Part 3 of a 3 part series
This post is one part of a three part story centered around my realization that, as a member of the craft beer community, I had a problem with alcohol and I needed to change my course before things got worse than they already were. If you have not read part 1, I would encourage you to, as there is some important context in there that will help you understand why this particular protocol for reducing my alcohol consumption was so essential for me. To find out how this worked for me and what it felt like to go through this protocol, please see this post.
Before we get into the body of this post, though, I want to include a couple of very important disclaimers.
The first disclaimer is that the Sinclair Method coupled with naltrexone is not the only therapy out there for alcohol related disorders. There are many treatments, ranging from complete abstinence and 12 step programs, to methods based in cognitive science like SMART, to other ways of using naltrexone such as the ‘Harm Reduction’ model, to other similar drugs that are thought to work to reduce alcohol cravings or even make alcohol consumption cause you to feel ill. I am not here to say that any one is ‘better’ or ‘more effective’ than the other. I’m not qualified to do that. More importantly, through my reading and research, I did not find that the evidence is there in the literature to unequivocally support claims like that by anyone. I am here to share my experience with the Sinclair Method, explain the science behind it, and show why it may be uniquely useful to those of us who are members of the craft beer community.
The second disclaimer is that the Sinclair Method addresses only the chemical/neurological side of alcohol dependence. Unlike other therapies out there, it does not address behavioral or mental health issues that may be underlying the alcohol use issues. So, depending on why someone ended up in a problematic relationship with alcohol, counseling or other medical treatments may be beneficial or necessary.
The next disclaimer is: While I am a scientist by training, I am not a neuroscientist, an addiction specialist or a recovery professional. So, the science I present below is my understanding of those resources I read before embarking on the Sinclair Method. This information helped me decide whether it was the right strategy for me, why it might work, and what ‘gotchas’ I needed to look out for. I make no claims that it is exhaustive. I make no claims that it might be shown to be incomplete in the future. (That’s the way all science works, by the way.) What I present is for context and to help show why this method is working for me, has worked for others I know, and may work for some of you reading this (or those you know) to address problems with overconsumption of alcohol, without having to resort to abstinence right out of the gate, or possibly ever.
The final disclaimer is: I make no promises that the method I am sharing with you here will necessarily work for you as it did for me (should you decide you want to try it). No method has 100% success. All methods require buy-in and effort from the participants. My point in presenting this information (and that in the other two related posts) is to expose a lesser known way to address alcohol related problems that may be well suited for people in the beer community. That’s it.
OK. Onward to the good stuff!
First, a bit about alcohol and alcohol dependence.
The number one thing that almost everyone agrees upon about alcohol and its effect on our brains is this: It’s complicated. Alcohol does not affect just one part of the brain. It doesn’t have just one kind of effect. Hell, it doesn’t even affect every person in the same way. That’s one big thing that makes treating alcohol related disorders so difficult. But, that said, one of the things that is pretty well established is that one of the parts of your brain affected by alcohol is the “opioid receptor system.” That last phrase may be one you have heard lately, as it’s been getting a fair amount of press in light of the opioid addiction crisis in our country right now. But, buried in that three word phrase is a lot of information that is very relevant to naltrexone and the Sinclair Method. So, let’s step away from alcohol for a second and learn a little background neuroscience.
I will present this neuroscience background as a set of fairly short and direct statements that lay out the essential information you need to know in order to understand the basis of the Sinclair Method. For each of those statements, I will link it to a more thorough explanation at the bottom of the article for anyone who wants to get more detail or a deeper understanding. This is my attempt to balance brevity with a thorough treatment of the topic.
Important point 1: Among its many effects, alcohol stimulates our reward/pleasure pathways – this is the opioid receptor system I referred to above. Things that stimulate that system tend to be addictive, and over time we require more and more of them to get the pleasant effects we have grown accustomed to. Hence, we start with low levels of consumption and ramp up over time. This will sound very familiar to anyone with a drug or alcohol problem.
Important point 2: Our brains are really good at learning to associate a chemical stimulus with the paired behavioral or neurological response. In many cases, once “trained,” we don’t even need the actual drug or chemical in our brain to elicit this behavioral or neurological response. Think of the classic experiments Pavlov did with dogs. This is what is known as a ‘conditioned response.’ After many repeated exposures (e.g. consistent or problem drinking), ingestion of alcohol (or nonalcoholic versions of beers or cocktails) will produce the pleasure/reward response BEFORE the alcohol ever makes it into the bloodstream and to your brain. In heavy drinkers even visual cues (pictures of alcoholic beverages) can produce this effect.
Important point 3: Naltrexone is a member of the opioid family of drugs. (Fortunately for the purpose of this treatment, it is NOT addictive. At all. Quite the opposite, actually.) Both Alcohol and Naltrexone will interact with the pleasure/reward pathways in our brain. Alcohol produces the pleasure/reward response but naltrexone will NOT. Naltrexone also prevents any other drug or chemical from generating the pleasure/reward response while it is present. This kind of drug is called an ‘opioid antagonist.’ In plain terms, it completely blocks the brain’s response to drugs, such as alcohol, that normally stimulate the opioid reward system. This idea sets up the basis of the Sinclair Method.
Important point 4: Just as we can induce a conditioned response in our brains, we can also de-condition the brain. This process is called ‘extinction’. If you repeatedly introduce the conditioned stimulus (in our case, exposure to alcohol), but prevent the neurochemical response (in our case, by blocking it with naltrexone so the pleasure response does not happen), our brain will ‘unlearn’ the conditioned response. In our case, that means it will unlink drinking alcohol from activation of the pleasure/reward system.
Important point 5: If you drink alcohol after you have taken naltrexone, you will still become intoxicated as normal. You just won’t have the pleasant warm ‘tipsy’ high that normally comes along with that. So, naltrexone in NO WAY prevents issues with drunkenness, DUIs, or that sort of thing. It just stops the ‘high’ that comes along with drinking – particularly in those of us that are problem drinkers. (This is not directly relevant to the Sinclair Method, but is important to understand for fairly obvious reasons. Naltrexone will not allow you to drink alcohol without consequences!)
Important point 6: For the Sinclair Method to work, it is necessary for you to continue drinking alcohol while taking naltrexone. This is how the extinction process works! If you repeatedly expose yourself to alcohol when you have taken naltrexone, your body starts the process of ‘unlearning’ the association between alcohol and pleasure. This process takes 90 days for the bulk of the effects and up to 9 months to totally complete. (Don’t freak out about the 9 month part! The changes that happen in 90 days are massive.) Once completed, that yearning or compulsion to drink (and drink a lot) goes away.
Important point 7: After the extinction process is complete, in theory you are right back where you were when you first encountered alcohol, lo those many years ago. You could have a drink without naltrexone present and no longer have the conditioned response, meaning the ‘high’ you got would be very mild, and not nearly as strongly addictive as it was before you started the Sinclair Method. In practice, the proponents of the Sinclair Method strongly advise against this. Instead, they advise that, going forward, you always take a naltrexone pill an hour before you have your first drink. This is to be sure that you don’t re-start the conditioning process again. This makes sense, as those of us who became strongly conditioned to alcohol are the most likely to have it happen a second time if we experience the same stimuli. So, don’t do that! Better safe than sorry, eh?
So, let’s integrate those statements and explain the process of the Sinclair Method.
The nuts and bolts of the Sinclair method:
If you have decided to pursue the Sinclair method to reduce your drinking (or stop completely), you will have been to your doctor (more on this in part 3) and will now have a supply of naltrexone to work with. Each day, about an hour before you would normally have your first drink, you take a naltrexone pill. This gives the naltrexone time to be absorbed by your system and effectively block the opioid receptor system.
Then, you consume alcohol just as you normally would. You won’t force yourself to drink any more or any less than you naturally desire, but rather consume it per your typical habit. While this seems antithetical to most treatment programs that demand abstinence, including some that utilize naltrexone, this is key to the extinction process. When you have that first drink with naltrexone on board, that rush you normally feel when you have your first beverage of the day will … not happen. (Full disclosure, at the very beginning, it may still happen to some degree because of the conditioning process. This effect will disappear within a very short time frame – a couple days to a week at most.)
When you keep repeating this day after day, your body begins to ‘unlearn’ the link between alcohol and a strong opioid receptor reward response. Thus, your natural craving for alcohol starts dropping quickly since it is no longer producing the ‘high’ it used to and which your body is looking for. As a key aside, it is not the naltrexone that is stopping the craving for alcohol, it is the learning/extinction process that’s doing it. It’s your brain finding that the alcohol will no longer produce the high it used to, so it no longer craves alcohol. This is a subtle, but important concept.
Moving forward, regardless of your reduced desire for alcohol, you keep taking a naltrexone daily 90 days, and you have at least a single drink each day, about an hour after taking your naltrexone pill. This drives the extinction process toward completion and makes sure that your body fully dissociates the link between alcohol and the ‘high’ it used to produce.
After 90 days, you have choices to make.
If you no longer have the desire to drink, then don’t! On any day you don’t drink, don’t take a naltrexone. By doing this on any non-drinking day, you open up your reward system to be stimulated by other things like flavorful/spicy/indulgent foods, exercise, sex, or anything else that gives you pleasure. In this way, you re-train your reward system once again so that it learns that something healthy, rather than alcohol, is the way to get that reward response.
If, after 90 days, you still want to drink, you can. Just make sure you take a naltrexone an hour before you consume alcohol so you don’t start re-conditioning your reward system. If you’re anything like most of the folks who have tried this method, you may be surprised to find that you’re not nearly as interested in alcoholic beverages as you once were. You’ll probably find that having non-drinking days becomes more normal and easier with each passing week. On the other hand, on days when you want to drink, you now know how to control it, such that you can have just one or two drinks and then… stop. Easily.
That’s it! That’s the whole method. Drink with naltrexone ‘on board’ until you have completed the extinction process, then decide when and how much you want to drink (but always with naltrexone beforehand) after that is done.
Now, I would be remiss to not remind you of the following: Many of us became problem drinkers because we were using it as a way to escape problems or deal with stress, or even to self-medicate to “treat” an unmanaged mental illness. If that’s true of you, and if you don’t address that underlying problem (either on your own or with the help of a counselor or doctor), then odds are that any success you have with this protocol will rapidly vanish. After all, you will have treated the symptom and not the cause. Please be aware of this and get the supplementary help you need.
I hope the information I have presented above is helpful to someone. If this was of interest to you and you’d like to hear more about my personal journey and experiences using the Sinclair method, please read on. After you have read that, if you have further questions, please feel free to ask in the comment section below any of the posts or to contact me directly. I can’t advise you on any medical fronts, as I am not a doctor. For anyone considering pursuing the moethod explained here, please have an honest conversation with a doctor who understands the issues surrounding substance abuse and withdrawal. Take the information presented here for what it is – a first person account – as I am not a neuroscientist or addiction specialist. But, I’m happy to share any part of my personal experience if that helps anyone else out there.
Important point 1 details: Lots of chemicals have effects on your brain and there are various ways they do this. The relevant model for what we’re discussing here is sometimes referred to as a ‘ligand-receptor interaction.’ What that means in common language is that a small molecule (the ligand) can bump into and stick to a protein (the receptor) on the surface of a cell. When that happens, the receptor sends a signal to the interior of the cell which results in some kind of response by the cell. It may cause the cell to move or release certain chemicals within the cell, or any number of other things. In the case we’re interested in (the opioid receptor system), the receptors are proteins that have evolved to recognize various molecules produced by our bodies which trigger the pleasure and reward systems in our brains. As a coincidence, they also recognize molecules from the opioid family of drugs, cannabinoids, nicotine, and, yes, alcohol. So, when one of these molecules sticks to the receptor, the receptor causes the release of a chemicals within the cell that cause you to experience feelings of pleasure and reward. As it turns out, that response is addictive – highly addictive for some of us, depending on our particular genetic makeup. What is also true about these ligand-receptor systems is that they habituate to the stimuli that trigger them. Again, in plain English, that means that when you repeatedly trigger them, each time you do it, it takes more ligand to get the same degree of response; a.k.a. you develop a tolerance to your substance of choice. Hence, drinking and drug use tend to escalate as we need successively more and more of the chemical to get that pleasant euphoria that we have experienced in the past.
Important point 2 details: The second key concept that helps explain our addictive response to drugs like alcohol, and which starts to explain the theory behind the Sinclair method, is that while habituation increases the amount of drug it takes to get a response over time, anticipation or ‘conditioning’ decreases the need for the drug at all. In the context of alcohol and the opioid response, this means that the first few (several, many) times we ingest alcohol, it’s the physical interaction between the alcohol and the opioid receptors that produces the pleasure response. In time, however, our brain learns that when alcohol is ingested, there is going to be a response, and it can essentially shortcut the circuit and generate the response immediately and in some cases without the presence of the real chemical at all. The classic example of this is Pavlov and his dogs. He conditioned them that every time he fed them, he rang a bell. They learned that the bell meant food was coming and they would begin to salivate. After a while of this, the food wasn’t even needed. He could ring the bell and the dogs would salivate. Alcohol and the opioid system do much the same thing. Over many years, heavy drinkers will begin to notice that as soon as they taste their first sip or two of an alcoholic drink, they get a ‘rush.’ For me, I’d perceive it as a wave of warmth that would pass through my head, over my scalp and down my neck. My shoulders would relax. I’d exhale a deep breath and think, “Ahhhhh…. that’s a tasty beer. Damn, I’ve been looking forward to that all day.” Bam. That’s the conditioned opioid response. NONE of the alcohol in that beer has made it to my brain yet, but I’m already getting the reward response. That, then tides me over until I can accumulate enough alcohol in my bloodstream to stimulate the actual opioid response, and I get a prolonged and wonderful high. This is where the addictive mechanisms really bloom forth and your brain has been fully conditioned that “alcohol = pleasure,” and you’re off on the wild ride toward alcohol dependence/abuse. The more complete the conditioning becomes, the more tangential the ‘stimulus’ can be. In the case of alcohol abuse, various studies have shown the reward system can be triggered by things like the aroma of a favored drink, the flavor of a non-alcoholic version of a drink, or even pictures of alcohol and the settings it is served in. This is one of the big challenges of classical 12-step/abstinence programs. They may well get a person to stop drinking, but they never address the conditioning issue, so any of those triggers mentioned above may stimulate the reward response and set off a serious relapse event. This is (in part) why a lot of those programs strongly counsel their patients to not even be around cues that are suggestive of alcohol – a situation that is not terribly tenable for those of us who work in the craft industry.
Important point 3 details: Remember in point 1 where I said that ligands binding to receptors cause them to signal for various things in the cell? Well, as my old graduate advisor said when he wanted to clarify something, “It’s time I lie to you a little less.” Most times when a ligand binds to a receptor, it causes the receptor to signal to the cell for some kind of response. But, occasionally, there are drugs that are chemically very similar to the ones which elicit receptor responses, but are different is subtle ways. Occasionally, this allows for a really unique thing to happen. The drug is similar enough to ‘fool’ the receptor so that it can bind to it. But, when it does so, it’s missing some key chemical feature that is the thing that trips the receptor to signal like it usually does. So, in our context, a drug like that will not elicit the normal pleasure response from the opioid receptors, but it will occupy the place that alcohol or an opioid drug would normally bind, and block the alcohol from binding to the receptor, thus preventing stimulation of the pleasure response like it normally would. Naltrexone interacts with our opioid receptors like this, and is known as an ‘opioid antagonist’ as a result.
So, in practical terms, if you take a dose of naltrexone, give it a little time to make it through your bloodstream and into your brain, then when you take a drink of alcohol… nothing happens. Well, that’s not totally true. You’ll still get intoxicated (eventually), but the alcohol will elicit no pleasure/reward response as long as the naltrexone is there!
Once again, that’s not wholly true, because when you first try this experiment, your brain will still give you the conditioned response. (After all, as a problem drinker, you have trained it well.) But, after a few minutes, you will not get the actual neurochemical response that normally follows. So, you’ll get a temporary reward, but the longer term reward will not follow. This is KEY to understanding why the Sinclair method works to reduce the desire to drink.
Important point 4 details: The simple example of this process goes right back to Pavlov and his dogs. After he conditioned them to expect food when a bell rang, and therefore start salivating, that response persisted until he started repeatedly ringing the bell and not giving them food. For a short time, the dogs would continue to salivate whether food was provided or not. But, in very short order they learned that the bell did not necessarily mean food and the salivation response went away. Extinction occurred! We can do the same thing with alcohol by blocking the opioid receptor response with naltrexone. We can re-train our brain that alcohol is NOT something that produces that pleasant high, and this is the start of being able to decondition the response that set up the addiction in the first place. This is huge!
Important point 5 details: There are no real additional details to share here. Just be aware that you may, in fact, feel less intoxicated than normal when you consume alcohol after having taken naltrexone since the initial reward/rush is not there. Assume you are more intoxicated than you feel. This becomes doubly an issue as the treatment goes on, as you will begin to lose some of the alcohol tolerance you have built up with consistent overconsumption. As I’ll discuss in the next part, it becomes very easy to mis-calibrate how much you can drink and how drunk you are. Be careful!
Important point 6 details: The key to the extinction process is unlinking the stimulus (alcohol) from the response (reward). So, if all you ever do is abstain, then your brain still is primed to think that IF it can get a hold of some alcohol, it will be able to elicit the reward response. Experiments done by Dr. Sinclair show this state persists almost indefinitely for those habituated to alcohol. Simply abstaining will NOT lead to a lessening of the craving – almost without regard to how long it has been since the last drink. As I mentioned above, this is a major issue with people who try to treat alcohol addiction by going “cold turkey” or “white knuckling it.” Worse, not only does the conditioning not go away, according to some fo Dr. Sinclair’s experiments, it can get worse over time. So, simple abstinence without going through the extinction process can mean indefinitely having to face the craving for alcohol.
On the other hand, if you do go through the extinction process, you essentially force your brain to learn that the presence of alcohol will no longer stimulate the reward system (with a little trickery and help from naltrexone). After doing this long enough (90 days for much of the effect, 9 months for the total effect), that link is broken in your brain and now a glass of beer, wine, whiskey, or whatever, becomes… just that. A glass of something you can drink. You may still enjoy it. You may find out you don’t any more. (More on that in part 3!) But, if/ when you have your first drink of the day, you should find out that the strong desire to have another (and another, and another) is no longer there, as that addictive high will not be present when you consume your first drink.
Important point 7 details: Based on the theories put forth by psychologists and neuroscientists, once someone has gone through conditioning and extinction, they should be right back where they started in terms of their response to the original stimulus. Certainly, in the case of Pavlov’s dogs (that I keep bringing up), this was the case. After completing the extinction process (ringing bells and not feeding them), the dogs no longer responded to the bells in any significant way.
However, for those of us who have had problems with alcohol, caution is warranted here. One of the reasons proposed for why some folks become alcoholics (or problem smokers, or addicted to painkillers) is that they have an innately stronger response to stimulants of the opioid receptor system.
The way I have heard this phrased is that everyone who consumes alcohol is on a pathway to become addicted. The question is simply how fast they will move along that path and how rapid the feedback between alcohol and their reward system will be. This model suggests that, for those of us who have had problems with overuse of alcohol, we simply have a much stronger response from our opioid receptor system to the presence of alcohol. We get a larger reward from a smaller amount of alcohol, and we condition our system much more rapidly as a result.
So, what that suggests is that we are uniquely susceptible to re-conditioning, if we allow ourselves to consume alcohol and do not block the reward response by using naltrexone. Thus, the strong recommendation from the proponents of the Sinclair method is to never take that risk and to always take a naltrexone at least an hour before consuming alcohol.
To put it another way: Assuming you have done the work to successfully complete the extinction process and the Sinclair method, why risk it? If you want to have a drink, go for it! But, take your naltrexone first. It’s cheap. It causes essentially no side effects. It staves off the risk of re-conditioning. Don’t play with fire.
Editors Note: Sommbeer.com is not providing nor is capable of providing medical advice. Further, we are not receiving compensation of any sort from this article. We do believe that change comes from within and that there are many many workers within the craft industry (and world at large) that suffer from alcohol dependency. The hurt extends to friends and family. If this series positively impacts even just one person – it will be worth it.
- Retraining the Brain to Fight Alcoholism using Naltrexone and the Sinclair Method - 01/02/2020
- My Experiences with the Sinclair Method and Naltrexone to Reduce My Alcohol Consumption - 01/02/2020
- An open letter from a craft beer enthusiast, a sporadic beer blog contributor, a brewing science scholar, a beer judge… and an alcoholic - 01/02/2020