An old man lives in my head. He is filthy, red-faced and dribbles. You would recognize him because it’s Father Jack, the drunken priest from the TV series Father Ted. At about 6 p.m. he wakes up from where he has been sleeping in his armchair and shouts, “Drink!” at me. And he doesn’t stop until I’ve had one. But I’m not an alcoholic. I’ve never drunk even as much as a whole bottle of wine in one evening. I don’t black out. Nothing really bad has ever happened to me because of alcohol, even in my twenties. It’s just a slow drip, drip, drip of booze.
Millions of people in the UK are like me. Nearly 80 percent of women in England reported drinking last year; the average number of units consumed per week was nine. About five million women in England regularly drink more than the NHS recommended limit of 14 units a week.
Are they alcoholics? Or are they among the third of British adults who end up with alcohol-related health problems but meet no criteria for alcohol addiction?
I’m 44 years old and I don’t want to be sober, but I want to stop drinking so much, so mindlessly. My friends fall into three camps: newly sober, moderate drinkers with no problem and heavy drinkers in denial.
I’m not a heavy drinker, but I resent how much alcohol is on my mind from about 4.30 p.m. onward. It’s like a mean, very attractive boyfriend and I feel a bit controlled by it. I am always able to cut down for a bit. But it inevitably creeps back up until I am knocking back four units a night and constantly feeling awful. Then I cut right back and the cycle starts all over again.
My husband goes for days on end without drinking. How? I used to be like that too. He has never accused me of drinking too much, but he has started to make fun of how quickly I can put away a glass of white wine.
Willpower is the only thing available to people like me. That, or AA. No, thanks. I am not—and I can’t state this emphatically enough—an alcoholic.
But there is, in fact, another option. A third way.
People who know about the opioid antagonist naltrexone all say the same thing: why aren’t more people with a drinking problem offered naltrexone? I heard about it on an episode of an American podcast, Reflector, which asked why the drug wasn’t more widely prescribed for overdrinking.
Naltrexone is not the same as disulfiram (sold as Antabuse), which is a drug that makes you violently ill if you drink. Naltrexone stops alcohol (and other stimulants) from giving you a buzz. The buzz you feel when you drink alcohol is the release of dopamine, and that is the thing that the human brain desires above all things. The brain wants that guaranteed dopamine hit and it wants you, with your hands and mouth, to go and fetch it.
I loved the sound of naltrexone and I was ready for a change. Out for dinner at the start of April, I found myself trapped in a hot, noisy restaurant, dizzy and bloated from three glasses of red and a cocktail. I wiped away a sheen of sweat from under one eye. I knew that I would wake up jittery with anxiety and nausea at 3 a.m., hating myself, but by 6 p.m. I’d be skipping my way toward the tonic tin again. It was all just so disgusting.
But the idea of being completely sober has always panicked me. I feared I would fall short and then feel like a failure. After all, sobriety programs are not especially effective. Hard data is difficult to come by, but the most positive success rate of a sobriety program such as AA (that is, sober for one to five years) is 24 percent. Elsewhere, 5 to 8 percent success rates are cited. Never drinking again felt both impossible and also unnecessary, seeing as I wasn’t drinking excessively. Naltrexone sounded like a solution to the mess I found myself in.
I’m pretty sure that it was having small children that drove me to drink. I’d say I had a pretty standard relationship with alcohol until I had kids. But living with small children is extremely stressful and my husband traveled a lot for work in those days. After bathtime, my shoulders up around my ears, I allowed myself exactly one big glass of wine. That was the amount that blurred the edges of the day but wouldn’t give me a hangover. If you do that four nights of the week, for ten years, you get pretty habituated to it.
I never addressed it because I didn’t have to. If there’s no problem, what’s the problem? I was a total cliché—the on-edge mommy who needed her wine. But there was also safety in that, because we were all at it. And I’m going to go out on a limb and say that the wine did help. But now my children are older—11 and 13—and don’t stress me out at all. And yet every evening at 6 p.m., Father Jack still screams, “Drink!” at me. And I obey.
DR. DAVID SINCLAIR, who died in 2015, was an expert in alcohol addiction and worked at the Finnish Foundation for Alcohol Studies. He developed the Sinclair Method, which uses naltrexone as a sort of off switch for problem drinkers. The idea is that the drinker keeps drinking while also taking naltrexone. Taken consistently and in good faith, naltrexone will reset the neural pathways that have been formed over time and created by regular drinking. If you drink and there is no buzz, the brain will stop insisting that you do it. Father Jack will be evicted, armchair and all.
The Sinclair Method UK is a private clinic that specializes in just this mind retraining. It offers addiction counseling as well as naltrexone.
I ring the clinic to see if I drink enough to qualify for help. Joanna, who answers my call, says, “I’m not sure what you mean by ‘qualify’.”
“I mean, do I drink enough to have a problem?”
“It’s not really about amounts,” she says, but asks me how much I drink anyway. I say that depends. Absolute minimum is one small gin and tonic per night. But occasionally it veers wildly upward, like if I have gone to a party and someone keeps refilling my glass. Or if something awful has happened. Or if I just accidentally one night have loads and loads of wine.
Then she asks me how I feel about my drinking. I say I feel a bit under its control. I am worried that I am going to end up drinking more and more, becoming a slave to this alcohol beast.
Then we get to my real fear: that when I am in my fifties, with no children at home and no brakes on anything, I will slosh about in wine from lunchtime to bedtime every day because there will be no reason not to.
Joanna listens and tells me that she is happy to recommend a naltrexone prescription. “Some people can’t take naltrexone because they have liver complications. But we don’t turn anyone away just because they don’t drink ‘enough’,” she says.
Later, I speak to Dr. Janey Merron, who will do the prescribing. “Our typical patient is a woman, an empty nester and either peri- or fully menopausal,” she says. “We don’t use the word ‘alcoholic’; we use the phrase ‘alcohol use disorder’ and patients self-diagnose. I treat people who drink a liter of vodka a day and people who drink two large glasses of wine a day and any variation on that.”
The clinic issues me with 28 naltrexone pills. The Sinclair Method service, which includes counseling and checkups, costs $450 and 28 pills cost me $115. I am advised to take a quarter of a 50mg naltrexone pill for a few days to get used to it. The quartered pill is tiny, smaller than a ladybug. The side effects are mostly stomach-related. I notice that my eyes feel a little tired and tight and later I have a bit of a gurgly stomach. All side effects have gone by day two.
I go about my evening as normal. I clear up my children’s dinner, tidy the kitchen, wave my husband off to a sporting commitment and then make a stiff gin and tonic. The drink tastes the same and does all sorts of things that I want it to do: it’s a nice, cold drink, it marks the end of the working day and it also does bring on a slight feeling of relaxation. But there is an extraordinary and noticeable absence of buzz. The really spooky thing is that I don’t want another drink. That feeling of, “Ooh yes, go on, another,” just isn’t there.
Gin is one thing, though. The real test is wine: when I look at a cold bottle of Picpoul, I swear my pupils dilate. The next evening my husband is out and my children are occupied elsewhere. This is a classic situation where I would drink probably three glasses of wine, which is two too many.
I sit down to watch Netflix (Bodkin—it’s great), with 2 ounces of cold Whispering Angel and some crisps. Total heaven. I munch my crisps and slug my wine. Normally, after that much rosé I would expect to be flying. Except I’m not.
I just feel quite sleepy, with lopsided vision and a grubby, sugary mouth. I pour another inch into my glass, just because I can, but end up tipping it down the sink. This is unheard of. It’s Whispering Angel!
It turns out that those other symptoms of drunkenness—woozy vision, fluffy mouth—aren’t very nice. I can really taste my gross parrot-cage mouth. I feel myopic and weird but there is no giddiness or feeling of well-being. I feel poisoned.
As I lurch up the stairs, it suddenly becomes clear: we put up with these side effects of alcohol because we want the dopamine that comes with them—but on their own, they suck.
I go to Spain for half-term. Sunny holidays are another danger zone, during which I may fall directly into a vat of Chardonnay. I take my pills with me but don’t take them as it doesn’t feel very festive, but I end up choosing to drink less anyway. In wine, I can now really taste the sugar and I can discern that poisoned feeling. I know for absolute certainty that there is nothing fun or good in glass number two.
Back in London, I keep the naltrexone quarters by the sink. If I’m having dinner with my husband and want to have wine, I will take one so that I don’t bully him into sharing the bottle with me. If I’m on my own in the evening and Father Jack is shrieking, “Drink!”, I will take one so that if I have a gin and tonic, it will only be one.
But as the days go on, Father Jack gets smaller and quieter until he is tiny and easily ignored.
A month after I start taking naltrexone, I go to my best friend’s birthday party. I take a pill beforehand, slightly resentfully. Swilling too much wine and laughing like a drain with my friends is a great joy in my life. I have a glass of champagne when I arrive and, with dinner, I have an inch of red wine just to join in. I have a lovely time and I’m in bed by 11.30pm. I lie there and think: in the past, was it swilling all the wine that was the joy? Or was it my friends that were the joy and the wine managed to convince me that it was indispensable?
Naltrexone has been staggeringly effective for me. Within four weeks I regain the functioning relationship with alcohol that I once had. Alcohol used to create so much noise in my head, and naltrexone turned down the dial to one. Yes, it requires willpower and a readiness to address bad habits, but not superhuman levels.
SO WHY ISN’T NALTREXONE, which is cheap and non-addictive, regularly prescribed on the NHS? Why isn’t the name as famous as, say, Ozempic?
Professor Colin Drummond, chair of the NICE (National Institute for Health and Care Excellence) guideline group on alcohol addiction, told The Lancet in 2015 that naltrexone is “now out of patent, cheap to prescribe, and yet hardly anybody who has alcohol dependence is actually prescribed [it].” He added, “It looks like many doctors are overlooking the evidence. There are huge missed opportunities.”
David Nutt, who is professor of psychopharmacology at Imperial College London, has some idea why this is. “The field of addiction treatment,” he says, “is divided philosophically between the puritans, like AA, and the pragmatists, like me.” It’s a pretty fundamental schism, he says. They just aren’t going to agree.
Bill Wilson, who founded Alcoholics Anonymous in 1935, believed that you cannot change an alcoholic into someone who has a “normal” relationship with alcohol. Abstinence forever, he argued, is the only way.
I speak to two AA members who are certainly contemptuous about the use of drugs like naltrexone. “I was never offered naltrexone and, to be honest, I think it sounds dumb,” one says. “If you need a pill for it, you probably shouldn’t be drinking at all.” Another explains that the sober community don’t approve of things such as naltrexone, because unless you “do the work”—i.e. the Twelve Steps—they believe you are likely to seek “drunkenness” elsewhere: in cigarettes or food.
This is quite a pervasive attitude in the NHS. I am told that many frontline workers in addiction recovery have been through AA themselves. Getting and staying sober is a great effort and the way you did it probably feels like the best. To many, the gold standard advice is to get off booze and then stay the hell away from it. (Everyone agrees that many heavy drinkers do need to quit completely.)
There is also a problem within us. The modern complaint is that we Brits are soft-handed whingers, but I disagree. I think we are a very stoic people—just look at how patient we are in queues and bad weather. The moral value we place on willpower is huge and we despise weakness. The British attitude is: get a grip. If you have been weak enough to develop a problem with alcohol, your punishment is now to cut down using willpower alone, and if you need help, it’s cheating.
But why are we like this? Alcohol is incredibly addictive—more for some than others. Certain people become dependent on alcohol because they are inclined to become dependent on substances, but many become reliant on it simply because they drink so bloody much. And they drink so much because it is deeply ingrained in our culture. There is a drink for every occasion; there is even a drink for every time of day.
Alcohol is the one addictive substance in this country that we actively celebrate. It’s really no wonder we get hopelessly hooked on it. Yet the words “alcoholic” and “alcoholism” still carry vast stigma. Sure, hip Gen Z types get away with being sober, but in large parts of this country if you don’t drink, it’s suspicious.
There’s a small-print problem with naltrexone too. The drug was only licensed to work alongside a program of abstinence. The NICE guidelines condone the use of naltrexone to avoid “relapse into heavy drinking” following “medically assisted withdrawal.” But taking naltrexone while abstaining from drink will not sever the link in the mind between the alcohol and the dopamine reward.
To enable them to prescribe naltrexone with a program of drinking, GPs have to prescribe “off label”—that is, not according to guidelines. They really don’t want to do this.
And the government doesn’t prioritize alcohol reduction. Instead, it wants the NHS to get patients to lose weight and quit smoking. One widely held view is that the government is in thrall to “Big Alcohol,” but who knows what the real reason is.
Almost every doctor I spoke to for this piece cited wealthy, educated patients who had no idea they had a drinking problem until, aged about 63, they turned yellow from liver failure. They never knew they were dependent on alcohol because they never stopped drinking and it never caused them any major problems. Like me, there was no problem, so what was the problem?
But are they alcoholics? Who knows. And it doesn’t matter anyway.
In May, a report found that drinking costs the economy $35 billion per year. More than $3.8 billion is spent on alcohol-related trips to the emergency room.
We drink too much. It’s not our fault, but we need to do something about it. The answer, for me, was naltrexone. Maybe it’s the answer for you too.
Esther Walker is a writer at The Times of London
