Alcohol Addiction Sinclair Method Step 3

STEP THREE: Naltrexone and nalmefene: Effective alternatives to abstaining from alcohol ‘cold turkey’

Naltrexone Treatment medication

Naltrexone is a substance that has long been used to treat alcohol and opioid dependencies. First formulated in 1965, it was approved by the Food and Drug Administration (FDA) in the US in 1994, and by several other medical authorities in later years, including in Australia, Canada, and the UK. In the 1990s, the World Health Organisation endorsed the use of naltrexone for combatting alcohol dependency. However, it was not until 2006 that the American Medical Association (AMA) published the results of a study known as Project COMBINE, which confirmed that the drug could be widely adopted in general medical settings.

A similar drug to naltrexone is nalmefene, which is also used to treat addictions such as alcohol dependency, opioid addiction, and even pathological gambling. It has never been sold in the US, primarily because it has never been considered cost-effective. It was, however, approved for use within the European Union in 2013, with Scotland becoming the first to prescribe the drug for alcohol addiction. England soon followed, approving the treatment for National Health Service (NHS) use in 2014. Both nalmefene and naltrexone fall into a category of drug known as opioid antagonists.

Despite the relatively popular uptake of naltrexone and nalmefene around the world, it is important to note that their use alone is usually not an effective way of treating alcohol addiction. Unfortunately, many doctors are content to prescribe naltrexone and send patients on their way, mistakenly believing that the drug will be able to target the root of the problem and immediately inhibit unhealthy drinking habits. In some ways, this is understandable. With conditions such as bacterial infection, diabetes or chronic pain, for example, there are plenty of targeted medications out there that can quickly and effectively treat them such as antibiotics, insulin-controlling drugs, and painkillers.

Alcohol addiction, however, is a little more complex, as it requires much more effort and personal input from the patient. Whilst clearing up a bacterial infection only requires the patient to pop a pill every morning, battling alcohol dependency is much more difficult than remembering to take a dose of naltrexone or nalmefene at regular intervals.

One of the most interesting and seemingly counterintuitive things about naltrexone and nalmefene is that they require the patient to actively drink in order to be effective. Although this may seem a little odd, it has been backed up by the results of over seventy clinical trials.

How safe is naltrexone?

As anyone who has ever taken a prescription drug will know, they tend to come with a very extensive list of possible side effects. Whilst many of these effects are unlikely to occur, they must be listed to avoid legal repercussions. Fortunately, naltrexone (sold under the brand name Nalorex ® in the UK) comes with few side effects and is generally considered a safe medication that cannot be abused. The most common side effects of naltrexone are gastrointestinal in nature and include symptoms such as stomach pain and diarrhoea.

How is naltrexone administered and how does it work?

Naltrexone comes in special time-release injections that ensure the drug is released gradually into the patient’s bloodstream and is always present in the body. Oral pills are also available, although this route of administration requires the patient to remember to take their dose on a regular basis.

Naltrexone works by blocking a person’s opioid receptors, thereby reducing their craving for alcohol. When you drink whilst taking naltrexone or, indeed, nalmefene, you will begin to find that your relationship with alcohol starts to change. Whilst it may feel strange to continue drinking alcohol whilst battling your addiction, it is important to remember that it is part of the process and will help you to develop a new relationship with the substance. Going cold turkey, unfortunately, will not help to reduce your cravings.

In short, drinking alcohol in combination with naltrexone or nalmefene will produce the following effects:

• Reduced interest in alcohol
• Reduced cravings for alcohol without having to go cold turkey
• Your drinking will start to approach safe limits (in other words, according to WHO guidelines, no more than 24 drinks per week for men and no more than 16 per week for women – with no more than five and four, respectively, being drunk in one session)
• The ability to eventually abstain completely (after around three to four months following the Sinclair Method)
• You will be able to set your own goals regarding your alcohol use, settling on complete abstinence or a significantly reduced weekly limit
• Your body will be detoxified of alcohol and your overall health will improve

What does drinking feel like whilst taking nalmefene or naltrexone?

Taking either nalmefene or naltrexone by itself will not usually produce any tangible effects. Although some patients may feel some nausea, this side effect occurs in less than 10% of people and is usually only temporary. Neither drug is psychoactive and will not make you feel any higher or lower than you normally do.

Interestingly, there tend to be even fewer adverse physical effects in patients who continue to drink whilst taking nalmefene or naltrexone. It does provide relief from alcohol in a way that many people can pin down. Rather, it significantly dampens the euphoric or relaxing feelings that come with drinking alcohol, making it less enticing for users.

One of the best things about these opioid antagonists is that they block the endorphin system, which is, ultimately, not fundamental to human survival in the modern world. Whilst endorphins can make us feel good, their main evolutionary purpose is to work as a painkiller. This is, of course, useful for wild animals who have to deal with tough injuries in order to survive. For humans in the twenty-first century, however, this is less important. In fact, most people given opioid antagonists in double-blind clinical trials could not tell whether they had been dosed with the drug itself or a placebo. This makes endorphins quite different from other neurochemicals such as serotonin, dopamine, and epinephrine. These are implicated in a wide range of vital bodily functions, and altering their function can come with severe side effects.

Of course, whilst it is easy to see why naltrexone and nalmefene offer attractive solutions for people battling alcohol addiction, it is important to remember that they are not magical cures. Contrary to many false claims on the internet, they will not immediately reduce cravings or ‘cure’ you within a matter of minutes. As shown by the reams of scientific literature about the Sinclair Method, the use of nalmefene or naltrexone is only effective if it is combined with drinking over a duration of at least three or four months. Breaking the cycle of addiction takes time, and this is something that patients will simply have to accept.

Why would someone want to take nalmefene or naltrexone?

To some, it may seem slightly odd that patients would willingly take naltrexone or nalmefene if they effectively block the pleasurable feelings that alcohol induces. Surely, you may find yourself asking, any rational drinker would stop taking the medication when their cravings started to overwhelm them?

This is a valid question. However, the evidence clearly shows that problem drinkers are highly compliant with courses of nalmefene or naltrexone. With the Sinclair Method, over 85% of people with alcohol addiction stick rigidly to their treatment plan, despite having been informed of its ability to block the pleasurable effects of alcohol.

To those without alcohol addiction, this may seem irrational. However, it is important to understand that alcohol abuse does not simply arise from the rational desire to chase feelings of euphoria. Many studies looking into the effects of alcohol have shown that feelings euphoria produced by alcohol tend to be fleeting and infrequent. If you feel low, a glass or two of wine could actually end up making you feel even glummer.

Whilst a touch of alcohol could make you feel more in the mood for a party if you are happy in the first place, it could end up producing feelings of aggression if you are already feeling frustrated or annoyed. It should come as no surprise that alcohol has been shown to have a significant effect on rates of violent crime.

People in the throes of alcohol addiction do not pour themselves glasses of scotch at 8 o’clock in the morning in order to get themselves in the party mood. In fact, several studies have shown that drinking under such conditions is very unlikely to provide many pleasurable feelings. Most people with alcohol dependencies turn to drink in order to numb painful feelings or to avoid the effects of withdrawal.

Ultimately, alcoholics become hardwired to run on alcohol. They do not ‘choose’ to have a glass of wine in the way that those without addictive tendencies would. Rather, drinking for them has become a reflex that requires a significant amount of intervention to unlearn.

So, to sum up, whilst naltrexone and nalmefene may indeed eliminate many of the pleasurable feelings derived from alcohol, this pleasure has very little to do with the root causes of addiction. This is why few patients have problems with taking nalmefene or naltrexone. Abstention from alcohol is much more difficult (and more likely to fail) than drinking on opioid antagonists. Alcoholism is, after all, defined as the near-incapability of totally abstaining from drink. Taking a pill or injections is a relatively easy first step to take towards a life without alcohol.

How should patients make up for lost endorphins?

Of course, whilst alcoholics may not be bothered by the loss of alcohol-induced pleasure (if they derived any in the first place), it is vital to consider that blocking endorphins may have an impact on their enjoyment of other aspects of life. Many of our most fundamentally enjoyable human behaviours are reinforced with the help of endorphins. To ensure that these behaviours are not lost, therefore, followers of the Sinclair Method should follow a process known as selective extinction. This removes the harmful habits associated with alcohol abuse whilst maintaining and even bolstering the other behaviours that make life valuable and exciting.

How does de-addiction with opioid antagonists work on a physiological level?

When a person takes nalmefene or naltrexone, the emotions they usually feel on a day-to-day basis may start to feel a little dampened. Whilst this may feel a little disconcerting at first, it tends to mean that the neural pathways that dictate their drinking habits are being gradually weakened. Indeed, this is a process that physically affects the brain, involving the rewiring of trillions of the brain’s connections between individual neurons. Anyone taking opioid antagonists for alcohol addiction will not be able to ‘feel’ their brain changing in any way, just as a person cannot feel the many bodily processes that take place in organs such as the kidney or liver on an almost constant basis.

As a person continues to drink alcohol whilst taking nalmefene or naltrexone, therefore, the circuitry of their brain’s neural connections changes and they no longer require endorphin reinforcements. This produces the phenomenon that Sinclair described as ‘pharmacological extinction’, whereby the wiring that causes addiction is slowly weakened and changed.

Perhaps most surprisingly, the process of de-addiction takes place quicker and more profoundly in those who drink frequently on opioid antagonists. The more often a person drinks, the more often the weakening processes in their brain take and the quicker their addiction starts to resolve itself. It may seem a little crass to say, but the Sinclair Method really does involve drinking yourself sober. For many, it offers a lifeline, particularly if they have had to endure several undignified and painful rounds of abstention.

How doctors can play a role in de-addiction

Taking control of your life and your drinking habits involves accepting your addiction and acting on it as soon as possible. Only a qualified doctor will be able to prescribe an opioid antagonist such as nalmefene or naltrexone, so it is very important that you enlist their help before following the Sinclair method unaided.

Of course, it should come as no surprise that most health professionals are quite reluctant to advise patients to carry on drinking whilst taking nalmefene or naltrexone. In all likelihood, they will say something along the lines of “If you do feel the need to drink, always remember to take your medication beforehand.” They may also tell you not to take these medications on days that you do not intend to drink, as they will have no beneficial effects on their own.

It may seem a little odd for doctors not to advise patients to drink whilst taking opioid antagonists when there is clear evidence that it works. However, it is clear to see that there are ethical implications associated with this advice. Ultimately, most doctors will prescribe nalmefene or naltrexone safe in the knowledge that their addicted patients are almost certain to drink anyway, regardless of the advice they give. Advising them to take the medication if they feel the urge to drink is a safe way to get the drug to work effectively without compromising their medical professionalism.

What is the aim of the Sinclair Method?

The ultimate goal of the Sinclair Method is to restore alcohol cravings and consumption to levels that are safe and will not damage the body. Whilst doctors are unlikely to advise drinking on opioid antagonists, it is worth noting the extensive research that has been done surrounding its clear efficacy. Success is depending on rewiring the neural connections responsible for maintaining addictive tendencies, rewiring that can only be done with alcohol consumption.

With this in mind, many with knowledge in the field of addiction have raised the point that instructing patients to take the medication in an ineffective way could be unethical. If you feel comfortable with your doctor, it may be worth guiding them towards relevant research articles and studies on the topic, particularly if they lack knowledge about the Sinclair Method or how naltrexone and nalmefene work.

Whilst they may dismiss it at first, they are likely to change their mind when they see that the notion of pharmacological extinction is now well-established in the realm of mainstream medicine, with over seventy clinical trials published to support its efficacy. It could also be helpful to inform them that naltrexone has been around for many years, having been approved by the FDA over 25 years ago and even endorsed by the WHO.

Is it possible for people to abuse nalmefene or naltrexone?

No. Opioid antagonists cannot be abused as they do not have the capability of providing their users with highs or pleasurable feelings. This makes them much safer to use than many other drugs available on prescription. It is also impossible to get addicted to nalmefene or naltrexone, meaning doctors should feel confident about prescribing them to patients.

What are the usual dosages for naltrexone or nalmefene?

The standard dose of naltrexone is 50mg taken around one hour prior to drinking. Some doctors recommend that patients begin on half dosages of 25mg to help their bodies get used to the medication.

For nalmefene, the average dose is around 18mg.

Are there any restrictions to who can take nalmefene or naltrexone?

Users of naltrexone are required to undergo a blood test before taking the medication to check for any signs of liver damage. This is done because the drug can put stress on the liver when taken in large amounts. It is important to note that normal doses of naltrexone should not cause any liver issues and that the tests tend to be done as a precautionary measure.

It should also be noted that whilst some patients are prescribed up to 150mg of naltrexone, it is imperative that every patient follows their individual treatment regime. If you are prescribed 50mg, do not take more than this. Ingesting a higher dose will not make the drug any more effective or speed up your rate of recovery. Indeed, most people find that a dose of 50mg is adequate to block 100% of their opioid receptors. People taking 100-150mg of the drug are unusual cases.

One of the best things about nalmefene is that it does need to be metabolised in the liver. As such, patients who are prescribed the drug do not need to undergo any liver function tests before taking it.

How often should opioid antagonists be taken?

You should only take nalmefene or naltrexone on the days that you drink. If you have a problem with weekend drinking but usually abstain on weekdays, for example, then you should only take your medication on the weekend. Of course, if you drink every day then you will need to take your dose of nalmefene or naltrexone every day.

If you accidentally drink some alcohol and realise that you have not taken your medication, make sure to dose yourself immediately. Indeed, it is very important to keep your medication with you at all times to avoid any slip-ups. Some people who have managed to stay sober for years actually keep a stash of medication with them in case of emergencies. It may seem excessive, but doing so often gives them the peace of mind they need to stay happy and sober.

Concluding notes

Hopefully, it is plain to see by now that drinking alongside taking naltrexone or nalmefene can be a hugely effective way of curing alcohol dependency, however counterintuitive it may seem at first. Many people have misconceptions about the medications, assuming that abstinence is a safer and more achievable pathway. The scientific studies show that this is not the case, however. Abstaining in general almost always ends up with frustrating cycles of relapse. Furthermore, abstaining whilst taking naltrexone or nalmefene is almost pointless.

The process of de-addiction is an active one that involves careful planning on the part of the patient. As well as drinking when they feel the urge, they must remember to take their medication as and when necessary. Breaking the cycle of addiction is also a long and gradual process, so it is important that users of opioid antagonists remain patient whilst their bodies get used to neurological changes.

It may be helpful to remember that around 80% of people who follow the Sinclair Method end up regaining their control over alcohol for good. These are very good odds.

To reach Step Three, then, it is time to start thinking about obtaining your prescription for nalmefene or naltrexone. Many doctors who work for the NHS are willing to prescribe their patients with these drugs if it is clear that they will benefit from them.

If your doctor is not convinced that the Sinclair Method is something they are happy to advise on, however, try not to be disappointed. If you are proactive, you may be able to seek help from a different doctor who is more willing to explore this fascinating area of medicine.

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