottom (“complete defeat admitted”) and then recovered. If you could locate yourself even early in the downward trajectory on that curve, you could see where your drinking was headed. In 1952 Jellinek noted that the word “alcoholic” had been adopted to describe anyone who drank excessively. He warned that overuse of that word would undermine the disease concept. He later beseeched AA to stay out of the way of scientists trying to do objective research.
But AA supporters worked to make sure their approach remained central. Marty Mann joined prominent Americans including Susan Anthony, the grandniece of Susan B. Anthony; Jan Clayton, the mom from Lassie; and decorated military officers in testifying before Congress. John D. Rockefeller Jr., a lifelong teetotaler, was an early booster of the group.
In 1970 Senator Harold Hughes of Iowa, a member of AA, persuaded Congress to pass the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act. It called for the establishment of the National Institute on Alcohol Abuse and Alcoholism, and dedicated funding for the study and treatment of alcoholism. The NIAAA, in turn, funded Marty Mann’s nonprofit advocacy group, the National Council on Alcoholism, to educate the public. The nonprofit became a mouthpiece for AA’s beliefs, especially the importance of abstinence, and has at times worked to quash research that challenges those beliefs.
In 1976, for instance, the RAND Corporation released a study of more than 2,000 men who had been patients at 44 different NIAAA-funded treatment centers. The report noted that 18 months after treatment, 22 percent of the men were drinking moderately. The authors concluded that it was possible for some alcohol-dependent men to return to controlled drinking. Researchers at the National Council on Alcoholism charged that the news would lead alcoholics to falsely believe they could drink safely. The NIAAA, which had funded the research, repudiated it. RAND repeated the study, this time looking over a four-year period. The results were similar.
After the Hughes Act was passed, insurers began to recognize alcoholism as a disease and pay for treatment. For-profit rehab facilities sprouted across the country, the beginnings of what would become a multibillion-dollar industry. (Hughes became a treatment entrepreneur himself, after retiring from the Senate.) If Betty Ford and Elizabeth Taylor could declare that they were alcoholics and seek help, so too could ordinary people who struggled with drinking. Today there are more than 13,000 rehab facilities in the United States, and 70 to 80 percent of them hew to the 12 steps, according to Anne M. Fletcher, the author of Inside Rehab, a 2013 book investigating the treatment industry.
The problem is that nothing about the 12-step approach draws on modern science: not the character building, not the tough love, not even the standard 28-day rehab stay.
Marvin D. Seppala, the chief medical officer at the Hazelden Betty Ford Foundation in Minnesota, one of the oldest inpatient rehab facilities in the country, described for me how 28 days became the norm: “In 1949 the founders found that it took about a week to get detoxed, another week to come around so [the patients] knew what they were up to, and after a couple of weeks they were doing well, and stable. That’s how it turned out to be 28 days. There’s no magic in it.”
Tom McLellan, a psychology professor at the University of Pennsylvania School of Medicine who has served as a deputy U.S. drug czar and is an adviser to the World Health Organization, says that while AA and other programs that focus on behavioral change have value, they don’t address what we now know about the biology of drinking.
Alcohol acts on many parts of the brain, making it in some ways more complex than drugs like cocaine and heroin, which target just one area of the brain. Among other effects, alcohol increases the amount of GABA (gamma-aminobutyric acid), a chemical that slows down activity in the nervous system, and decreases the flow of glutamate, which activates the nervous system. (This is why drinking can make you relax, shed inhibitions, and forget your worries.) Alcohol also prompts the brain to release dopamine, a chemical associated with pleasure.
Over time, though, the brain of a heavy drinker adjusts to the steady flow of alcohol by producing less GABA and more glutamate, resulting in anxiety and irritability. Dopamine production also slows, and the person gets less pleasure out of everyday things. Combined, these changes gradually bring about a crucial shift: instead of drinking to feel good, the person ends up drinking to avoid feeling bad. Alcohol also damages the prefrontal cortex, which is responsible for judging risks and regulating behavior—one reason some people keep drinking even as they realize that the habit is destroying their lives. The good news is that the damage can be undone if they’re able to get their consumption under control.
Studies of twins and adopted children suggest that about half of a person’s vulnerability to alcohol-use disorder is hereditary, and that anxiety, depression, and environment—all considered “outside issues” by many in Alcoholics Anonymous and the rehab industry—also play a role. Still, science can’t yet fully explain why some heavy drinkers become physiologically dependent on alcohol and others don’t, or why some recover while others founder. We don’t know how much drinking it takes to cause major changes in the brain, or whether the brains of alcohol-dependent people are in some ways different from “normal” brains to begin with. What we do know, McLellan says, is that “the brains of the alcohol-addicted aren’t like those of the non-alcohol-dependent.”
Bill Wilson, AA’s founding father, was right when he insisted, 80 years ago, that alcohol dependence is an illness, not a moral failing. Why, then, do we so rarely treat it medically? It’s a question I’ve heard many times from researchers and clinicians. “Alcohol- and substance-use disorders are the realm of medicine,” McLellan says. “This is not the realm of priests.”
When the Hazelden treatment center opened in 1949, it espoused five goals for its patients: behave responsibly, attend lectures on the 12 steps, make your bed, stay sober, and talk with other patients. Even today, Hazelden’s website states:
People addicted to alcohol can be secretive, self-centered, and filled with resentment. In response, Hazelden’s founders insisted that patients attend to the details of daily life, tell their stories, and listen to each other . . . This led to a heartening discovery, one that’s become a cornerstone of the Minnesota Model: Alcoholics and addicts can help each other.
That may be heartening, but it’s not science. As the rehab industry began expanding in the 1970s, its profit motives dovetailed nicely with AA’s view that counseling could be delivered by people who had themselves struggled with addiction, rather than by highly trained (and highly paid) doctors and mental health professionals. No other area of medicine or counseling makes such allowances.
There is no mandatory national certification exam for addiction counselors. The 2012 Columbia University report on addiction medicine found that only six states required alcohol- and substance-abuse counselors to have at least a bachelor’s degree and that only one state, Vermont, required a master’s degree. Fourteen states had no license requirements whatsoever—not even a GED or an introductory training course was necessary—and yet counselors are often called on by the judicial system and medical boards to give expert opinions on their clients’ prospects for recovery.
Mark Willenbring, the St. Paul psychiatrist, winced when I mentioned this. “What’s wrong,” he asked me rhetorically, “with people with no qualifications or talents—other than being recovering alcoholics—being licensed as professionals with decision-making authority over whether you are imprisoned or lose your medical license?
“The history—and current state—is really, really dismal,” Willenbring said.
Perhaps even worse is the pace of research on drugs to treat alcohol-use disorder. The FDA has approved just three: Antabuse,
the drug that induces nausea and dizziness when taken with alcohol; acamprosate, which has been shown to be helpful in quelling cravings; and naltrexone. (There is also Vivitrol, the injectable form of naltrexone.)
Reid K. Hester, a psychologist and the director of research at Behavior Therapy Associates, an organization of psychologists in Albuquerque, says there has long been resistance in the United States to the idea that alcohol-use disorder can be treated with drugs. For a brief period, DuPont, which held the patent for naltrexone when the FDA approved it for alcohol-abuse treatment in 1994, paid Hester to speak about the drug at medical conferences. “The reaction was always ‘How can you be giving alcoholics drugs?’” he recalls.
Hester says this attitude dates to the 1950s and ’60s, when psychiatrists regularly prescribed heavy drinkers Valium and other sedatives with great potential for abuse. Many patients wound up dependent on both booze and benzodiazepines. “They’d look at me like I was promoting Valley of the Dolls 2.0,” Hester says.
There has been some progress: the Hazelden center began prescribing naltrexone and acamprosate to patients in 2003. But this makes Hazelden a pioneer among rehab centers. “Everyone has a bias,” Marvin Seppala, the chief medical officer, told me. “I honestly thought AA was the only way anyone could ever get sober, but I learned that I was wrong.”
Stephanie O’Malley, a clinical researcher in psychiatry at Yale who has studied the use of naltrexone and other drugs for alcohol-use disorder for more than two decades, says naltrexone’s limited use is “baffling.”
