Naltrexone is an FDA-approved medication that has been repeatedly shown to significantly reduce drinking, and subscribers to the Sinclair Method swear by its effectiveness. But does it work for everyone? And when can the side effects of naltrexone, which are normally very mild, get to be too much for some people? I recently spoke with Ria Health’s Chief Medical Officer, John Mendelson, about how naltrexone works. Watch our conversation below, or read a transcript of it, which has been lightly edited for clarity.
Dr. John Mendelson Explains the Side Effects of Naltrexone
Katie Lain: Hi everybody, it’s Katie with Ria Health, and today I’m here with Dr. Mendelson, researcher and physician here at Ria Health. Dr. Mendelson and I were just chatting about the online Sinclair Method communities, where people are sharing that perhaps they’re not getting the results they hoped for on the medication naltrexone. And I wanted talk to Dr. Mendelson today about his perspective on what the medication naltrexone is, why some people don’t get the results that others do, and what can be done about it. So thank you for being here, Dr. Mendelson. I look forward to hearing what you have to say.
Dr. John Mendelson: It’s a pleasure being able to talk to people. I want to say, I’ve been reading many of the comments coming through the Sinclair Method Warriors group Facebook page. This is not directed to any one person’s comments. I’m not trying to give medical advice here, so I’m going to keep this very general. But a lot of people struggle with naltrexone. The drug is difficult for many, many patients. At Ria, about 10 percent of our patients just don’t tolerate it at all, and that’s due to side effects of naltrexone. And they don’t tolerate it at any dose. Even when we reduce it down to 12.5mg a day, they have intolerable side effects.
Where are these side effects of naltrexone coming from? And why are they different between people? That’s a really interesting question, and it’s because naltrexone is a really complicated drug. In addition to having effects at what are called “mu opiate receptors,” which are the ones that seem to mediate pain and pleasure, naltrexone can also have effects at “kappa opiate receptors,” which are ones that cause discomfort or displeasure.
In some people, naltrexone appears to be a kappa agonist—that means it increases the effects of kappa, which means that is has unpleasant effects. Many patients report, when they take naltrexone, that they feel some kind of strange intoxication. They feel weird. And some people say things like, “I felt high all day, I couldn’t sleep, and I had weird dreams.” Many of us think that’s due to the kappa agonist effects of naltrexone, which, although minimal, are ones that your body doesn’t usually see. If you’re a person who responds that way—you have a strong kappa response to naltrexone—you may never be able to get rid of those adverse side effects of naltrexone, and it won’t be a medication you can use.
At Ria, about 10 percent of our patients just don’t tolerate [naltrexone] at all, and that’s due to side effects.
So my big point here is, I love the enthusiasm of the group. I love the fact that people share their knowledge. But not everyone is going to get a good response, and it’s not just because they didn’t give it a good effort. It’s because their biology is different. And for those individuals, we do have medications that are effective and safe and can work well. You’ll need to work with your physicians on that—a good, knowledgeable physician.
So one set of adverse effects is that weirdness, that feeling weird, high, intoxicated. Another are the G.I. ones—gastrointestinal—where people have nausea, they have diarrhea, they’re queasy all the time. That is probably due to some of the mu effects, as well as the kappa effects of the drug. And it’s probably more a dose-dependent phenomenon. So if you’re have a lot of G.I. stuff, you may be able to affect that by either increasing or decreasing the dose and waiting. It turns out the amount of opiate receptors in your gut exceed the amount of opiate receptors in your brain.
John: In fact, opiate receptors were initially isolated from guinea pigs’ ileum, which is part of the small intestine.
John: Because that’s where most of them are. And drugs that constipate you, if you have diarrhea—like Lomotil—those are all opiates. And in opiate withdrawal, one of the principal symptoms is vomiting and diarrhea, as well as abdominal pain and cramping.
Some of us are willing to tolerate some medication side effects if we’re getting better as a result. If we take an antihistamine because we have allergies, and it’s sedating, it beats the heck out of sneezing continuously, right?
There are a ton of gastrointestinal side effects of naltrexone. Most of them aren’t bothersome enough for people to stop medication. But one law of medicine…or at least one of Mendelson’s “plastic pearls”—you know, plastic pearls can look good, but they’re not real? Well, this is a plastic pearl, but it’s a pretty good one: “You can’t make a well person better.”
Some of us are willing to tolerate some medication side effects if we’re getting better as a result. If we take an antihistamine because we have allergies, and it’s sedating, it beats the heck out of sneezing continuously, right? But on the other hand, if we don’t have any symptoms, and it makes us sedated, the medication’s doing no benefit. It’s only giving problems.
So many people find when they cut their drinking down, some of the adverse effects of naltrexone begin to emerge for them. And that’s because they’re better! So maybe it’s a subtle message that they’re actually better and they don’t need the medication as much. But at any rate, the point is that you can have good effects of naltrexone that later turn into neutral-to-negative effects, because maybe you’re better. It could also be that the G.I. system is responding different than the brain—we really don’t have a good science handle on that. Also, naltrexone has other effects on other receptor systems that can vary between people. Therefore, naltrexone may not work for everyone.
I guess the final point I’ll make on naltrexone: I see a lot of people talking about increasing doses. And I don’t think that’s particularly bad, but there is a risk of liver problems from naltrexone. And it’s a good idea, if you’re going to increase the dose, that you have a physician following you. I wouldn’t do this at home alone. At this point, you need professional help. Someone should be monitoring blood tests, or at least symptoms, to make sure that you’re not getting into any risks with naltrexone.
It’s a good idea, if you’re going to increase the dose, that you have a physician following you. I wouldn’t do this at home alone.
Doses below 100 mg appear to be very safe, other than these side effects we just talked about—the weird intoxication and the G.I. stuff. It’s pretty hard to hurt someone with naltrexone, unless they’re opiate-dependent and having those side effects. But if you escalate doses, risks do increase, and you want to have a professional working with you at that point.
Katie: Wonderful, thank you. I have one quick follow-up question: What is the amount of time someone should really give to see if this medication is going to work for them? Because I know some people get side effects early on, and then they go away. I also see people in online forums who spend months and they’re still having severe side effects and they’re not seeing a reduction in drinking. So, in general, what are your thoughts and recommendations there?
John: I think if you’re not seeing an effect at one month, it’s time to look at something else. You should see an effect within the first month. People are wonderfully different. You know, this is the holiday season. So if you started naltrexone the day before Thanksgiving, then you went to your family celebration and came back, and then you had three Christmas parties for work, and then you had your holidays, and it didn’t go very well, well, I might give naltrexone till February to really make sure it’s working. But if it’s January 2 and by February 2 you’re not doing any better at all, I think you need a different medication. And there are different ones. The question always is, “What constitutes better? What is better?” And we should talk about that some other time. That’s a complicated question.
Katie: Great. That’s really helpful. Thank you so much for talking about that. If you have any questions about naltrexone, and you’re watching this video, please feel free to post them in the comments below. And thank you, Dr. Mendelson, we’ll talk to you again soon.