"I puked my guts out yesterday, and I've never been happier," Simon told me. "Five beers made me vomit. It's a fucking miracle."
Spending a night bent over a toilet might not be most people's idea of a good time, but Simon (not his real name) is thrilled. He's a loud and excitable person, the kind of guy who says your name frequently in conversation, and at the age of 36, he's had a serious drinking problem for most of his life.
"Let me tell you, Katie," he said. "Ever since I started drinking, back when I was a child—there's something in me, Katie. I just can't stop."
Simon has been in and out of recovery (including Alcoholics Anonymous and rehab) since he was a young teen. Even if something worked briefly, even if he could white-knuckle it through sobriety for a while, it wouldn't stick.
As Simon got older, drinking took over every aspect of his life. He was constantly hungover, and as soon as the hangover lifted, he'd be back at the bar or drinking alone a ret his house. He was underperforming at work and too consumed by his booze to really care. He was unhealthy and overweight. His body trembled and ached most mornings. He knew that if he didn't do something, alcohol would eventually kill him.
Like many people with alcohol use disorder—the clinically preferred term for what used to be called alcoholism—alcohol was always in the back of Simon's mind, even when he wasn't drinking. Am I going to drink? I want to drink. I can't drink. I need to drink. Am I going to drink? These were the thoughts constantly running through his head.
If he had a date or a night out with friends or coworkers, he'd plan strategically: "Get out of there early, so you can go to a dive bar and get shit-faced in secret," he'd tell himself. It's hard to maintain friendships living like this, much less romantic relationships, but he couldn't stop hiding, plotting his time with a drink.
Alcohol addiction is often thought of in recovery circles as something that can be successfully treated if you just show up to meetings and work through the steps. "If you work it, it works," as they say in AA. This, however, is contrary to what most research tells us about how alcohol affects human beings.
Alcohol is primed to be addictive. After it is absorbed into the bloodstream, it soon moves to the brain, where it impacts several chemicals, or neurotransmitters, including gamma-aminobutyric acid (or GABA), glutamate, and dopamine (the so-called "pleasure molecule"). The combined effect of these chemicals is that you let go of inhibitions, feel euphoric, and become relaxed but energized at the same time. It feels good in both your mind and body—at least in the beginning.
After repeated exposure to alcohol, things start to change: The brain starts to produce less dopamine and GABA and more glutamate. This tends to make people anxious, irritable, and depressed. You get sick and go through withdrawal. In time, you don't drink because it feels good, you drink because not drinking starts to feel awful.
The physical effects of ongoing drinking are serious. Besides damaging major organs from the heart to the liver, long-term heavy alcohol use can do terrifying things to the mind. One particularly horrifying effect called Korsakoff syndrome is caused by a thiamine deficiency related to chronic, long-term alcohol overuse, and it prevents the formation of new memories. Neurologist Oliver Sacks wrote about Jimmie, a Korsakoff patient and long-term alcoholic, in his book The Man Who Mistook His Wife for a Hat. The two men met in the 1970s, but Jimmie was convinced it was 1945, he was 19 years old, and he had just gotten home from the war. At one point, Sacks showed Jimmie a mirror, and the man understood, for just a moment, that something had gone terribly wrong.
"It was," Sacks wrote, "or would have been, the height of cruelty had there been any possibility of Jimmie's remembering it." Two minutes later, Jimmie introduced himself to Sacks as though it were the first time.
In less dramatic cases like Simon's, alcohol can still have negative effects on the psyche. For some alcoholics, you start to feel like you can't do anything. Even the smallest tasks—taking out the garbage, changing a light bulb, showing up to work on time—seem impossible. You think everyone can see the truth in your face, even while you're trying to hide it. You may recognize that it's controlling (even destroying) your life, but all you can do, all you can think about, is drinking.
Simon was that kind of drinker: chronic, compulsive, and prone to blacking out. Gregarious, the fun guy when he's sober, he would go to bars just to get in fights. "I'd play the same song on the jukebox over and over just to piss everyone off," he said. He was regularly cut off at bars, and when he'd get belligerent with bartenders, he'd get kicked out, go home, and drink until he passed out. He's been arrested, gotten DUIs, and spent days alone in his apartment, drinking, throwing up, and then starting over again. It was a vicious cycle of shame, regret, and suicidal ideation. At one point, he sat in a garage with the car engine running, contemplating letting it all end.
At the height of his drinking, Simon was averaging about 13 drinks a night. Five beers, back then, would have just been his warm-up, and never would have made him throw up. But then Simon discovered something that few problem drinkers in the United States are aware of, even though it has a remarkably high rate of success: It's called Naltrexone, and Simon is convinced that it saved his life.
In the 1960s, an American scientist named John David Sinclair began to study the impact of alcohol on rats. Sinclair hypothesized that when rats were given alcohol for an extended amount of time and then cut off from alcohol for a few weeks, they would show less interest in drinking when alcohol was reintroduced. The opposite happened: Abstaining only made the rats want alcohol more. This, he suspected, was also true in humans, and it would explain why even long-term abstinence doesn't necessarily end cravings. Some recovering alcoholics battle their desire for alcohol forever.
This research eventually led Sinclair to Naltrexone, a drug that blocks endorphins from reaching the brain. If alcohol stopped producing a pleasurable effect, maybe the brain (and the person) would eventually lose interest, and the desire to drink would gradually cease, Sinclair thought, like Pavlov's ringing bell in reverse. The effect is called "extinction," and Sinclair found that it worked.
Sinclair died in 2015 at the age of 72, but Naltrexone has proven to be a solution for many people who struggle with alcohol. It's the treatment of choice in Finland, where Sinclair spent most of his career, and the success rate is an astounding 78 percent.
The Sinclair Method, as the protocol is known, is simple: You take Naltrexone one hour before you start drinking, each and every time you drink (and preferably not on an empty stomach). Instead of feeling that familiar euphoric buzz, drinking just makes you feel kind of sloppy and muddy-headed.
"It's not this rush like it used to be," Simon told me. "I used to drink so fast just to get to the place I needed to get to, but now that place never comes." Instead of drinking until he passes out, now he drinks until he feels like quitting. Lately, that's about six or seven beers a few times a week. While this is still above recommended guidelines, it's been life-changing for Simon.
"It's just not that big of a deal to me anymore," he said. "On my non-drinking days, I don't carry the guilt and the shame and the obsession with alcohol. Before Nal, the life I was living, you constantly think about alcohol. You plan your life around drinking and recovery. But now it's not like that. For the first time in my life, I'll pour a beer out. I physically could not do that before."
Science backs this up. With Naltrexone, "alcohol becomes non-reinforcing," said Brian Noonan, a psychiatric nurse practitioner and the owner of Ballard Psychiatric Services. "With repeated trials of drinking without reward, the association of drinking with reward begins to extinguish." The patient starts drinking less and less often. Some eventually stop altogether.
Noonan practiced abstinence-based therapy for 12 years before he stumbled across the Sinclair Method in a book. He was interested immediately. Conventional therapy and giving his patients a list of nearby Alcoholics Anonymous meetings just wasn't working. The failure rate was high, and his patients often felt guilty when they'd relapse, perhaps in part because AA and other 12-step programs teach that taking even one drink is a broken promise to yourself. Who wouldn't feel guilty about that?
Noonan started introducing the idea to his patients. They were interested, too. For these patients, the idea of never drinking again—not today, not tomorrow, not ever—was unfathomable. It would be like never seeing a loved one again. Because Naltrexone doesn't require you to divorce yourself from drinking, it offered a way out of the cycle without doing something patients thought was impossible.
It's been three years since Noonan first learned about Naltrexone, and today his practice revolves around it. He's licensed to prescribe in 20 states, and he consults with patients all over the country via video chat, along with five other health-care providers working under him. (On the day I visited his office in Ballard, he'd just consulted with a man in Colorado who was out snowboarding.) Since making the switch, Noonan says he's personally prescribed Naltrexone to an estimated 1,000 patients, and about 80 percent of them, he says, have found success.
Unlike AA, where success is measured in the number of days sober, "The only marker for success I have is that the patient feels in control," Noonan said. "They can drink or not drink in a manner that is appropriate to them. Sometimes that's abstinence, or sometimes that's just drinking on the weekends, or sometimes it's just drinking on special occasions. I measure success by when people are happy about the way they are drinking or not drinking."
This idea, that some alcoholics can continue to drink, is anathema in conventional recovery circles, which argue that the only solution to alcohol dependence is complete and total sobriety. There is little evidence to support this claim, but still, the rhetoric of sobriety is widespread.
Alcoholics Anonymous, which was founded in 1935 by an alcoholic named Bill Wilson, doesn't keep records (that's part of the promise of anonymity), but according to Gabrielle Glaser, the author of the 2013 book Her Best-Kept Secret: Why Women Drink—And How They Can Regain Control, AA has an estimated success rate of just 5 to 8 percent. And yet, the organization, which says it has two million members worldwide, claims that if you just stick with the program, it will work.
Despite the lack of evidence that AA is effective for most people, there is one benefit: It's cheap, which means that many rehab centers—part of the $35 billion addiction treatment industry—take advantage of the 12-step model. These treatment centers are often under-regulated and frequently employ former addicts as counselors instead of paying high prices for doctors and experts. Rehab centers can charge up to $40,000 a month, but their counselors often have no training besides going through the program themselves. And drugs like Naltrexone don't really fit into this model. Not only does medication counter the idea that recovery is about willpower, it doesn't require much upkeep. You don't need daily meetings or weekly talk therapy; you just need a prescription. As far as rehab-related business models go, it won't get anyone rich.
Of course, AA and rehab do work for some people. There are countless stories of success—and when you ask adherents, many say it saved their lives. But for others, abstinence-based programs are less effective than seeking no help at all.
AA and abstinence are still the only models most doctors in the US are taught, despite a lack of empirical evidence that 12-step programs work. Perhaps more would be interested in medicines like Naltrexone, but most have never even heard of the Sinclair Method—which, as far as I've been able to find, isn't taught in any American medical schools. More than one Naltrexone patient told me they get their drugs through an online pharmacy based in India because their doctors just don't know anything about it.
Claudia Christian—an actor best known for her role on the show Babylon 5—started out as a social drinker in her 20s. But by the time she was in her 40s, her drinking had ballooned into a debilitating addiction. She tried to get clean dozens of times, but once the initial honeymoon phase of sobriety wore off, the cravings would come back, stronger than ever. Eventually she'd find herself buying liqueur in the morning and telling the cashier that she was cooking a soufflé.
Christian tried everything, from $200 talk therapy sessions to $400 hypnosis. She tried rehab, AA, prayer, getting her chakras realigned, and adopting a vegan macrobiotic diet. Each time, she relapsed. The cycle continued—drinking, getting sick, going cold turkey—over and over, until she ended up in a medical detox in 2009. While there, she happened to see a brochure for Vivitrol, an injectable form of Naltrexone, and when she got home, she searched online until she came across the Sinclair Method.
This was the beginning of Christian's renewal. The more she took the drug, the less she desired to drink. She was, quite literally, drinking herself to sobriety. And when she saw how effective this was, she decided to make the Sinclair Method her life's work. She's now something of an evangelist for Naltrexone. In addition to creating the C Three Foundation, an awareness and advocacy group for the Sinclair Method, she produced a documentary about it called One Little Pill and hosted a TEDx Talk that has been viewed more than 1.5 million times. If there's any cure for alcoholism, Christian is convinced this is it. And thanks to the internet, more and more people are discovering this treatment on their own.
Still, Naltrexone isn't an instant fix. It can take 6 to 12 months to see a measurable effect. "People think it's going to take 15 days," Christian told me. "I tell them, 'It took decades to do this to your brain. It's going to take a little while to undo it.'" There can be side effects as well. Naltrexone can cause headaches and upset stomach, not unlike a hangover. There are ups and downs. Your drinking might decline for a while, then increase, then decline again, and then level out. And for around 20 percent of patients, it just doesn't work. No one knows why, Noonan said, although he thinks there's probably a genetic component.
"I'm just so fucking grateful that it works for me," Simon said when we talked by phone nearly a year after he started Naltrexone. Everything is different these days, he said, even more so than in the beginning. He's taking care of his body and exercising regularly. He's lost weight. He enjoys his job and his life for the first time in years, and he's no longer planning his day around drinking.
"I'll tell you what, Katie," Simon said. "I'm sitting in the parking lot of a bar right now, and I'm going to go get a cheeseburger, and I'm going to get a water because I just don't feel like drinking. That would never have happened before, not in a million years."
There is, he added, one thing the Sinclair Method has in common with 12-step programs: You have to really want it. If you don't take the pill each and every time you drink, the destructive feedback loop in your brain will keep going. Naltrexone, after all, isn't magic. It's just science.