Why Isn’t the Sinclair Method Used More Often?

We are often asked why Naltrexone is not prescribed more often for Alcohol Use Disorders, given that it is:

  • FDA-Approved for Alcohol Dependence (since 1994)
  • Generally well-tolerated (upset stomach is the most common side effect)
  • Inexpensive (about $1.25/pill out of pocket).

One possibility is that Naltrexone is at odds with the clinical philosophy of many providers. This 2015 article published in Substance Abuse Treatment, Prevention, and Policy examines the use of naltexone in the context of a counselor’s views of a patient’s responsibility for his or her addiction. “Responsibility” was divided into two categories:

  1. Responsibility for the onset of the addiction (i.e. the patient could have avoided the dependence).
  2. Responsibility for the treatment of the addiction (i.e the patient is personally responsible for the recovery and creating solutions).

The researchers provided counselors with a vignette describing a patient seeking treatment for Alcohol Use Disorder. The authors were careful to exclude any information from the vignette that might bias the counselors views on the patient’s responsibility for the onset of the addiction, the patient’s responsibility for the subsequent treatment of the addiction, and the advantages/disadvantages of using naltrexone. Here is a sample of the vignette:

Paul enters addiction treatment due to inability to stop drinking. He is having troubles at work and home. He has to drink twice as much as he used to just to feel “normal.” After a thorough evaluation, he is diagnosed with Alcohol Use Disorder, Moderate. Paul’s clinician decides to treat him with Naltrexone, a drug that claims to reduce or eliminate the rewarding effects of alcohol. He also suggests a 12-step program. Another clinician at the clinic raises objections to the use of Naltrexone for Paul’s treatment.

The authors compiled a list of common objections to using Naltrexone, based on published literature. The counselors were provided six options and asked to rate their degree of agreement on a Likert scale. Our objections to these objections are in italics.

  1. Compliance. Counselors are often worried that patients will simply not take the Naltrexone as prescribed. There is some validity to this concern, as the rates of compliance for naltrexone range from 40% to 90%, depending on the study. While the worst-case scenario of 40% compliance with Naltrexone may seem low, it is in line with a compliance rate in general medicine of around 50%. Given this data, if one objects to the use of Naltrexone on the basis of compliance, one must object to the use of medications in general. There is nothing usual or specific about the rates of compliance with Naltrexone.
  2. Side Effects. Counselors are often worried that Naltrexone will cause unpleasant or unsafe side effects. Again, this is true for all medications. The most common side effects of Naltrexone are gastrointestinal (nausea, diarrhea, and vomiting). This occurs in about 10% of users. Of course, some users may be allergic to Naltrexone or develop other side effects, including liver damage. However, this is why the use of prescription medications is monitored by a provider. If one objects to the use of Naltrexone on the basis of potential side effects, one must object to the use of medications in general.
  3. Risk of Combining Opioids. Naltrexone blocks opioid receptors, which means that prescription opiates (morphine, oxycodone, Vicodin, Percocet, etc.) and heroin will not have an effect on the user. The concern here is that a patient using Naltrexone cannot take opiate pain medications. This is true. They will have to stop taking Naltrexone prior to dental surgery, for example.
  4. Symptoms vs. Cause. Counselors are sometimes concerned that although Naltrexone is effective, it does not treat the “underlying” or “root” cause of the drinking. The was the strongest concern of the counselors, with 58% agreeing or strongly agreeing that the medication would not improve the “underlying” causes of the drinking. What we know about alcoholism is that there is unquestionably a strong genetic component, with a 50% risk of alcoholism based on your biological family. Even if you believe that the issue is psychological or psychodynamic, can we make a prediction that patients will benefit from therapy more if their brains are not being saturated with alcohol on a daily basis? The desire to create a Narrative is not often observed when discussing other ailments. For example: What’s the “root cause” of lactose intolerance?
  5. Willpower. Counselors are sometimes worried that using Naltrexone will undermine a patient’s resolve, impulse control, and willpower to stop drinking.This is the opposite of what usually happens. Naltrexone improves control over alcohol and instills hope in the alcoholic that they will be able to successfully manage the addiction.
  6. Motivation. Counselors are concerned that Naltrexone will decrease a patient’s motivation to participate in 12-step groups or other interventions to help him or herself.In our experience, patients are highly motivated to engage in treatments that work. When they observe the benefits of taking naltrexone, they are motivated to continue taking it. Typically, the reduction in alcohol use results in improved sleep, increased energy, increased engagement in hobbies, improved relationships, and better overall health. These positive changes are highly motivating, and increase the likelihood of a patient participating in additional self-care. Consider the withholding a blood pressure medication because the provider was concerned that the patient’s motivation for regular exercise and eating a low-sodium diet could be reduced. A provider might reasonably do this, depending on the severity of the hypertension, but the rationale for withholding should be explained to the patient.

The authors collected data regarding the characteristics of the 117 counselors in the study, including their gender, age, level of education, whether they accepted insurance as payment, and if the counselors were in recovery from addiction themselves.

Results indicated that

  1. Counselors who assigned greater personal responsibility for the onset of addiction were less likely to support the use of medications for four of the six reasons above.
  2. Assignment of personal responsibility for the recovery from addiction was less predictive of views of using naltrexone.
  3. Counselors who saw a higher percentage of patients paying out of pocket were less likely to support the use of medications.

The researchers do not speculate on the origins of these views. However, they do conclude with a question appealing to cynics, wondering if it is “possible that these organizations that deliberately do not accept insurance have chosen to adopt a highly responsibility-focused view of addiction that rejects both medical insurance and medication.”

The clinical orientation of your provider is critical. As this study demonstrates, you may not be offered a particular evidenced-based treatment if your provider has a philosophical objection to it. Your provider may not reveal this aversion voluntarily, so be sure to investigate. Good questions include:

  • What is your explaination for my drinking problem?
  • What causes my loss of control?
  • Are there treatment options other than AA?
  • Will medications help me? Why or why not?