Australia Has a Pill for Alcohol Dependency. Why Isn’t It Being Prescribed?

By the time that Kate, 50-years-old and living in Melbourne, had spoken to a doctor about her drinking, she had already decided she needed a prescription for a drug called “naltrexone”.

Naltrexone is an opioid antagonist: it blocks the brain’s opioid receptors without activating them, dampening any euphoria caused by substances like heroin, morphine and alcohol. It’s a sort of red light for the brain.

It’s because of this that naltrexone is considered by many to be an optimistic treatment for alcohol use disorder (AUD). In 2012, a meta-analysis of almost 40 years of clinical trials concluded that for every nine people treated with naltrexone, one would be prevented from returning to heavy drinking. It is not the silver bullet for treatment, but for some, it can be revelatory.

In Australia, the drug is approved for use in a “comprehensive treatment program for alcohol dependence”. This involves taking one dose, every day, as part of a wider strategy to maintain abstinence. Since 2001, the medication has been listed on the Pharmaceutical Benefits Scheme, currently with an out-of-pocket cost of $42.50 per month.

Kate discovered this potential while scouring the internet for a remedy. Since her mid-40s, she had fallen into a familiar rhythm of finishing up to two bottles of whisky a week, and while she didn’t know whether naltrexone would address her dependence on alcohol, she did know that the approaches that championed strict sobriety, like Alcoholics Anonymous, wouldn’t have an effect.

“I wanted to be able to do this with dignity,” Kate, now 55 and no longer experiencing AUD, told VICE. “I just knew that I was beyond the point of abstinence.”

“The next stop for me was the gutter – once my husband and child had kicked me out.”

Alcohol use is abundant throughout Australia, considered to be the most commonly used drug in the country. One analysis by the National Centre for Education and Training on Addiction (NCETA)  found that, in 2019, roughly five per cent of Australia’s population over the age of 14 were drinking every day – a rate that accounts for roughly 1.01 million people.

Naltrexone, with its accessibility and relative effectiveness, would be a shining treatment for a condition like AUD. However, the medications approved to address these conditions are not embraced by the medical community. 

According to government data, roughly 59,000 prescriptions for naltrexone were provided under the PBS in 2021. Acamprosate, another subsidised medication for AUD, was reported as being prescribed around 43,000 times over the same period.

Dr Philip Crowley, an addiction medicine specialist based in Melbourne, says there’s no medical reason why GPs would refuse to prescribe it.

“Alcohol pharmacotherapy actually works quite well,” he told VICE, explaining that the benefits roughly equate to how antidepressants can address significant depression. 

“You don't get addicted to [naltrexone] or abuse it. It's relatively cheap.”

Instead, Dr Crowley suggests that external influences are behind the lack of prescriptions, like a misunderstanding of the chronic nature of AUD and a lack of awareness of these medicines amongst both users and medical professionals.

“There's probably a cultural aspect,” he added. “Australian doctors are very good at treating alcohol withdrawal – I think they see a lot of alcohol withdrawal in hospitals, and they tend to see it very much as the treatment that people get offered.”

“I think there is a degree of almost therapeutic nihilism, where people just don't treat alcohol effectively.”

Accessing naltrexone is a varied experience in Australia. Some find it relatively straightforward and others either face difficulty or are refused outright. 

“A friend in Brisbane was made to go to a rehab facility and medically detox before she was given a script,” explains Johanna, a 53-year-old based in the ACT who follows the Sinclair Method – a movement to address AUD that incorporates naltrexone.

“There have been a few people who say their doctor has said they can't prescribe it.”

Dr. David Shap, a general practitioner based in Melbourne’s south, told VICE that any reluctance to prescribe naltrexone could be tied to a lack of consensus over its effectiveness.

“It could be that a lot of GPs don't have a lot of experience in prescribing them,” he said. “And GPs generally don't like prescribing drugs that they are unfamiliar with.”

Alcohol use disorder is still considered a heavily stigmatised condition across the world, with one 2014 study from the University of Queensland concluding that almost one-third of participants saw AUD as the result of “bad character”.

Dr. Paul Grinzi, a GP and addiction medicine educator with Melbourne’s Royal Park Medical, told VICE that these rates are tied to stigma, with patients unwilling to admit that they have a substance dependence. 

“I think, firstly, the main barrier is the stigma in our community around people suffering a long term health issue like alcohol use disorder,” Dr Grinzi said. 

“If you look at asthma, it's a long term condition. You have flares up of asthma. You've got times where it's actually well controlled. But there's no stigma around that.”

For Kate, that first prescription five years ago came from a one-off telehealth appointment with a naltrexone-friendly prescriber based in Tasmania. She said the decision was born out of a reluctance to admit to her regular GP that she was dependent on alcohol. 

“I just felt so ashamed and just hated myself for what had happened to me.”

“Alcohol use disorder is highly stigmatised,” Dr Paul Haber, a Professor of addiction medicine at the University of Sydney, told VICE. “We look down on people with that problem. And so stigma means that people don't want to get involved.”

“Many of the people with AUD are socially disadvantaged and poor. Not all – some are high functioning and very rich – but the majority are not in that situation. And so it's not a very lucrative area of medicine.”

In 2016, Dr Haber co-authored a paper that found a range of factors were potentially impacting these prescriptions, one being a reluctance amongst providers to engage with AUD patients. It’s a hesitation that he says still exists.

“Addiction, alcoholism, other drug dependence – it's generally not in the top five, 10, 15 or 20 things that most GPs are interested in,” said Dr Adrian Dunlop, a foundation Fellow at the Royal Australasian College of Physicians’ Chapter of Addiction Medicine. 

“Same for hospital doctors and most other specialties.”

According to Dr Dunlop, this reluctance to engage with patients experiencing AUD is more than limiting access to prescription medicines. It’s also an unveiling of the deep shortcomings in how the medical system interacts with those experiencing alcohol dependence.  

“A lot of doctors don't want to ask, a lot of patients don't want to tell. And so things continue, as they did last year and the year before and the year before and the year before.”

Follow Sam on Twitter

Read more from VICE Australia and subscribe to our weekly newsletter, This Week Online.