If you drink more alcohol than you want to or should, you're not alone. A nationwide survey by the National Institutes of Health found that 28 percent of adults in the U.S. are heavy drinkers or drink more than is recommended.
Yet, most heavy drinkers don't get the help they need.
"The biggest problem we have in the field is that less than 10 percent of individuals with an alcohol use disorder get any treatment whatsoever," says George Koob, director of the National Institute on Alcohol Abuse and Alcoholism.
Part of the challenge, researchers say, is that many drinkers don't realize that a medicine long used to help people addicted to opioids quit their drug habit can help alcoholics and other heavy drinkers cut back, too.
"I thought my only option was AA," John tells NPR. We've agreed to use only his middle name; disclosing his trouble with alcohol publicly, he says, would jeopardize his business.
He's a 47-year-old professional who says he started out as a social drinker — a few beers with his softball team after a game. But he sank into a deep depression after several deaths in his family, and sought "solace in the bottle," he says.
"I wanted to numb my thoughts," says John.
He'd often start with hard liquor in the morning, John says, and it wasn't uncommon to have eight drinks or more before the end of the day.
He worked from home, so he was able to mask the problem for a while. But eventually his wife confronted him.
"She had come home and I was rushing to hide a glass and she was furious with me," he recalls. "Just absolutely furious."
He went to see Paula DeSanto, a therapist and director of Minnesota Alternatives, in Spring Lake Park, Minn. The center provides outpatient mental health and substance use treatment services.
"I would say John's story is not unique," DeSanto tells us. "A lot of people are reluctant."
Sometimes, traditional treatments — such as residential rehab or a 12-step program like Alcoholics Anonymous — "can [lead to] a significant disruption in their lives," she explains. "There's stigma, shame and embarrassment."
DeSanto suggested a different approach to John. To help work through the loss and grief he was feeling, counseling can help, she told him. She also recommended he try naltrexone, a prescription drug.
"Naltrexone is an effective medication for the treatment of alcohol use disorders," says Koob. He points to a recent meta-analysis published in the journal Addiction that concluded that naltrexone helped reduce heavy drinking and cravings for alcohol.
The analysis included data from 64 clinical trials in which people were given either the medication or a placebo pill to test the effectiveness of the treatment. The analysis also found that another drug, acamprosate, is effective at helping people who have already stopped drinking to maintain abstinence, perhaps partly by easing the physical and emotional cravings experienced by heavy drinkers who quit.
So, how does naltrexone work? The drug seems to curb the euphoric and sedative effects of opiates in the brain. Alcohol is known to activate some of the same receptors in the brain that opioids do, and studies find that by tempering the pleasure from alcohol, naltrexone can help people drink less.
"It blunts the effects of alcohol," says Koob. "People [who use naltrexone] will say they have a drink, and it's not doing much for them."
That was exactly John's experience. After taking the naltrexone pill, he didn't get the buzz he was used to getting, so didn't want to keep drinking. "I actually didn't feel the alcohol's effects," he says. "It was startling."
It's now been about five months since he started taking the medication. He has not stopped drinking completely, but says he has cut way back.
"This is helping me," John says. "I can go out with friends and not worry that I'm going to end up inebriated or sloppy."
According to the findings of a recent review, both naltrexone and acamprosate, are safe, cost-effective and efficacious. But they are substantially underused, according to the review.
Many physicians are "unaware that there are medications to treat alcohol use disorders," says Koob. His institute is stepping up efforts to work with the medical community on that front, he says, and is also touting Rethinking Drinking, a website aimed at consumers that offers the latest research-based information on a range of treatment options.
Any health care provider who is licensed to prescribe medicine can prescribe naltrexone — not just mental health professionals or addiction specialists. As as long ago as 1997, a published study showed that treatment of alcohol dependence with naltrexone by primary care doctors can be effective; follow-up research has confirmed that the primary care approach not only works, but makes treatment much more accessible.
According to the NIAAA, "patients can now receive effective alcohol treatment from their primary care doctors or mental health practitioners by combining the newer medications with a series of brief office visits for support."
Naltrexone is certainly not a cure-all, researchers say. And it won't help everyone who has a drinking problem — especially if the disorder is severe.
"I use these medications as an adjunct to therapy, and group [sessions] and 12-step meetings" says Dr. Jeffrey Hsu, a psychiatrist at Johns Hopkins University who is certified in addiction medicine. He says that when used alone the medicines are only modestly effective.
But there's good evidence that the combination of counseling and drugs such as naltrexone can help people cut back on drinking, or move toward abstinence.
RACHEL MARTIN, HOST:
A strategy to help problem drinkers cut back, a strategy that involves a prescription drug that's been around for more than 20 years. Here's NPR's Allison Aubrey.
ALLISON AUBREY, BYLINE: Millions of people drink more than they should or want to. And for those who struggle, this may sound familiar.
JOHN: It's hard to admit that you have a problem. I would say, for me, that was the No. 1 thing that held me back initially.
AUBREY: That's John. He asked us not to use his full name. He worries disclosing his trouble with alcohol could affect his career. He says for years, he was a social drinker. He'd grab a few beers with his softball team after a game. But then after several deaths in his family, he sunk into a dark depression.
JOHN: So I definitely tried to seek solace in the bottle, so to speak. You know, I wanted to kind of numb my thoughts.
AUBREY: He'd started about 10 in the morning with hard liquor. He'd pour a glass of vodka and drink it straight up. This went on for months. He works from home, and he continued to do well professionally. So at first, no one noticed. Some afternoons, by the time his family came home, he'd had eight drinks or more.
JOHN: As any alcoholic or anyone that struggles with alcohol will tell you - we become very good at hiding things.
AUBREY: He would sneak empty bottles out on garbage day. But eventually, his wife was on to him.
JOHN: She had come home, and I was rushing to hide a glass that I had been using. And she was furious with me - just absolutely furious.
AUBREY: He knew he needed help, but the prospect of being sent off to rehab or going to AA turned him off.
PAULA DESANTO: I would say his story is not unique.
AUBREY: That's Paula DeSanto, a therapist in Minneapolis area who works with John.
DESANTO: I think a lot of people are reluctant to get treatment because it traditionally can mean a significant disruption in their lives. There's a lot of stigma, shame and embarrassment.
AUBREY: She says there are alternatives to residential rehab and 12-step abstinence programs, and the recommendation she gave John was to get counseling to help him deal with the loss and grief he was feeling and to try a prescription drug. The drug is called Naltrexone. It blocks the opiate receptors in the brain. It's used for treating drug addiction. And George Koob, who directs the National Institute on Alcohol Abuse and Alcoholism, part of the NIH, says it can help drinkers too.
GEORGE KOOB: With alcohol, it tends to blunt the effects of alcohol's pleasurable effects. So you know, the report that people say is they have a drink and it's OK, and then they have a second drink, and it's really not doing much for them.
AUBREY: So they don't keep refilling the glass. Koob says there are multiple studies to show it can help drinkers cut back or even abstain. He says Naltrexone is safe. It doesn't make you feel sick. And above all, as a recent clinical trial shows, it means people can receive effective treatment for alcohol use disorders from their primary care doctors by combining the medication with a series of brief office visits for support.
KOOB: Absolutely. I mean, Naltrexone is an effective medication for the treatment of alcohol use disorders. And its effectiveness is similar to that of antidepressants for major depressive episodes.
AUBREY: John says the first time he took Naltrexone, he noticed a difference. Normally, after one drink, it was hard for him to stop but not after taking this pill.
JOHN: I actually didn't really feel any of the alcohol effects, and it was startling at first.
AUBREY: It's been about five months since he started taking Naltrexone. And he says he has not stopped drinking completely, but he has cut way back.
JOHN: This is clearly helping me. And I can go out with friends and not worry that I'm going to escalate it or that I'm going to end up inebriated and sloppy and all of those things.
AUBREY: Now, Naltrexone won't help everyone, especially if a drinking disorder is too severe. But for John, the combination of Naltrexone and counseling has put him on the right path. And the important thing is he's actually getting help. Here's George Koob again.
KOOB: The biggest problem we have in the field is that less than 10 percent of individuals with an alcohol use disorder get any treatment whatsoever.
AUBREY: This is in part due to patients' resistance but also because many primary care doctors don't get much training in treating alcohol use disorders.
KOOB: Physicians are actually unaware that there are medications. So it's really a problem, and we are stepping up our efforts in the medical community.
AUBREY: And the NIH is also reaching out directly to the public. They have a website called Rethinking Drinking, which guides you through all the treatment options that are available.
Allison Aubrey, NPR News. Transcript provided by NPR, Copyright NPR.