In 2017, Katie Lain was passing out from drinking alcohol several times a week. During the week, she typically drank at least a bottle of wine, often more, and on the weekends she drank vodka. But even after suffering a pulmonary embolism in her 30s that her doctor linked to her excessive drinking, she struggled to stop.
Later that year, a doctor prescribed naltrexone, a drug that blocks chemical activity in the brain’s reward centers. She noticed an immediate change. “I poured a third glass of wine and it just sat there,” she said. “I couldn’t believe it. It was life-changing.” At the time of reporting, she hadn’t had a drink in four years.
Nearly 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 dependence is responsible for 500 deaths a day from car accidents, organ failure, related cancers and acute alcohol poisoning combined.
While not a miracle cure, naltrexone has been shown in hundreds of studies to be a safe and effective medication to help people drink less 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 disorder in 1994, 30 years ago.
Despite its effectiveness, however, naltrexone is rarely prescribed. In the U.S., about 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 disorders were least likely to be prescribed naltrexone compared to people with other substance use disorders.
The reason is complex. But experts I spoke with told me they believe it comes down to two factors: lack of education about naltrexone and the stigma surrounding alcohol use disorder, which is often seen as a lack of willpower rather than a medical problem.
“Even in health care, people often think that alcohol addiction is ‘making bad choices,’” Andrew Saxon, an addiction psychiatrist and professor at the 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 haven’t kept up with the latest research on addiction treatments, which has changed dramatically over the past decade. “Until recently, we thought the only treatment for alcohol addiction was total abstinence,” Saxon says. That’s 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 are still convinced that alcohol addiction is something that is a kind of personal moral failing, and not something that is amenable to treatment with a pill,” he said.
That focus on sobriety is part of the core philosophy of Alcoholics Anonymous, which rejects medication and views recovery as an all-or-nothing proposition in which one drink can wipe out years of sobriety. Among addiction researchers, however, any reduction in drinking is increasingly seen as a victory.
In addition to naltrexone, there are two other FDA-approved medications for treating alcohol abuse: acamprosate and disulfiram. Both work by making people very sick when they drink. But the illness can be prevented by simply skipping a dose when you plan to drink.
Naltrexone, on the other hand, works by blocking neurotransmitters in the brain’s reward system, dulling the positive emotions that alcohol can create. Chemically, it’s related to Narcan, the overdose antidote that recently became available over the counter. But instead of delivering a massive dose straight to the brain via a nasal spray, naltrexone is a slower-acting pill that interrupts the feedback loop of addiction.
“When I’m treating alcohol addiction, naltrexone is almost always my first-line drug,” Saxon said.
Despite this, it can still be incredibly difficult to find a prescription. Lain contacted five doctors before she found one who would prescribe naltrexone, which she had heard about on YouTube. The reasons they gave her reflected common misconceptions about the drug. One told her he couldn’t prescribe it until she had been sober for five straight days. Another advised her to enter an inpatient rehabilitation program instead.
“There’s a misconception that patients should avoid taking naltrexone,” Jonathan Leung, a physician at the Mayo Clinic who surveyed Mayo Clinic doctors about naltrexone, told me. In a 2022 study published in Frontiers in Psychiatry, most of the 150 doctors at three Mayo Clinic centers in Arizona, Minnesota, and Florida reported that they had either never heard of naltrexone or didn’t know enough about it to prescribe it. Doctors who didn’t prescribe the drug were more likely to give inaccurate information about how the drug works and how effective and safe it is.
“Compared to many common medications, naltrexone is very effective,” Bernstein said, noting that, as with many medications, “different patients respond differently.” For some, “the response can be life-changing,” while for others the effects may be minimal.
In studies, people with alcohol dependence who took naltrexone drank significantly less per month, both in frequency and amount, compared to people who took a placebo. When prescribed at hospital discharge, naltrexone resulted in 42 percent fewer deaths and hospitalizations after 30 days.
There’s also evidence that naltrexone works best when patients continue drinking normally, at least once they start taking the medication. In a 2022 meta-analysis published in the scientific journal Addiction, patients taking naltrexone drank an average of two days less per month than patients taking a placebo. When participants weren’t required to be abstinent, the reductions were even greater.
Another reason doctors often cite for not prescribing naltrexone is that patients didn’t have “appropriate follow-up care” or weren’t on therapy. That’s also a misconception, according to researchers. “Naltrexone is a pretty harmless drug,” Saxon said. “There are almost no side effects, so the risk to people is very low and the potential benefits are very high.”
Because the same reward system in the brain is involved to some extent in almost all types of addiction, naltrexone has shown promise in treating other problems as well. It was originally developed and approved for the treatment of opioid addiction. Combined with the antidepressant bupropion, it has been approved as a weight loss medication under the name Contrave.
Saxon sees other parallels between alcohol use disorder and overeating. There is a tremendous amount of stigma against obesity and being overweight, which, like alcohol use disorder, is seen as a lack of willpower rather than a legitimate medical condition.
When Ozempic and other GLP-1 agonists first hit the market last year as the first truly effective weight-loss drugs, there was a wave of backlash driven at least in part by the idea that losing weight by popping a pill is a form of “cheating,” a way to avoid the hard work required to make up for getting fat in the first place.
But despite the stigma, and a host of serious side effects, Ozempic and related weight-loss drugs have become wildly popular. Bernstein suggests that their success may hold lessons for expanding access to naltrexone.
Demand for Ozempic and other weight loss drugs is largely fueled by patients asking their doctors for a prescription after hearing about them through news articles and pharmaceutical advertisements. “Advertising has contributed to the cultural awareness of these drugs as treatment options for obesity, and we don’t see that with drugs for alcohol abuse,” Bernstein said.
Unlike Ozempic, which may not be covered by insurance, naltrexone is inexpensive and typically covered by insurance. But without the same advertising push, raising patient awareness may come at the expense of doctors.
A study published in February in the journal Academic Emergency Medicine found that prescribing of naltrexone increased sixfold when a simple prompt was included in routine checkups. Bernstein also believes that even people who are “soberly curious” can be interested in the drug. “We know that more people want to cut back, even though they may not be ready to stop completely.”
“I might drink again someday if the urge comes. I love that alcohol is not a forbidden fruit,” Lain said. “I feel like naltrexone has taken the addiction away. For me, it’s freedom.”