Silence on This: There Are Pills That Kill the Desire for Alcohol

When something or someone breaks into the mainstream in the U.S., you can be sure that Trey Parker and Matt Stone will run it through their legendary animated, satirical, yet reliable ‘South Park’. It is a cartoon that has been darkly humorously and satirically depicting social, political, and cultural issues for nearly three decades and usually hits the mark. When the story about the miraculous drug for type 2 diabetes, Ozempic, which magically sheds pounds from healthy people without the need for exercise, rolled out, a real frenzy ensued, and many celebrity women rushed for this drug, which is not cheap. In ‘South Park’, they wondered what about those who cannot afford it, so when one of the cartoon characters goes to the doctor to get a prescription for the drug and finds out it is too expensive for him and his family, the doctor recommends body positivity. Because for the rich, there is a drug, and for the poor, it is to accept their weight and their body just as it is.

When they tackled alcoholism a few years ago, the character Randy learns at an alcoholics’ meeting that alcoholism is a disease, so he starts playing that game. He accepts that he is sick and that he cannot do anything about it, so he drinks even more because he is simply powerless to fight this disease. Also, in the lines where people are waiting, Randy passes to the front yelling that he is sick, an alcoholic, so he has the right to some benefits, for example, to push through the line.

But although Randy does not actually have a problem, alcoholism in the world represents a really big problem. Almost 12 million people in the U.S. struggle with alcohol use disorder, defined as ‘more than four drinks approximately for women and more than six for men’, according to the Centers for Disease Control. Alcohol use disorder takes 500 lives daily in the U.S., whether related to car accidents, organ failure, or acute alcohol poisoning. On the home front, according to data from the Croatian Institute of Public Health from 2022, Croatia had about 250,000 alcoholics and was among the top five countries in the European Union for alcohol consumption, which is certainly not a good statistical indicator.

From Religion to Morality

Although abstinence is the best medicine, it is clear that it is not always that simple. Throughout history, the treatment of alcoholism has gone through many phases, from moral to religious approaches to medical programs and treatments. The first treatment centers opened as early as the 19th century, and the founding of ‘Alcoholics Anonymous’ occurred only in 1935 when Bill Wilson and Dr. Bob Smith started AA meetings and introduced the 12 steps of recovery.

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In the mid-20th century, doctors began developing medical approaches to treating alcoholism. The first such drug was approved in 1951 and was called Disulfiram. This drug causes unpleasant effects even when small amounts of alcohol are consumed. This means that its main effect is to create an unpleasant and potentially dangerous reaction in a person who consumes even a small amount of alcohol while taking Disulfiram. However, due to the danger of severe, even deadly reactions, therapy with it is now used less frequently than before.

Fortunately for many, there is another drug that blocks chemical activity in the brain’s reward center and helps addicts quit drinking. This is Naltrexone, which has been confirmed in hundreds of studies to be a safe and effective drug that helps people reduce or completely stop drinking alcohol, but doctors do not prescribe it to their patients. The drug, classified as an opioid antagonist, was first approved by the U.S. Food and Drug Administration for the treatment of alcohol use disorder in 1994, meaning 30 years ago.

Where It Got Stuck

Despite its effectiveness, Naltrexone is rarely prescribed. In the U.S., only one percent of people with alcohol use disorders received it from their doctor, according to a national survey from 2023. In a study published this spring, people with alcohol use disorders were the least likely to receive Naltrexone on prescription compared to individuals with other substance use disorders. The reasons are complex, but experts believe it boils down to two factors: a lack of knowledge about Naltrexone and the stigma of alcohol use disorders, which is often seen as a lack of willpower rather than a medical problem.

– Even in healthcare, people tend to think of alcohol use disorder as ‘making bad decisions’ – said Andrew Saxon, an addiction psychiatrist and professor at the University of Washington School of Medicine.

As a result, many doctors have not kept up with the latest research in addiction treatment, which has drastically changed in the last decade.

– Until recently, we believed that the only way to treat alcohol use disorders was complete abstinence – said Saxon, adding that this is no longer the case.

Focus on Sobriety

Eden Bernstein, a primary care associate at Harvard Medical School and Mass General Hospital, agrees with this assessment.

– Many medical professionals still believe that alcohol use disorder is a type of personal moral failing, not a disease suitable for treatment with pills – he emphasized.

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This focus on sobriety is part of the fundamental philosophy of Alcoholics Anonymous, which avoids medications and views recovery as an ‘all or nothing’ proposition, where one drink can undo years of sobriety. Among addiction researchers, any reduction in drinking is seen as a victory.

Along with Naltrexone, there are two other drugs for treating alcohol use disorders that have been approved by the FDA: Acamprosate and the aforementioned Disulfiram. Acamprosate works by stabilizing chemicals and pathways in the brain that may be damaged by chronic heavy drinking and has been shown to help maintain abstinence. However, patients must take several pills a day. Disulfiram, on the other hand, works by causing severe pain in people when they drink. But the pain can be avoided simply by skipping a dose when planning to drink. Naltrexone, in contrast, works by blocking neurotransmitters in the brain’s reward system, dulling the positive emotions that alcohol can create. It is chemically related to Narcan, an overdose antidote that has recently become available over the counter in the U.S. But instead of delivering a large dose directly to the brain via a nasal spray, Naltrexone is a slow-release pill that interrupts the addiction feedback loop. It is best for reducing cravings for alcohol and requires only occasional injections or a pill every day.

There is a misconception that patients must be abstinent from alcohol when taking Naltrexone, says Jonathan Leung, a practitioner at the Mayo Clinic who surveyed Mayo Clinic doctors about Naltrexone.

Never Heard of It

In a survey published in 2022 in the journal Frontiers in Psychiatry, of 150 doctors in three Mayo Clinic centers in Arizona, Minnesota, and Florida, most stated that they simply had not heard of Naltrexone or did not know enough about it to prescribe it.

– Compared to many common medications, Naltrexone is very effective, noting that, as with many medications, different patients respond differently. For some, this medication can change their lives, while for others, the effects may be minimal – states Eden Bernstein.

In studies, people who took Naltrexone drank significantly less each month in frequency and quantity compared to those who took a placebo. When prescribed at discharge from the hospital, Naltrexone resulted in 42 percent fewer deaths and readmissions after 30 days. There is also evidence that it works best when patients continue to drink as usual, at least at the beginning of taking the medication. In a meta-analysis published in 2022 in the scientific journal Addiction, on average, patients taking Naltrexone drank two days less per month compared to patients taking a placebo. When participants were not asked to abstain, reductions were even greater. Another reason that doctors often cited for not prescribing Naltrexone was that patients did not have ‘appropriate follow-up care’ or were not involved in therapy. This is also a misconception, researchers believe.

– Naltrexone is a fairly benign drug. It almost never has harmful side effects, so the risk for people is very low, and the benefits could potentially be very high – explains Professor Saxon.

Brain Reward Systems

Since the same reward system in the brain is involved to some extent in almost all types of addiction, Naltrexone has also shown promise in treating other addictions. It was originally developed and approved for treating opioid addiction. In combination with the antidepressant Bupropion, it has been approved as a weight loss drug under the name Contrave. Saxon sees parallels between alcohol use disorders and overeating. There is a huge amount of stigma against obesity and overweight, which, like alcohol use disorders, is seen as a lack of willpower rather than a legitimate health condition.

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As a result, when drugs like Ozempic, the first truly effective weight loss drugs, appeared on the market last year, a wave of opposition arose, at least partly fueled by the idea that losing weight by taking pills is a form of ‘cheating’, a way to avoid the hard work needed to atone for being overweight. But despite the stigma, as well as a range of harsh side effects, Ozempic and related weight loss drugs have become extremely popular. Bernstein suggests that their success could serve as a lesson for increasing access to Naltrexone. The buzz around Ozempic and other weight loss drugs has largely been driven by patients asking their doctors for prescriptions because they heard about it from news articles and pharmaceutical ads.

– Advertising has contributed to cultural awareness of these drugs as possible treatments for obesity, but we do not see such things when it comes to alcohol-related disorders – said Bernstein.

Unlike Ozempic, which may not be covered by insurance, making body positivity the option for the poor, Naltrexone is inexpensive and is usually covered by insurance. But without the same advertising push, increasing patient awareness could fall to the responsibility of doctors.