Science may one day accomplish this…

Sinclair Method

By life-j.

AA seems to work by a combination of mutual self help and a spiritual practice however you wish to define that. Several million people have gotten sober in AA in this way. And while we in AA have gotten used to the ideas of “once an alcoholic always an alcoholic”, and abstinence being the only way to arrest typical dysfunctional alcoholism, Bill Wilson was aware that one day science might catch up with our way of working recovery:

Physicians who are familiar with alcoholism agree there is no such thing as making a normal drinker out of an alcoholic. Science may one day accomplish this, but it hasn’t done so yet.

It is now almost 80 years since Bill wrote this, and science has indeed made some progress in this area, though AA by no means has become obsolete.

Several physicians, including Gabor Maté and David Sinclair have been working on developing a biological understanding of alcoholism.

There is now pretty good general agreement that the mechanism of alcoholism involves a particular, less than optimal way of our body’s processing of endorphines, dopamine, and other “happy-hormones”.

Since our primary purpose is to help the suffering alcoholic we ought to consider all options, even those that differ from regular AA philosophy. For what it’s worth, I think Bill Wilson would have liked that, he experimented with LSD and other substances that held out promise in helping with alcohol recovery. In this article I will focus on the work of Dr. David Sinclair, an American physician, who spent most of his working life in Finland, because his work was well received there and attained considerable success which is now slowly spreading to the rest of the world.

Dr Sinclair, who recently died, was using an opioid antagonist in treatment of alcoholism. In the brain there are opioid receptors which, when endorphines attach to them, create a pleasurable feeling. Alcoholics seem to be born with a low natural output of endorphines, thus we are likely to look for pleasurable activities which will trigger the release endorphines. Drinking or any other addictive behavior will. So what we’re really addicted to is the endorphine release, that’s why for many of us our favorite substance was “more”. This endorphine release by addictive behavior is a learned phenomenon, much like pavlovian conditioning, and can be unlearned by blocking the process. If the opioid receptors are blocked by an opioid antagonist, they can not receive the endorphines, and there will be no sensation of pleasure associated with taking a drink. The opioid antagonist primarily used is Naltrexone. There is a newer formula called Nalmefene, and there is also a long acting injectionable version of Naltrexone called Vivitrol, The latter is very expensive, and does not even appear to work that well.

Naltrexone has been around since the 70s, and Dr Sinclair worked with it for most of that time. The treatment method approved by the FDA in the US with Naltrexone calls for abstinence, and taking it every day. Dr Sinclair has found that this does not work nearly as well as taking it in combination with drinking. When taking it an hour before drinking it blocks all opioid receptors, the drinking will be a bland experience, even though a person can still get every bit as drunk, only there is no pleasure associated with it. Thus the craving will subside in a process called pharmacological extinxtion.

Most alcoholics when they quit drinking experience a craving for alcohol, and can even have withdrawal symptoms which can be quite severe. With abstinence the craving can remain for a long time, or come back when we least expect it. Taking Antabuse which has been the main pharmacological treatment of alcoholics does nothing to subdue the craving, it just makes it potentially life threatening to drink. That doesn’t scare some of us. For many of us it already is.

Naltrexone on the other hand, in combination with drinking not only takes the craving away in a gradual, controlled manner, it also makes it possible to taper off the alcohol in such a manner that it does not cause severe withdrawal symptoms.

The success rate when done according to The Sinclair Method appears to be significant. According to Sinclair’s statistics over a few months 40% stop drinking altogether, another 40% cut their drinking in half or better, and the remaining 20% seem to have little or no success with it. Still that’s way better than we can generally present in AA. As for the long term success rate they tell me that the main problem is compliance. Just like we in AA often keep going to meetings and work our program for the rest of our lives, and of those that don’t many relapse, so in TSM you are supposed to carry a pill with you wherever you go, just in case you drink, and most wind up getting lax about it after a while, and of course if they drink without it, they get sucked right back in just like when an AA’er relapses.

So, there’s 40% that stop altogether, their craving apparently gone. This is impressive enough to where it ought to get any recovering alcoholic’s attention. As for the other 40%, the first objection we will hear in AA is of course that we can’t imagine that anything other than total abstinence will work. With 28 years sober myself, I can indeed not imagine drinking again, but the Sinclair Method is not for me, I am already abstinent, I have my program. And AA works for all those of us that it works for. As for all those that do not thoroughly follow our path, and relapse over and over, well, what do we want to do with them? Write them off as recalcitrants or be glad that they have cut back to the point where they may be on a path to recovery? If they keep following the Sinclair Method they will apparently wind up drinking ever less – so long as they take that one little pill before they drink.

And be dependent on that pill for the rest of your life? Well, yes, or be dependent on the AA program for the rest of your life. I don’t think the difference there is all that great. Especially if it works that well.

Now there is of course another aspect to this. There is a social and emotional, and maybe a spiritual component to our drinking, and that part does not get addressed by the medication at all. This is where AA’s strength lies. We address those issues. And I can imagine that many of Sinclair’s clients are in need of further help in those areas. I guess it is up to us whether we are willing to embrace that science has indeed made progress in this area, and accept that recovery may begin somewhere other than total abstinence for some people, and that we can help them, or we can dismiss them because they arent following our path the way we’re used to doing it.

If we do, then there is of course Cognitive Behavioral Therapy, and a few other recovery programs of a more secular nature. But let’s admit it – no-one is forcing those of us who have been sober for a while to start drinking again, just so we can cut back, or even advocating that we do. We’re already sober. This is strictly for the alcoholic who still suffers, and can’t seem to get sober the regular AA way. When anyone, anywhere reaches out for help, I want there to be a hand to help them, whether they want to do it my way or not, so long as I can tell they indeed have a desire to stop drinking. It’s not my way or the highway anymore.


For a longer discussion on the workings of Naltrexone and other opoid antagonists, please see AA Beyond Belief: The Sinclair Method.

There is also an interesting article, with a number of links, here: Why Isn’t The Sinclair Method Used More Often?


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Science may one day accomplish this… — 21 Comments

  1. I really appreciate your article. I was in AA for 28 years and at the end was having relapse after relapse. I started believing I was one of those unfortunates that is in the preamble read before every meeting. And had decided I might as well kill myself. If I left AA, I had been told for years I would die, but I was going to die in AA. I left a meeting one night and googled treatment for alcoholism, and went by the newest information. And found The Sinclair Method. I was amazed. I got some and started using it, and no longer have a drinking problem. I hear things like I wasn’t a real alcoholic, etc. Believe me, I was a real alcoholic. Still hurts that the “friends I had in AA” have disowned me, like I have something catching. Oh well, better to be alive and lose AA and the people in it, than be dead.

  2. Excellent observations and assessments, life-j. I believe our founders would have celebrated our growing body of scientifically evidence-based information, which enhances further our opportunities to find joyful sober living, even when it relegates their own magical fundamentalist convictions to historical footnotes. Bill W. and Dr. Bob did earn their permanent spots in our 20th century history books.

  3. Something is really amiss here.

    When reading Dave J’s comment I’m puzzled by the extent to which people make an effort to not understand what this medication is about.

    This is not about having excuses to drink, or be able to keep drinking with impunity, or have your drinking spoiled, but keeping desperately trying to get drunk, or any of the other miserable scenarios some people paint.

    It seems like while AA has indeed helped all of us get and stay sober – we are after all the ones who didn’t go back out and stay out – a lot of people are still stuck in the idea that AA recovery is the only way, only with us it is minus god, but otherwise everything is all the same, every last irrational bit of it.

    And every twisted AA explanation gets to be the standard that we measure everything else by.

    There are so many other strange questions we could ask ourselves, such as “why would I want to quit drinking, if what I really want is to drink myself to death?” “Why take a pill to help me get sober, if I can suffer instead?” “How can I in good conscience support taking a medication which makes sobering up easier, when I’m aware of how much previous generations of AAs had to go through to get sober?” “Why would I want to take a pill that takes the pleasure of drinking away, if I want to quit drinking anyway?”

    Huh?

    So many questions, so little sense….

    • Thanks for a great article, life. Being a bit ornery myself (grumpy old woman, me :-), I always appreciate your perspective which seriously and intelligently interrogates a few of the traditional AA dictums – 0f which many of us here know are overdue for puncturing.

      I was offered / recommended Naltrexone (via GP and rehab) last year, I think – after one of my relapses, anyway. Philosophically, I had no problem with trialling such a med. But unfortunately, I had realised several years ago, before getting some serious rehab treatment and starting AA attendance (both from 2012), that the newer drugs for dealing with cravings just had too many hideous side-effects for me. I was on Baclofen + Topamax + Campral, together!

      I was still drinking at the time, but desperate to stop, and took them under the tutelage of an addiction-specialist GP where I lived at the time. (And they’re as rare as hens’ teeth). That’s how desperate I was, so I persevered for about 6? months before giving them up completely and abandoning myself to full-on active alcoholism.

      Returning to more recently, when offered Nal, and having done quite a lot of my own research beforehand anyway out of interest, I declined. I was very concerned about the depression side-effect (oft-reported) and couldn’t afford to risk adding to my existing lifelong depression. So that’s just me.

      Overall, I do believe that it does need to be offered to the still-suffering alcoholic (as per the Sinclair method) even just to try – much like any other of these newer medications. On that note, I just re-read the entire AA-on-medications pamphlet [link below], and surprise surprise, it’s solely devoted to things like meds for mental illnesses and a few other chronic physiological illnesses. No mention at all of any of the explicitly-targeted meds for cravings.

      To give the benefit of the doubt: I’m guessing these meds were barely known about for alcoholism in 2011. That’s when the pamphlet was revised. Already that’s five years ago, a long time in science. I noted with part-horror, part-amusement, that the first and only other edition of the pamphlet was published in…. wait for it: 1984. Sheesh!

      AA and Medications

      In closing, here’s an interesting article (with equally interesting comments) on the subject, from the American Society of Addiction Medicine: Treatment Toolkit: AA.

  4. If they have a pill which will allow me to have 3 martinis that instantly make me funnier, smarter and better looking AND call a cab to get me home at the time I said I’d be home. I definitely want a prescription for that. But a pill that gets me drunk without any of the above. Why?

  5. I was given naltrexone (Revia) once, when I began my last rehab in 2001 (I had been through detox before I got there). After the first dose of naltrexone I was overcome with a horrifying depression that only went away when I stopped taking the drug. All I could figure out was that I must have needed every bit of my naturally produced endorphins just to feel minimally OK, and that the naltrexone must have robbed me of that little bit of endorphin effect. I don’t know if that’s true. I ran it by the Dr. in charge, a Dr. John Gant, but it seemed he was so invested in proving the drug regimen worked that he dismissed my complaint and my thesis.

    Way back in 1969, when I was 19 and already a severe alcoholic, I began to abuse opioid drugs as an alternative to my blackout drinking. In 1974, after 5 years of hellish alcoholism and drug addiction, I was intrigued when I read about the discovery of endorphins. I quickly theorized that my ravenous affinity for narcotic drugs was the result of my being born with an endorphin deficiency. When I got to AA 20 years later, I used to share that story as being an example of my misguided rationales for my drug and alcohol abuse. Now, it appears that it was true!

    • Skip, an interesting response to the drug, and it kind of makes sense, that some would have a response like that, sort of like over-reacting to the absence of pleasure. Would be interesting to hear how frequent that scenario is. And it is only by keeping experimenting (those that can) and by openly reporting all results that we can establish what works for whom and how well. No one thing is for everybody. It would stand to reason that naltrexone, like everything else, doesn’t work for everyone. but of course we cant thereby dismiss that it may work very well for a large number of people for whom AA and other approaches don’t seem to work so well.

      • Yes, I’m sure it works for some, and it should be more available than it seems to be. It’s like Antabuse (you could call naltrexone Cantabuse), Antabuse works well for some, but not 40%. I also doubt that the naltrexone 40% rate would hold up in a real treatment environment, but it would maybe help a meaningful percentage.

  6. Can you imagine a world where AA, as a whole – as an organization, is compatible with contemporary science and and the variety of belief and non-belief that exists in the world? I really do think the foundation we are built on could accommodate that. It would require evolution to be part of our equation.

    • Bill W had done all the research necessary to give us alcoholics his Vitamin-B-3 Therapy in the sixties that was helping over 70% hardcore treatment failure alcoholics to sober up: The Vitamin B-3 Therapy. (Don’t miss the last page. And on its second last page, you will see that those who did not stop drinking continued taking Vitamin B-3 because they found the alcohol withdrawal tolerable – were they hard drinkers who had become social drinkers!). But unfortunately even Bill was not allowed by the AA General Service Board to share about this vitamin cure for alcoholism in AA. I sincerely hope General Service Board allows us agnostics to talk about this fantastic research of Bill W in AA.

      Life-j, the physicians and medical professionals today are trained only in arts of pharmacology and surgery that prescribe pharmaceutical drugs designed by the biophysicists trained in physiology and use surgical equipment designed by bio-engineering research scholars. While the natural science of the body works is Physiology. I know this because I have been doing my research in physiology the past five years to understand the addiction problem, and fortunately, I had also been one of the top ranking students of the Indian Institute of Technology (IIT), one of the best Universities of India.

      Physiology is the study of body function, and physiologists use the principles of physics and chemistry to understand body functions. And the medical physicians are not well trained in it. It requires real mastery over physics to understand the physics involved in physiology, and these physicians are not good at it. This is why most physicians prescribe drugs without even knowing how the body or the brain functions. For instance, the brain is such a sensitive organ that it has its own blood-brain barrier that prevents any chemical nutrient that is alien to the brain-chemistry from entering the brain from the body. But today the pharmaceutical companies are making psychoactive medications that can cross the blood-brain barrier, and physicians are prescribing these drugs. This is how they make us addicted to their medications. And today prescription painkiller drugs are causing more overdose deaths than heroin and cocaine combined: CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. And of these deaths one in every three deaths is cause by Methadone: Prescription Painkiller Overdoses. But these physicians are claiming the Methadone is the best evidence based therapy for heroin addiction. It’s a very grave situation indeed!!

      • If they find a cure for cancer and you get it, you won’t use it, and just die? I just don’t understand that reasoning. I’m going to use the latest and best treatment I can find. Jehovah Witness won’t have blood transfusions because of what they read in the Bible. I just won’t do either.

  7. Good article, life-j. What I don’t understand, as an alcoholic, is why I would bother drinking alcohol if I cut off the effects. Sure, I enjoyed the taste of beer, wine, and Manhattans until the later days, but no more than I enjoy T-bones or waffles. I do enjoy a nonalcoholic beer on a hot day or with pizza, but if I don’t have any in the house, I just drink something else. If I do open one, I’m apt not to finish it. In a way, the Sinclair method may make too big a deal out of the beverage. I guess I have more to learn.

    • Thanks, Pat — I too on occasion since 2001 have imbibed NA beers with no dire negative impact. I was not “struck drunk” by drinking NA beers, as some of my colleagues even in liberal New York City AA at the time predicted I would.

      I consider myself as a successfully social NA beer drinker . . . 😉 I can take it or leave it, even leaving some not drunk in an open bottle, which I prefer rather than in a glass.

    • Pat, I guess it would be if you would want to quit drinking. I guess the reason you would “bother drinking alcohol” would be that you were still used to the idea that it was the thing that would solve your problem, or you would sometimes say yes to a drink out of habit or perceived social pressure – in other words – THE reasons that relapsers drink, or people drink who can not even stop, much less get sober the AA way. You have been sober for many years, so this is not for you to use on yourself, this is for you to help the person who is still drinking, but wants to stop.

      So the scenario would be that a person wants to quit drinking, but cannot. Sounds familiar? So this person takes a pill an hour before drinking. The drinking gets that person drunk, but there is no pleasure associated with it. I have been told that at this stage, the first couple of times the person may spontaneously drink extra hard in pursuit of a pleasurable feeling, with his body not really connecting the dots – it’s because I took that pill, that I feel no pleasure.

      So there are two outcomes here: The person – who wanted to quit drinking, remember? – either says no, I need the pleasurable feeling, I don’t want to or dare to quit after all, to hell with this pill (and he may already have said to hell with AA in the course of several tries). If a person is not able to let go of the need to feel good on any level, whether by pill or by AA, nothing can really be done.

      The other outcome is that the person realizes that this pill may indeed take away the pleasurable feeling from drinking – since indeed this is what he was told it would do, and that this might be a good way to quit drinking. Thus, while he is still in the grips of craving, he keeps taking the pill an hour before he drinks, and over a few weeks his craving diminishes, in many cases to the point of non-existence.

      Then he would look back on the last few weeks and say to himself – this stuff works! Then hopefully his next thought would be – I drank for a reason, that reason is still there, so while I have to keep carrying the little pill with me in case I ever am inclined to have a drink again (we alcoholics have been known to do that at obscure times and for obscure reasons) – I will need something more – I will need some therapy, or I will need to go to AA or another mutual self help program to work on that stuff.

      So – we would keep drinking even if the pleasure wanes until the pleasure had waned entirely, because we were addicted to alcohol.

      I don’t know if you were addicted to T-bones, but I can tell you, I’m still addicted to sweets, such as waffles. I constantly struggle with not eating sweets. Doesn’t get me arrested, but it does remind me what craving is. Remember craving? What we’re trying to do here is extinguish craving by a process where, interestingly our body requires a combination of the pill and the alcohol, in order for the craving to diminish.

      When going to AA and abstaining, the craving does not stop. By application of a lot of tough self will – or by application of God’s grace – for some people the craving diminishes, and by having support from each other to grind our teeth through it, some of us indeed remain sober, and the craving diminishes over time. But for the vast majority of those who go to AA the craving either does not go away, or it comes back with a vengeance at some very inopportune moment, and they drink again. Some go through this cycle many times before they either pull together enough self-will or enough god to pull off sobriety.

      What I don’t understand is what don’t you understand about how this pill works?

      Is it just too much to understand that this pill can’t work in a vacuum? It can’t get a person to stop drinking unless it actually gets to interact with the drinking directly. Why is this so hard a concept? Isn’t that how ALL medications work? Take a medication for a mental affliction – in order for it to work, then you must stop the mental affliction before you use the medication – right? no, on the contrary! you are still afflicted, and maybe when taking the medication while you still are, it will work.

      Have a stomach problem? Well before you take a pill to fix your stomach problem you must first stop having the stomach problem, and then take the pill – I have never heard such an absurd line of reasoning – this medication works just like every other medication: You have a problem, you take a pill, the problem diminishes. For some the problem goes away entirely, whether it is a stomach problem or alcoholism. For others all they experience is improvement.

      The only other issue associated with this problem complex is the protestant idea of suffering that AA foists upon the situation: You must not be allowed to quit drinking by simply taking a pill. You must go through suffering in the process of getting sober, otherwise it is not good enough in the eyes of god. But I would think both you and I ought to be able to see through that one?

  8. Thanks life-j for this article, which is a good addition to your your previous article on AA Beyond Belief. I especially appreciate your full respect for both AA and for scientific advancements regarding what we know about addiction and how it works for different cohorts of addicted people. It appears there is no one silver bullet or cookie-cutter approach that works equally well for everyone with an addictive disorder.

    Throughout my recovery for the past 44 years primarily in AA, I have never been medication-aversive, having used a number of pharmaceutical medications for other mental health disorders that I have in addition to addiction. I have even used plant medicines, which addiction experts such as Dr. Gabor Maté believe may be helpful to induce spiritual awareness, particularly in regard to childhood and other experiences of trauma.

    Recent scientific exploration of the use of LSD and other psycho-active substances have yielded promising results for persons suffering from addiction as well as PTSD. It seems that Bill Wilson’s use of LSD in the 50s and 60s with the hope that it might help some alcoholics to have a spiritual experience has today been scientifically demonstrated to have validity.

    I believe as gospel truth what Bill wrote on page 164 of the Big Book, “We know but a little.” Almost 80 years have passed since he wrote those words, and we know a lot more !~!~!

  9. “Since our primary purpose is to help the suffering alcoholic we ought to consider all options, even those that differ from regular AA philosophy.”

    Nicely put, Life. Your article points out that while I feel put upon by others insistence that I do it their way, I have also been inclined to suggest that others do it my way. I do think, sortta, that total abstinence is the answer. Somehow, I just can’t imagine someone being very contented with life if they are avoiding an urge or an obsession with drinking.

    But that is my case. Others might very well find some reason why a drink or two without relief or pleasure would be valuable. Or maybe some people could get relief without pleasure.

    In any case, thanks for your article and another bit of insight for me to incorporate.

    • Lance, maybe we’re putting things on their head?

      I often have a craving – not for alcohol anymore, but for sweets. This craving is so strong sometimes that it is overpowering. It exhibits all the typical insanity of alcohol craving: internal debates of should / shouldn’t, circling around the grocery store, eating cookies in secret, disposing of the box away from home, guilt, shame, remorse – the whole 9 years. So I still know what craving is. I can still readily understand why it might be good to be able to take a pill, and then give in to the craving – KNOWING THAT THIS WOULD PRECISELY BE WHAT WILL TAKE AWAY THE CRAVING IN THE LONG RUN IN A VERY WELL EXPLAINED PHYSIOLOGICAL PROCESS – rather than keeping struggling with the craving, beating myself up, and then sometimes giving in to the craving *without* taking the pill that would actually make the giving in have a positive effect, while giving in without the pill, only brings us back to or toward a full relapse.

  10. Interesting article Roger. I like the idea of being open to other methods. I’ve found that not to be the case with quite a few AA s But each to their own. I did use Disulfiren (antibuse) for a year maybe 18 months in early sobriety, actually used it without going to AA for six months then relapsed. Got sober. Started going back to AA seriously but still took it for maybe another 18 months as stated together with an SSRI anti depressant. But managed to come off both of them and been okay. Coming up to 10 years in August.

    So I will always believe in Many ways to recovery.