Targeted Naltrexone -
The Sinclair Method of Treating
Alcohol Use Disorder
When someone is “trapped” by alcohol, the use of naltrexone can sometimes bring an amazing freedom from the compulsion to drink. Although the effects vary, many people experience remarkable results with this pill. The targeted use of naltrexone method of helping people with alcohol use disorder was developed through research conducted by David Sinclair PhD. I have explained how this works in a recent research publication.
Dr. Sinclair noted that taking a naltrexone pill to block alcohol’s reinforcing effect could, over time, reduce a person’s craving for alcohol and help them get more control over how much they drink. Other medications, such as acamprosate, which can reduce craving, or disulfiram, which makes someone sick if they drink, may also help, but they have not been proven to have a long-term effect to reduce alcohol craving.
Based on our experience treating people with alcohol use disorder, we know that counseling, social supports and diet can help make the benefits of using naltrexone last a lifetime. Together, they can help prevent the long-term damaging effects of excessive alcohol consumption and can help restore a life threatened by alcoholism.
A hugely successful actress who saw her personal life and career tested by addiction, Claudia Christian shares her journey of overcoming alcoholism and offers fresh perspectives on alcohol use disorder treatments. In this compelling TEDex talk, Claudia Christian describes her experience with Alcohol Use Disorder, and her search for lasting help; She describes how her use of naltrexone following the Sinclair Method gave her freedom from the compulsion to drink.
One of my Patients describes a similar effect:
… I am nothing short of amazed at the difference in my attitude towards alcohol. The very first drink I took after my first dosage was vastly different than any other drink I can remember. The intense satisfaction and almost euphoric feeling was simply not there. I really struggled to finish that glass of wine the first time -I just wasn’t terribly interested in drinking it.
My alcohol intake over the past six weeks has gone down about 40%. Although I am still drinking more than I want to I know that the naltrexone is working for me and I am unlearning my 30 years of drinking behavior.
A lot of my drinking now remains habit. I do not have the intense cravings and thoughts about alcohol all day long like I used to before I started using naltrexone. My attitude towards alcohol is vastly different now. Before the Sinclair method alcohol was truly one of the most important relationships in my life. I would plan activities around drinking and make sure that I could involve alcohol in whatever I was doing. Now the drive to drink constantly is simply not there. I drink now more out of habit than anything else. And slowly I am learning to change my habits so that I don’t automatically reach for a drink under certain circumstances.
Before I started naltrexone I could honestly say that I was fearful about my future. I did not think I could moderate my drinking because I had tried before and failed. And I did not think that I could abstain from drinking forever. I knew I would eventually relapse. Now I can say that I am hopeful that in the future abstinence is within my reach. I am no longer afraid that alcohol will forever rule my life.
I am very grateful to have found you and naltrexone! Thank you!
The Sinclair Method (T.S.M.) of using Naltrexone
Dr. John David Sinclair PhD (1943-2015) was an alcohol researcher who studied naltrexone, a medication that blocks the opiate or endorphin induced pleasure normally caused by alcohol. Sinclair's research demonstrated that animals trained to drink alcohol would unlearn, or extinguish their drinking behavior if alcohol were given with naltrexone. Similarly, Dr. Sinclair found that people given naltrexone before they drank alcohol could sometimes extinguish their excessive drinking behavior, and essentially "unlearn" their habit of drinking.
According to Sinclair, for naltrexone to help people stop drinking excessively, they need to drink with naltrexone in their system so they would no longer get the anticipated pleasure or “buzz” from endorphins released by alcohol. Over time, they would gradually unlearn, or extinguish their drinking behavior. This gradual reduction in drinking is called pharmacological extinction and it forms the basis for the Sinclair method of treating people with alcohol use disorder.
For many patients, over many years, the Sinclair method has been effective. As with any treatment, however, it does not work for everyone. It might not work for you; there is no way to know in advance. Long experience with the method, however, supports its use even though we cannot be certain it will work, or even be safe, in any given individual. As with most medications, there may be side effects (e.g. headache, nausea) as the body gets used to the medication.
Naltrexone Blocks the Natural Endorphins Produced by Drinking
Naltrexone taken one hour before taking a drink progressively decreased alcohol craving, a process Dr. Sinclair called pharmacological extinction.
From: Alcohol and Alcoholism 36;1 (2001):2-10.
The Process of the Sinclair Method
The key to the Sinclair method is that the person with alcohol use disorder must take naltrexone 50 mg, 1 hour before drinking - every time they drink, for the rest of their life. Many, but not all, people treated this way will gradually reduce their consumption of alcohol. Sinclair found that this gradual reduction in drinking permitted heavy drinkers to stop drinking entirely without the need for acute detoxification.
The Sinclair method describes a very specific method of using naltrexone. Commonly, when a physician prescribes naltrexone, it is for a patient who has detoxed off alcohol entirely; Patients are advised to completely abstain from alcohol while taking the naltrexone. However, Sinclair did not believe that this was the correct advice for people who were still drinking. Sinclair's research suggested that counseling patients with different Cognitive Behavioral Therapy (CBT) methods during naltrexone studies made a critical difference in the results: when patients were merely admonished to be abstinent, the naltrexone had no effect. However, when patients were encouraged to drink moderately, naltrexone was effective.
The Sinclair method requires that no alcohol drinking ever occur without naltrexone in the blood stream. For the method to work, people must not drink unless they have taken naltrexone an hour before. Compliance with this rule is critical - it is 100% non-negotiable. It is possible that with intermittent use of the Sinclair Method, that is, sometimes using naltrexone and sometimes not, someone's drinking will increase. If someone will not be compliant with this rule, the use of long acting injectable naltrexone is an alternative form of treatment to consider.
The process of the Sinclair method can take anywhere from four to eight months to reach full extinction of cravings, sometimes even longer. Two to three weeks is not long enough. If someone should forget to take their naltrexone, they will often know it when they take a drink - they may feel an extremely strong 'hit' from the very first mouthful. If someone forgets, the method requires that they stop drinking immediately, take the tablet of naltrexone, and wait an hour before finishing the drink.
The optimum dosage for naltrexone has been found to be one 50 mg tablet, one hour prior to drinking. A 50 mg dose of naltrexone will usually do its job for about 10-12 hours - the protection of naltrexone has a limited effect. Also, naltrexone may not work as well for someone taking strong drinks; the rapid effect of concentrated alcohol may overcome the opiate blocking effect of the naltrexone, rendering it less effective. As with most medications, there may be side effects (e.g. headache, nausea) as the body gets used to the medication. For the first couple of doses, taking a half a tablet will often minimize these effects. To further minimize these side effects, patients often drink lots of water and eat a meal before taking the naltrexone. Most people are not bothered by side effects after they have taken the medication for several weeks. Another negative issue with naltrexone is that while someone is taking it, opioid medications used for emergency pain treatment will not work.
NEVER DRINK AND DRIVE
Naltrexone does not block alcohol intoxication. Instead, it may enhance aspects of intoxication, such as impairment of peripheral vision and divided attention. If someone gets into trouble from drinking, the safest course of action is to never drink again - abstinence is the best advice in this situation. However, abstaining completely is not acceptable or a realistic goal for many people. The targeted use of medication before drinking recognizes this reality, which is why I find it helpful for many people with alcohol use disorder.
An important distinction of the Sinclair Method of naltrexone use is that on days when drinking will definitely not occur, the individual does not take the naltrexone but instead takes part in a pleasurable activity. This is an important benefit that comes with using naltrexone only before drinking - the effect that it has to reduce the natural opiates in the brain, (endorphins), is only working on the days people drink alcohol. In this manner, naltrexone is not acting to reduce the pleasure of healthy activities that take place on days when naltrexone is not taken.
Anything that naturally causes pleasure is an endorphin releasing activity. This can be a walk, playing a game, exercise, taking a sun bath, or even eating a spicy meal. Without the medication blocking the effect of natural endorphins, the person who goes off naltrexone for a couple of days may feel particularly good when this happens. According to Sinclair, over time, the combination of blocking the 'bad' drinking endorphins but allowing the 'good' endorphins for healthy activities, allows the brain to develop new thought paths that lead away from excessive alcohol drinking. As the brain naturally begins to crave what feels rewarding, and drinking no longer feels as rewarding, the person will begin to want the healthy activities that provide a natural endorphin reward.
John David Sinclair PhD (1943-2015)
Benefits of The Sinclair Method:
Alcohol craving may be eliminated permanently
People who don't want to stop drinking entirely can be helped
Costly and inconvenient inpatient treatment may be avoided
Using naltrexone only as needed costs less than daily use
Fewer side effects when naltrexone is only used as needed
Long term compliance is easier compared with daily use
Natural endorphins from healthy activities are not blocked so non-drinking pleasures are promoted
Gradual reduction of drinking with the Sinclair Method minimizes the risk of delirium tremens
Because treatment is relatively inexpensive it is appropriate in developing countries
Problems with The Sinclair Method:
People who have problems with alcohol may be led to embrace a risky path of “moderate drinking” rather than the more established safety of abstinence
People who rely on naltrexone to control their drinking may drink too fast or too long for their dose of naltrexone to be effective, leading to a relapse
If drinking ever occurs without first taking naltrexone, an unregulated endorphin system can lead to excessive alcohol drinking
People who forget to take their naltrexone pill may initially believe they are "cured"; this invariably leads to a relapse which may be especially severe
People who would and could remain abstinent may be encouraged to drink
People with AUD may feel that continued drinking has been sanctioned by their physician
If driving occurs while intoxicated, naltrexone may further impair coordination.
The use of medications may delay someone from seeking needed psychosocial support for abstinence
Other Sources of Information about the Sinclair Method
I describe my experience with The Sinclair Method in an article I wrote for "Advances in Addiction and Recovery", the official publication of NAADAC, the Association for Addiction Professionals. Some of the comments about the Sinclair Method noted above were adapted from the C3 Foundation, which was started by actress Claudia Christian. The C3 Foundation is dedicated to helping spread the word about the Sinclair Method of helping people with alcohol use disorder, and has created a growing number of free resources.
If you take naltrexone, click on the image above to download a pdf wallet card to carry with you
Recording the Effect of Naltrexone on Drinking
A critical feature for success with the Sinclair Method is to keep a careful drinking record. To make this easier, there are a number of ways to you can keep a record, as described here.
Some people report that after taking naltrexone and waiting the required time, if they reflect on what is happening as they slowly drink their alcohol, they will notice that they do not enjoy the effect of drinking as much as before. They report that careful concentration on feelings and thoughts and the process of drinking, even writing about these thoughts and feelings, will allow for a more deliberate appreciation of the effect of naltrexone. In this way, a person with alcohol use disorder is able to recognize and appreciate that the endorphin 'hit' or ‘buzz’ from their drink is missing, and to realize that they are satisfied and have little desire for another drink.