Rehab 4 Addiction

Alcohol dependence is a worldwide problem that affects millions of people. It is the leading cause of disability among 15-49 year-olds and accounts for 10% of the deaths in this age group. [1]

Alcohol can produce both psychological and physical dependency. In other words, you can become dependent on the psychological rewards that you experience when drinking alcohol, and your body can also become physically dependent on alcohol.

This is why you can experience unpleasant withdrawal symptoms when you have access to alcohol.

Because of the powerful psychological and physical effects of alcohol, it can be easy to become dependent on it. 38% of men and 19% of women in the UK aged 55 to 64 usually drank over 14 units in a week. [2]

If you are looking for a way to reduce or eliminate your alcohol dependency, there are several different options. Most treatments such as Alcoholics Anonymous promote an approach of complete lifetime abstinence.

In other words, in order for these treatments to work, you have to never have another alcoholic drink again. If alcohol is causing problems in your life and you want to eliminate it altogether, this can be a useful treatment option for you.

These treatments can be effective for many people, but if you have tried them in the past and they haven’t worked, or if you aren’t willing to never drink again, a different approach might be needed. [3]

Another option can be to use medication-based approaches that work to limit how much you want to drink, without you having to promise to never touch alcohol again. The most popular of these is the Sinclair Method (TSM).

The Sinclair Method

In contrast to the abstinence treatment options, the Sinclair Method (named after its creator, Dr John Sinclair) encourages you to carry on drinking. In fact, if you want the treatment to work, you need to drink alcohol.

It is easy to see why this method is controversial when compared to the treatment options that say you should never drink again, but it is the leading treatment for alcohol dependency in Finland. [4]

Of course, the goal of the Sinclair Method (TSM) isn’t to carry on drinking to excess. The goal is to reduce alcohol intake to a non-damaging level, or to no alcohol at all.

The core of TSM is to break the connection between alcohol and dependency to make you not want to drink. Sinclair proposed that alcohol dependency could work in the same way as Pavlovian conditioning.

When you drink alcohol, it releases endorphins in your brain. These endorphins then bind to opioid receptors, causing them to release dopamine. When a large amount of dopamine gets released, you experience a rush of pleasure.

Over time, your brain starts to make a stronger and stronger connection between alcohol and the feeling of pleasure, and this can lead you to become dependent on alcohol.

Once you become dependent on alcohol, you may start to feel discomfort when you don’t have an alcoholic drink. Drinking alcohol can reduce this discomfort, which strengthens the connection between alcohol and pleasure.

Drugs such as Naltrexone and Nalmefene (they are slightly different but work in the same way) are opioid antagonists. They bind to the opioid receptors which then blocks endorphins from reaching them.

So when you drink, the endorphins that are released can’t bind to the opioid receptors, so dopamine can’t be released, and you don’t feel any pleasure. [5]

Over time, as you drink but don’t get a rush of pleasure, that connection between alcohol and pleasure starts to get broken. This is known as pharmacological extinction. Eventually, your drive to drink alcohol will be reduced, and you will no longer be dependent on it.

How does the Sinclair Method work in practice?

TSM is effective for people who have a high level of alcohol consumption: 60g per day for men or 40g per day for women. [6]

There is some evidence that it is more effective for people who have a family history of alcohol dependency, possible because of genetic factors. Because they are opioid antagonists, Naltrexone and Nalmefene are not suitable for people who take opioid-based painkillers.

Naltrexone (Reviva in the USA and Nalorex in the UK) can come in two forms: a pill form or an extended-release injection. Nalmefene (Selincro in Europe and the UK) comes in pill form. We will come back to the extended-release injection later, but most of the time they will both be prescribed in pill form.

The basic idea is that you don’t have to take the Naltrexone or Nalmefene pill every single day. You only take it one to two hours before you have your first drink.

Then, when the alcohol reaches your system, you won’t get the same rush of pleasure as you usually do. Over time, usually 3-4 months, you will begin to want a drink less and less.

For some people, the goal is to stop drinking alcohol altogether. For others, the goal is to be able to have a drink or two in social situations and stop there.

These medications can help you to achieve either of these. When you start the treatment, however, you do have to drink alcohol. The medications won’t be able to break the connection between alcohol and pleasure if you don’t drink any alcohol.

It is important to remember that while Naltroxene and Nalmefene stop the rush of pleasure you have when drinking alcohol, they do not stop you from getting drunk. They are both, however, non-addictive and they don’t give you any sort of high.

Controversies

TSM is controversial. It takes a very different approach to most other treatment methods for alcohol dependency. Most approaches to treating alcohol dependency come from the point of view that once you have a dependency on alcohol, you should never have another drink again.

Because for TSM to work, you have to drink alcohol, it is directly opposed to the other alcohol dependency treatments. People who are opposed to TSM do have other reasons for their concerns, and we will go through them in turn.

  1. TSM alone does not treat the underlying causes of alcohol dependency. TSM boils alcohol dependency down to simple conditioning between alcohol and pleasure, but this ignores the many complex and deeply personal reasons that drive many people to become dependent on alcohol. Without helping people to deal with these issues, and the thought patterns and behaviours that go with them, it can be difficult for people to become completely free of alcohol dependency
  2. When the opiate receptors are blocked, this is not ignored by the brain. In response, it increases the sensitivity of the receptors to make sure that it can take in as many of the pleasure hormones as possible when they are available. What this means is that if you stop taking your medication and then have a drink, the pleasure that you experience will be even greater than it would have been before the treatment. If we boil it back down to the conditioning between alcohol and pleasure, an increase in the amount of pleasure after drinking alcohol could make the connection even stronger than it was before
  3. TSM may encourage people to drink more to try and chase the pleasure that they used to experience from alcohol. This could make health problems related to alcohol worse, cause them to overdose, or lead to an alcohol-related accident
  4. Because the medications block opiate receptors in the brain, less pleasure will be felt from other endorphin-releasing activities, such as exercise or music. This could reduce the quality of life in people who are using the TSM method and could make underlying issues that led them to become dependent on alcohol in the first place worse. This is especially the case if the extended-release injection is used, as it blocks the opiate receptors for 4 weeks at a time

Support

With that being said, TSM does have a lot of support. Many people hail it as a scientific breakthrough in the treatment of alcohol dependency, and argue that there are benefits to many people of using this method instead of an abstinence-based one:

  1. The idea that the goal should always be abstinence is too moralistic. In other words, it frames alcohol dependency as a moral failing in the individual. In contrast, TSM views alcohol dependency as a medical problem that can be fixed with medication. Medication is used to treat all sorts of different physical and mental health problems, and alcohol dependency should be no different. It is no more a moral failing than diabetes is
  2. It works. When followed properly, scientific studies have shown that TSM reduces the number of heavy drinking days significantly. It also results in improved liver enzyme functioning. [7] So TSM can prevent excessive drinking and can help to reverse the health problems that stem from alcohol dependency. This is enough for many people and can bring them away from alcohol dependency towards a healthy relationship with alcohol. In the studies that have shown that TSM doesn’t work, this is often because the medications are being used without following the protocol. Many programmes, especially in the USA, use Naltrexone or Nalmefene as a way of reducing cravings for alcohol alongside a total abstinence programme. These medications do not work as an anti-craving medication and they don’t work when there is no alcohol intake at all
  3. TSM and therapy treatments can be used together, and are most effective if they are. In fact, Nalmefene cannot be prescribed on its own. It has to be prescribed alongside psychosocial support. For TSM to be effective, people have to be willing to take their medication before they drink. Tackling the underlying issues that might lead them to become dependent on alcohol can help them to keep going with TSM
  4. Taking Naltrexone and Nalmefene only when drinking means that pleasure can still be felt the rest of the time. If the extended-release injection is used, or people take the medications every day even without drinking alcohol, this can make the problem of a lack of pleasure worse. This is because they block the opiate receptors all of the time, so it is not only the endorphins from alcohol that are prevented from binding, it is all of them. Only taking the medications an hour or so before drinking means that the opiate receptors are not blocked the rest of the time, and endorphins that result from exercise or music will still reach them

Who does TSM work for?

TSM can be most effective for:

  • People who experience cravings for alcohol
  • People with a family history of alcohol dependency
  • People who have a healthy liver
  • People who want to drink less or not at al

TSM may not work for:

  • People who want to quit cold turkey and never touch alcohol again
  • People who want a fast-action solution (TSM can take months)
  • People who are taking opiate-based medications

What are the side effects of Naltrexone and Nalmefene?

As with any drug, Naltrexone and Nalmefene do have side effects. The most common are:

  • Nausea (and/or vomiting)
  • Sweating
  • Muscle tightness
  • Fatigue
  • Malaise (feeling weak and uncomfortable)
  • Insomnia
  • Dizziness
  • Impaired sense of taste
  • Hangovers

A small number of people may also experience a sense of unreality, nightmares, anxiety, and agitation, or even hallucinations. [8]

Some people experience no side effects at all and some people do experience side effects but decide that the benefits of reduced alcohol consumption are worth it.

Most of the time, side effects disappear after a month, but some people are more sensitive to the effects of opioid antagonists and may experience severe side effects that do not go away. For these people, a different treatment option may be needed.

Final thoughts

There are many treatment options available for people living with alcohol dependency. Finding a method that works for you, long term, is important if you want to move on from dependency on alcohol.

While approaches that encourage you to never drink again can work for many people, for others a medication-based approach that reduces the connection between alcohol and pleasure (and so can reduce how much you want to drink) can be the treatment option that is best for them.

References

[1]  https://www.who.int/health-topics/alcohol#tab=tab_1

[2] https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-alcohol/2020

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746426/

[4] https://www.sinclairmethod.org/sinclair-method-tsm-atlantic-magazine/

[5] https://www.sinclairmethod.org/sinclair-method-tsm-atlantic-magazine/

[6] https://www.sinclairmethod.org/sinclair-method-tsm-atlantic-magazine/

[7] https://www.sinclairmethod.org/sinclair-method-tsm-atlantic-magazine/

[8] https://www.sciencedirect.com/topics/neuroscience/nalmefene