If you've spent any real time around people trying to change their relationship with alcohol, you've probably heard the phrase "the noise." This isn't a clinical term, but just about anyone who's lived it knows exactly what it means. It's the running internal negotiation. The grocery store you can't drive past without a small debate. The clock-watching toward an acceptable enough hour. The argument you have with yourself, on a loop, that never seems to end even when you win it.
Here's something you may not know: there's a medication for that. For a meaningful number of people, taking one little pill turns that noise down or sometimes off entirely. It's called naltrexone, and it's been sitting in plain sight in American medicine for thirty years, remaining almost unknown outside of addiction medicine circles, despite being FDA-approved, generic, and inexpensive. That's starting to change, helped along by Facebook groups and Reddit communities dedicated to the subject as well as increased media coverage, including a notable recent memoir from journalist and podcaster Katie Herzog, Drink Your Way Sober, detailing hers and others' experience with medication-assisted recovery.
This piece is about what naltrexone is, what the evidence says it does, the different ways people actually take it, and where the real uncertainty and limits are. Please note that this resource is informational, not intended as medical advice. If you're considering naltrexone or other medication assistance, make sure you do so under the supervision of your doctor.
What naltrexone actually is
Naltrexone is an opioid antagonist, which is a precise way of saying it blocks opioid receptors rather than activating them. It was first developed in the 1960s and approved by the FDA in 1984 for opioid use disorder, under the brand name Trexan. A decade later, in 1994, it was approved for a second and quite different use: alcohol use disorder, eventually rebranded as ReVia.
The connection between an opioid blocker and a drinking problem isn't obvious until you understand the mechanism. When you drink, alcohol triggers the release of endorphins, which are your body's own opioid-like compounds, in the brain's reward circuitry. That endorphin release is a meaningful part of what makes drinking feel good. Naltrexone sits on the receptors those endorphins would normally bind to and blocks them. You consume the alcohol, but the reward signal that used to follow it is muted or absent.
Researchers studying this in animals in the 1980s found that opioid blockers reduced drinking in rats. Human trials followed, and by the early 1990s there was a real evidence base showing that naltrexone, combined with counseling, reduced both cravings and relapse to heavy drinking. It's now one of three medications approved by the FDA specifically for alcohol use disorder, alongside acamprosate and disulfiram, and among the three it has some of the strongest supporting evidence.
The space naltrexone opens isn't a cure — it's a window of quiet to do something with.
Two different ways people take it
This is the part that gets confused most often in casual conversation about naltrexone, so it's worth being precise about it.
A standard dose — typically 50mg, sometimes higher under medical supervision — taken once a day, every day, regardless of whether you're drinking. Keeps receptors blocked continuously. The version most doctors are trained to prescribe, with the most direct FDA approval history.
Taken only about an hour before drinking, never on alcohol-free days. The goal is gradual "extinction" of the reward — over months, drinking and not feeling rewarded for it slowly uncouples the two in your brain.
Daily dosing is the original and still most common protocol. The idea is to keep the receptors blocked continuously, which both blunts the reward of any drinking that happens and, over time, seems to reduce the baseline intensity of craving itself.
Targeted, or "as-needed," dosing is different, and this is where the Sinclair Method lives. Developed by the American researcher John David Sinclair starting in the 1980s, the protocol is specific: you take naltrexone only in anticipation of drinking (typically one hour before) and not on days you don't plan to drink. Sinclair's own term for the underlying theory was pharmacological extinction: repeatedly drinking without getting the usual reward eventually helps the brain to unlearn the association between alcohol and pleasure. On alcohol-free days, your receptors are left unblocked, so ordinary sources of reward such as exercise, food, and human connection can still provide a natural, healthy neurological reward.
This is the protocol Katie Herzog writes about in Drink Your Way Sober. She'd struggled with heavy daily drinking for two decades, tried AA multiple times without success, and finally found her way to the Sinclair Method through a 2015 Atlantic article by Gabrielle Glaser. Her book highlights an aspect of the method that many people find surprising: the goal isn't necessarily abstinence. In her telling, the drug doesn't stop you from drinking so much as it removes the reason to look forward to it. The giddy lift of the first drink just isn't there anymore, so for a large share of people who stick with the protocol, drinking gradually loses its pull. Herzog cites research suggesting that around 75-80% of people see significant improvement using the Sinclair Method specifically. It's important to note though that success isn't universal. As with any single approach to addiction treatment, your mileage may vary.
Targeted, situational dosing — "take it when you feel the urge" — isn't itself FDA-approved as a labeled protocol the way daily dosing is, even though there's real research behind it and plenty of prescribers who use it. If you're curious about it, that's a conversation to have directly with whoever is prescribing.
What it doesn't do
Naltrexone isn't a sedative, and it isn't a deterrent drug like Antabuse, which makes you violently ill if you drink. You can drink on naltrexone — in fact, that's what allows the Sinclair Method to work its neurological magic. You just won't feel the effects of the booze the way you used to.
It also isn't instant. The Sinclair Method is explicitly built around repetition over months. The extinction effect is the result of the compounding of instances of pairing drinking with no reward. Daily dosing protocols are typically run for three to four months as an initial course, sometimes longer, under medical monitoring.
Side effects are usually mild and most common early on. Some people experience nausea, headache, fatigue, or low mood for the first dose or two before the body adjusts. There's a black-box warning about liver toxicity, though it's almost always associated with doses far higher than what's clinically prescribed; naltrexone at standard doses isn't considered hepatotoxic, but anyone with active liver disease needs that conversation with a doctor specifically. And critically: naltrexone blocks opioid receptors, so it cannot be combined with opioid pain medication, and starting it too soon after opioid use can trigger withdrawal. If you're managing both an opioid history and a drinking concern, the sequencing matters and needs medical guidance.
A personal note
I've tried just about every tool out there in my journey to treat my alcohol addiction, including naltrexone. Take this account with a grain of salt, as it's just my personal, anecdotal experience. I took Nal for about 2 months in 2023. As soon as I took the first dose, the alcohol noise in my head was quiet, for the first time in a really, really long time. I was in a period when it was really hard for me to stay sober. The noise was constant. Then suddenly, it was gone. It was a huge relief.
Unlike Katie Herzog, I did not complete the full Sinclair Method protocol to extinction. But naltrexone was a huge help on my winding road of recovery, like a neurological accelerant to the work I was doing in therapy and (occasionally) AA. Though I stopped taking Nal in early 2024, the alcohol noise has never returned to anywhere near the volume it was prior. It was like a link was broken and became scarred over.
If you're thinking about naltrexone, I highly encourage you to have a conversation with your doctor. Good luck as you carve your own winding road.
If you're considering it
Naltrexone is inexpensive, generic, and most primary care doctors can prescribe it — though, as Herzog and others have noted, many doctors still aren't familiar with the targeted dosing protocol specifically, even if they know the drug well for its standard use. If you bring it up, be prepared that you may be the one explaining the Sinclair Method to your doctor rather than the other way around. Don't be discouraged: it's a legitimate and validated medical approach that your physician should easily be able to find resources on.
Naltrexone is not a cure-all, nor is it the only evidence-based option — acamprosate and disulfiram exist for a reason, and plenty of people do better on one of those, or on a combination of medication and a program like SMART Recovery or AA, or no medication at all. What naltrexone offers, for the people it works for, is something specific and useful: a way to turn the volume down on the noise long enough to think clearly about what you actually want to do next.