Why Isn’t The Sinclair Method Used More Often?
By Michael D.
Originally published on June 3, 2015
I was really sorry to read that Dr. David Sinclair, who did so much research in the area of treating alcoholism, passed away at the beginning of April after a battle with cancer. The Sinclair Method is named after him and I hope that one day he will be as famous in the recovery world as Bill Wilson, the founder of AA.
In my opinion, the Sinclair Method is a system that could help so many people if more realized it existed and it was offered more often by treatment providers. In fact, I wish I had used it myself and been told about it by doctors back when I was struggling with alcoholism. It could have saved me a lot of pain and helped me control my drinking earlier, before I hit my rock bottom.
The Sinclair Method involves taking a simple pill, such as the prescription drug naltrexone (brand names: Revia, Vivitrol), an hour before you consume alcohol. Over time, the medication diminishes the desire to drink. The pill has no diminishing effect without alcohol (so if you don’t drink nothing will happen) and it is non-addictive.
How the Sinclair Method Began
Dr. Sinclair started his research in America during the 1960s. He established what he called the “alcohol deprivation effect” as a driving force in alcohol addiction. He later moved to Helsinki, Finland, to take his research forward using specially bred rats genetically predisposed to becoming alcoholic. The conclusion of Sinclair’s experiments? That alcoholism is a learned behavior. When a response or emotion has been “reinforced” with alcohol over a period of time it is learned. Some people (and some rats) have genetic traits that lead them to feel a lot of “reinforcement” from consuming alcohol, which eventually creates uncontrollable cravings.
Sinclair was influenced by the work of the physiologist, Ivan Pavlov, famous for making dogs salivate when a bell was sounded. Once conditioned, dogs rewarded with food after a bell had been rung would salivate at the sound of the bell itself. Over time, Pavlov would ring the bell, but he stopped rewarding the dogs with food; the salivating tapered off. This is called “extinction” and Sinclair thought the learned behavior of an addiction to alcohol could be removed by extinction, too.
Following his early research, Sinclair hypothesized that alcohol produces reinforcement in the brain in a way that’s similar to opiates. His research indicated that alcohol produced reinforcement by releasing endorphins that bind with opioid receptors in the brain. So a solution to stopping the reinforcement cycle might be to block the receptors every time alcohol was used. Sinclair tested his theory on rats using naltrexone, an opiate blocker, and after that he conducted clinical trials in people. The results encouraging.
Claudia Christian has given a Tedx Talk and created a documentary called “One Little Pill” (both available on YouTube) about the Sinclair Method. You can see her TedX Talk (How I overcame alcoholism) by clicking on the above image.
The solution discovered by Sinclair effectively means you have to drink yourself sober! This would surely be the perfect solution for many alcoholics and is probably a solution I could have excelled at. “Extinction” of the impulse to drink takes place over time and works for around 80% of people who use the method properly. It’s important to note that you take the pill an hour before drinking, not simply when you feel like it. Over time, the desire to consume alcohol will diminish and people end up abstaining most of the time or occasionally have a drink when they wish. You need to continue taking the medication before drinking, even when you feel things are under control.
There are a few people who don’t seem to respond to the medication, and others may have too much liver damage to use this treatment, but this is very rare. (They will do much more damage to their liver if they carry on drinking.) The Sinclair Method is not an instant solution and can take a few months to have the desired effect.
A Better “Cure”?
This may be the future of alcoholism treatment. It is common in the U.S. to call alcoholism a “disease” and this seems to be treating it as one. It will take time for people to accept such a radical concept, as it does go against the complete abstinence approach that most treatment centers advise people to use. Abstinence is great if you can manage it, but sadly, most people with a serious problem do not always do well. People I talk with who use the Sinclair Method often say how they struggled with the more traditional solutions; I can understand that. I wanted to stop many years before I finally managed abstinence and was nearly dead by the time I got my act together. I was lucky that I managed to stop with the support of others.
I think Bill Wilson would have approved of Sinclair’s work; after all, he himself experimented with niacin and even LSD in an effort to improve recovery from alcoholism. In chapter three of the AA Big Book it states, “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.” That was written in the 1930s and Sinclair may well have finally achieved this. I think if this solution had been discovered in Wilson’s lifetime he would have probably endorsed it. Unfortunately, AA does not seem to endorse any of the newer solutions that have been developed since Bill passed away, which is sad, as it is the perfect organization to reach the largest number of people needing help.
In reality, I think it will take time for this solution to gain wider acceptance, especially in the US, where the treatment industry seems dominated by 12-step ideology. The Sinclair Method is becoming popular in other countries and is now available on the National Health Service in the UK, as well as being used extensively in Scandinavian countries such as Finland, with great success. It is gaining popularity in underdeveloped countries that don’t have a pre-existing 12-step recovery treatment industry, too. It is a much cheaper solution compared to inpatient rehab and this will be attractive to countries without the infrastructure to support hospitalization for many people.
There are some useful resources that explain the Sinclair Method in much more detail than I can do so here. The actress Claudia Christian has produced a great film explaining how the solution works, called “One Little Pill.”
The best book I have found so far on the subject is by Roy Eskapa, PhD, and is called The Cure for Alcoholism.
Existe este cura en Montreal Canada?
Det gør den sikkert
I agree naltrexone can be a helpful therapeutic adjunct during the early stages of the treatment of alcoholism, as it reduces part of the neurochemical reinforcement or reward induced by ethanol. However, and this comment applies to the other medication treatments for addiction, the bulk of treatment and the long-term recovery journey has nothing to do with consumption or non-consumption of the drug – once abstinence is attained – and everything to do with learning and practicing a set of attitudes, knowledge and skills by which to live happier healthy lives – the very definition of recovery. Without addressing the fundamental problems – for which alcohol and other drugs served as imperfect solutions – taking pills like naltrexone, buprenorphine or disulfiram are insufficient for many of us, those of us without sufficient recovery capital to make it on our own.
In the US it seems the biggest hurdle at present is to get doctors to use it according to Dr Sinclair, because the FDA guidelines specify taking it every day along with abstinence, the thing exactly not to do, but many doctors are reluctant to experiment with off-label use. I have done a bit of advocacy on the issue – even had a fellow alcoholic approach a doctor in the program, I went to great length explaining it to the doctor, and he still prescribed it the FDA way, so it didn’t do any good.
My friend did say she had too much nausea from it anyway. I have also introduced it to my own doctor to see if she would experiment with it. It is after all without serious side effects for almost all, who take it. But she’s evasive about it when I ask her about it. So there is a lot of resistance.
Part of the problem is of course that the patient needs to keep drinking for it to work. Few doctors are willing to tell a patient with a bad drinking problem to keep drinking. First, there is a sense of liability involved, what if that is the time they have a fatal accident? But also it goes against everything AA has “taught” the medical community.
I think it is true as Ray points out that the medication way of sobering up does not address the underlying emotional problems that caused most of us to drink in the first place. AA does that to some degree for some people of course, and most of us do, if nothing else learn to find help in the mutual support of the fellowship, but we also have to acknowledge problems with the AA philosophy. Talking to god about it does nothing for unbelievers. Ego deflation probably has limited benefits for victims of rape and beatings. There are limitations to every approach, but still some benefit to most. It seems that CBT would be better for many in helping resolve the emotional underlying issues, than AA is.
AA *could* help those who try the Sinclair method, but there is a seriously bad attitude about naltrexone in AA, even to the point where it seems people in AA would rather that a person continue drinking “so they can hit bottom” than to cut back from a case to two beers, and save their life for the time being, while looking into what to do next to get back to emotional and physical health. People in AA often will treat naltrexone with the same arrogant “naltrexone is not mentioned in the BB” attitude which they reserve for “atheists can’t possibly be truly sober without a god”.
It’s too bad we have a program based on a book that fosters willful ignorance. Hopefully we will be able to salvage *the fellowship* as *the program* falters. Because we do need each other.
I am a member of AA and I am working with a woman who is using nal. I encourage her to and it takes nothing from AA for her to do so.
Because AA is not a medical solution, but a spiritual one. You talk about liability but don’t address why AA might not want that. It endorses no other methods and does recognize that we aren’t doctors.
I have no problem at all with people in the fellowship using nal or anabuse and I know people who take both. While it may not be mentioned in the BB, reaching out to the medical community for what it offers us does.
Because the 12 step cult religion shames people into believing that their “disease” cannot be cured unless they attend thought-stopping meetings for all eternity. That’s why.
No, it doesn’t, CC. You should know because your own and was arrested for 7 years in AA. I have recovered from a seeming hopeless condition of the mind, body and spirit. I used AA to reach that end.
While I agree with its use and that there are members of AA I know who do use it, it isn’t up to AA to promote other methods of recovery. It has always taken that position. I would think the medical community would be promoting it since it take medical intervention to even get the medication.
Our purpose is to “help the next suffering alcoholic”. Why should we not promote other methods of recovery? Every one that holds at least the 5% success rate we’re now promoting?
Life-j, because AA doesn’t endorse. If you as an individual want to tell someone ab out it, you can but AA won’t ever do that.
I’m in the camp that believes science will one day find a cure for alcoholism. I don’t think we’re there yet. Nora Volkow, director of NIDA foresees a time when talk therapy (AA for some) will be augmented by medication that diminishes the strong urges to drink that so many of us get in early sobriety. This is the answer to Ray’s very good point in the comments – a two-pronged approach.
Wilson was looking for something like this in the niacin research.
I don’t think that it’s AA job to lobby for other methods. When AA members talk about anything and everything either that has helped them, or they’ve heard about, it becomes a shitshow. I’ve heard a few mentions of naltrexone in meetings, and I’ve yet to hear the term pronounced correctly.
Some of the folks who have tried naltrexone have experienced significant, and unpleasant side effects.
A friend of mine asks a simple question, “If there was a pill that diminished the pleasure of sex, would you take it?” I can live without the fitting in afforded from sipping 2 glasses of wine over a 5 hour party. If I’m drinking, there are surely times I’m going to not take the meds, and get what I really want from drinking, and that doesn’t come from 2 drinks.
It was never my desire to be a 3 beer social drinker. That has never been on my radar. I would have liked to have 15 beers and get the positive effect, without the negative. I have to confess that I really don’t get the “having a couple” thing as a top motivation for alcoholics.
Bob, as usual all your point are well taken, but if you were told, say, that you’d die within a year from drinking a case a day, and you couldn’t seem to quit, even with AA, wouldn’t you rather take naltrexone and wind up drinking two beers than die? – and with the possibility of quitting entirely a bit down the road, and the possibly going to AA down the road, even if all you could do right now would be to cut back enough to survive?
With naltrexone we’re talking damage control and survival. With AA too often we’re talking perfection (with respect to not drinking).
Hi Life.. I hope you are having a good day…I really was not going to comment here having a real “aversion” to anything having to do with the Sinclair Method but I will make one simple observation after many years of observing “slips” and “slippers” in AA.
Alcoholics want to drink. It’s the overwhelming urge that brought them to our doors in the first place. Anything short of total abstinence seems, eventually, to fuel that urge which, inevitably, for most,will progress to stage four alcoholism and death. My favorite book on the topic of the progression of the condition in those who fail to stop is the still classic,’Natural History of Alcoholism’ by George Vaillant who discusses a “Return to Asymptomatic Drinking” in Chapter 5 of this book. Though I have no doubt there are such cases in the literature on this (which, according to Vaillant, goes back all the way to 1962) I also have do doubt that I would personally fall out of that range and I tend to focus on the majority of cases reported in the literature who progress to stage four alcoholism and death.In other words, I think I’ll stick to being totally abstinent which seems to be the model that also seems to fit the sober alcoholics I know best.
It might be used frequently, but we’d never know about it. If the treatment involves A) taking a pill and B) drinking like a gentleman, I figure the only people you need to engage with for “recovery” is the pharmacist and the bartender. We’d never encounter first-hand reports of naltrexone treatment in meetings or elsewhere in the recovery community.
The Sinclair Method promises an end to peer-supported recovery. You can recover in the same isolation you drank in!
Excellent point. The fellowship of AA is for me why it’s been so successful & appealing.
“It’s important to note that you take the pill an hour before drinking, not simply when you feel like it.”
That’s where the Sinclair Method would not have worked for me, alas.
I watched Claudia Christian’s TED talk when it came out. What I took away from it was that the Sinclair Method worked for her because she took the medication only before attending business/social events where alcohol was served. She was not taking the medication daily and continuing to drink daily. Actors like Ms. Christian have to be social to line up new work, and to promote current projects, so she understandably saw the Sinclair Method as a lifesaver.
An exciting development is a slow release implant version of the medication. That would sure solve the “taking the pill when you feel like it” issue. It seems judges sentencing multiple DUI offenders are looking at the implant medication as a condition of parole.
The problem with slow release implants is you can’t quickly disconinue the medication if there are uncomfortable or even dangerous side effects. I assume a person would have to do a pill trial first to determine if they can tolerate the medication.
Naltrexone implants are being used in other countries (not sure about the U.S.) to treat drug addictions such as heroin.
I can see the value of the implant, but it also makes me uneasy. It could be more or less forced on people. Jail is horrible; most people would accept the implant if it meant they could get out of the slammer. I’m reminded of the hormones forced on gay people back in the 1950s (most notably Alan Turing) to “cure” their homosexuality.
Because of the implant version, I think we will eventually see a sharp increase in Naltrexone prescriptions.
Just did a news search on naltrexone implants and discovered prescriptions are not skyrocketing because “insurance reimbursement is not consistent,” according to BioCorRx, a naltrexone implant manufacturer. Not getting paid definitely puts a damper on things. But it seems implant manufacturers like BioCorRx are using the opioid crisis to prod the FDA and insurers into acceptance. And therefore make billions.
I think the lack of acceptance of naltrexone-as-treatment has nothing to do with AA (except in the sense that AA is part of our culture and is influenced by it). Insurers do not want to pay for naltrexone because our culture views alcohol and drug addiction as moral failures that only affect “bad” people. Bad people don’t deserve medication that might make recovery less painful. 😉
There are two threads in this discussion of The Sinclair Method.
The first is that addiction involves a biological / neurological problem. And that’s true. Substance abuse changes the brain and over time the substance becomes a biological / neurological obsession. And the role of a medication such as naltrexone is to mute that obsession.
The other thread is the psychological component of addiction. Gabor Mate points to PTSD as a source of addiction. I believe the cause of my addiction was “existential angst”. I didn’t like my own existence and I needed to numb that down, which I did with substance abuse. A moral failing, as some would understand it and it can be acknowledged that addiction often leads to behavior that is reprehensible. In dealing with this psychological component, there is often a need for a personality change and that is not accomplished by naltrexone or any other medication.
That’s what AA does. Any group or therapy in which our experience, strength and hope are shared and support for each other is paramount is often an essential part of dealing with addiction.
So, two threads. A biological / neurological one and a psychological / existential thread.
Can one thread alone deal with addiction? Absolutely. Many of us know hundreds of women and men who owe their recovery to meetings, “one alcoholic talking to another alcoholic”. Does this work for every alcoholic / addict? Certainly not. Again, we know hundreds of women and men… Does this mean that in such a situation it might be reasonable to add a biological / neurological component, such as a naltrexone, to our meetings, the psychological / existential thread?
I leave the answer to that question up to you. And we shall no doubt learn more over time. As Bill Wilson put it in 1965, “Research has already come up with significant and helpful findings. And research will do far more.”
Roger, you have expressed an important observation that perpetuates the problem. As long as we view addiction from reductionistic points of view – as either a neurobiological disorder requiring pharmacotherapy, or alternatively a psychosocial condition which is the result of emotional trauma, cultural isolation, unhealthy behaviour and/or socioeconomic deprivation, we will get it wrong. Like the other chronic diseases overburdening our healthcare systems, epidemic obesity, type 2 diabetes, coronary artery disease and many types of cancer – addiction is complex. Biopsychosocial-spiritual. Lifestyle disease. And the population of sufferers is heterogeneous, each with his or her own therapeutic needs. So it’s not an adversarial battle. We need each other. AA just happens to have accumulated more of the therapeutic components with efficacy for assisting with recovery from addiction than any other single source. But that doesn’t mean some individuals with addiction do not require additional forms of treatment as well. For a vivid illustration of this read the biography of Bill Wilson and the clinical course of his recovery from alcoholism.
I went to a VA outpatient clinic to ask questions about naltrexone. The VA will script it and its pharmacies can fill on site. This means that it is free or a small copay, depending on your service benefits. To me, that is awesome.
In my area, we are home to the second largest military base in the country. There are plenty of people in our meetings with AUD, various form of PTSD that are self-medicated. This is good news.
The military is building a new VA hospital in our town that is to be a state of the art facility. I hope to be involved as a civilian liaison.
Three years ago I got to know Will H. through a group that meets once monthly for lunch in Boston. One month he didn’t show up, and the next he appeared, not looking well. He had been hospitalized for alcohol. After lunch I explained the AA basics to him and gave him a list of Boston groups he would like. A few months later he was hospitalized again, and this time he was lucky to make it out alive. Again I explained AA to him, putting strong emphasis on the 24-Hour Plan. He said that his doctor had prescribed Naltrexone, and with this he would be able to control his drinking. I said that for two centuries it has been known that for true alcoholics, like himself, recovery can only come from total abstinence. He listened to me, but indicated that the word of a doctor carried more weight than mine.
A couple of months later Will and I were the only ones who showed up for lunch, and we had a good talk — about alcoholism, science fiction, and writing. He ostentatiously ordered two dark beers, which he drank slowly, to show me that with his pill he was now in control. A month later I heard that he had died, at the age of 56. The Sinclair Method killed him.
From the best book on alcoholism — *Under the Influence* by James R. Milam:
MYTH; Some alcoholics can learn to drink normally and can continue to drink with no ill effects as long as they limit the amount.
REALITY: Alcoholics can never safely return to drinking because drinking in any amount will sooner or later reactivate their addiction.
I nearly died in severe alcohol withdrawal fifty years ago. In a week I’ll celebrate 50 years of continuous AA sobriety — staying away from the First Drink a day at a time. I’m grateful to be alive.
Just for the record, John, I am aware of people who have thoroughly followed the path of AA and failed as well, and died as a result.
I think whatever helps an individual get sobriety is likely a good thing. For myself today, having a few years sober, I would not like to take Naltrexone thinking I could then take a couple of drinks with no craving to drink more. Today I don’t miss alcohol. It’s not on my agenda, meetings are though.
I am having a great success with the Sinclair method. In three months, my alcohol consumption dropped 2/3rds to limits that are close to being “safe”. I used to consume about 40-45 units of alcohol weekly, where 1 unit=10ml of pure alcohol.
The Sinclair method has removed cravings and triggers for me, the constant obsession about alcohol is gone. I can have a couple of beers on Friday night and not go on a 3-day binge (that used to be my pattern for many years). I can have an open bottle of wine in my fridge and it is not whispering “drink me” anymore. My overall health and well being has improved. I am intending to practice TSM for the rest of my life or as long as I continue to drink.
I believe that my addiction to alcohol is (was?) of neurological spectrum, as I never drank out of depression, stress or to numb feelings. I love my life, with all its ups and downs and that sneaky voice in my head, demanding a drink, used to be the biggest problem. Now it is gone. I also had a genetic testing done, and discovered that I have an “alcoholic gene”, which is a gene that is associated with increased cravings for alcohol, and increased probability of developing alcohol addiction. I do understand however, that for many people alcoholism is a symptom of psychological issues, and for them therapy and peer support are essential parts in their fights against this horrible disease.
I honestly hope that one day the Sinclair method is widely known and accepted as a form of treatment.
Hi Julia. I am a retired Addiction Medicine physician writing a book, Recovery Medicine: Varieties of Recovery Experience. If you are willing I would like to interview you sometime in the not too distant future. RB. My email is healthquest@shaw.ca
Hi Ray, I sent you an email.
Julia, thank you very much for sharing your experience. It’s great the Sinclair Method is being discussed here.
I wanted to comment on this, “I believe that my addiction to alcohol is (was?) of neurological spectrum, as I never drank out of depression, stress or to numb feelings,” and “…for many people alcoholism is a symptom of psychological issues, and for them therapy and peer support are essential parts in their fights against this horrible disease.”
I also did not begin drinking due to psychological issues. I was not a person who felt “uncomfortable in my own skin” until I drank alcohol. I drank at first because everyone around me, family members as well as peers, drank; it was the early 1970s.
However, I do not think it is possible to drink in an addictive way for an extended period (ten years in my case) without accumulating psychological and social issues along the way. My drinking damaged my relationships with everyone around me, and especially damaged my view of myself as an honest, caring, and responsible human being. Without the group support of peers (in AA and ACA), I am not sure I would still be sober.
Because my alcoholism affected everyone who knew me, I cannot imagine a situation in which a person could experience no negative psychological and social fallout from alcoholism.
Physical allergy: An alcoholic cannot safely drink, just as a peanut allergic person cannot have just one spoon of peanut butter. Alcoholism must be addressed with complete abstinence after a period, if necessary, of medically managed detox which can include tapered-down psychoactive drugs. The old fashioned way was to administer alcohol in smaller and smaller doses. For this reason, early AA’s kept some booze on hand to help detox newcomers, since there wasn’t always proper hospital treatment available.
Mental obsession: The rest of the nonalcoholic world normalizes drinking and also drinks to reduce stress, let go of inhibitions, etc. They too can be traumatized and have psychological & social issues which they might ease with a drink. Alcoholics by contrast must address psychological trauma and social conditioning which could lead to breaking abstinence risking a future relapse.
So ironically, the sober alcoholic may end up psychologically better off than the traumatized nonalcoholic who has less motivation to address personal issues.
We truly are the lucky ones.
Our “character defects” did not cause our alcoholism but they are fertile ground for a slip which is why psychic change is best for long term recovery.