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?