STEP FOUR: CHARTING REDUCED CRAVING AND DRINKING
Beginning Your De-Addiction with Naltrexone (or Nalmefene) + Drinking
Now that you have your prescription for the medication, you can actively and enthusiastically begin your de-addiction treatment. The science behind the treatment proves that you have every reason to be optimistic. You continue drinking as you normally do except that now, you are sure to take naltrexone or nalmefene an hour before every drinking session.
You must decide for yourself if you feel comfortable about telling others that you are in treatment. This is a matter of personal choice and judgment. For instance, you might feel secure telling people close to you – loved ones or close friends – that you are following the Sinclair Method. They should not be concerned if they see you drinking because now you are taking naltrexone or nalmefene, and Naltrexone or Nalmefene +Drinking will break your addiction in about three to four months. At the same time, you might feel better keeping your treatment to yourself with people with whom you aren’t as close – employers, colleagues, or acquaintances. Cultural differences should also be considered. In some cultures, one’s health is a completely personal matter. In others, it is the concern of the family or the whole community.
Drinking habits and styles vary enormously from person to person. Some of you may be drinking heavily of a daily basis, starting your day with an alcoholic drink early in the morning or with one at noon. Others might begin at 6 p.m. and drink steadily throughout the rest of the evening. Some of you may be bingeing only on weekends or only after a period of days or weeks when the craving has built to a breaking point. Drinking problems come in many shapes and forms and there are probably as many triggers for drinking as there are varieties of alcoholic beverages.
It’s Like Learning to Use a Parachute
By now, you should know that the end of your craving and addiction won’t come from trying to abstain. If you are unable to control or stop your drinking through normal psychological or faith-based treatments, you actually have to start using the Sinclair Method.
Starting treatment can feel like attending preparatory classes for skydiving. Your instructor may use instructional videos to show you how to jump out of the plane, how to overcome your initial fear of heights, how to use your safety parachute if your main on malfunctions. The instructor may be repetitive and even very boring. Of course, you understand the reasoning behind your instructor’s repetition – doing things properly can make your trip from an altitude of 15,000 feet back to earth smooth and enjoyable. Above all, doing things properly can save your life. The Sinclair Method is similar.
Now, as the urges arise, you permit yourself to drink – but only if you have already taken your medication. Each drink on naltrexone or nalmefene is part of your curative curve as you start the first of many Naltrexone or Nalmefeme + Drinking sessions to break free of your addiction. Remember, the cure occurs incrementally – drink by drink – as the microscopic yet densely wired system driving the addiction in your brain is dismantled, weakened, and ultimately broken through extinction.
Starting with the first application of the Sinclair Method, the usual practice has been to have patients record their drinking in a diary. However, the benefits from Naltrexone or Nalmefene + Drinking are not dependent on keeping the diary. (The rats never kept drinking diaries and it worked for them.) On the other hand, diligently keeping the records probably is beneficial to your progress and being able to look back and see the progress you have made often helps maintain motivation. Therefore, keeping a Drinking Diary is strongly recommended.
Before you begin taking your medication and start your Drinking Diary, you should familiarise yourself with drinking measures, which indicate the number of alcohol units in a beer, a short of vodka, or a glass of wine. Many people think that there is a difference between drinking beer, wine, and spirits, but it’s all the same as far as your brain is concerned – alcohol is alcohol. The following Drinking Diary lists the alcohol content of each drink. Although restaurants, bars, and pubs measure alcohol by standardised servings, it has been found that when people drink on their own, they tend to pour larger quantities. Research shows that people underestimate how much and how frequently they drink. Please keep Drinking Diary using the following format and be aware of the safe drinking levels outlined below.
Sinclair recommends the follow format for your Drinking Diary. Use a small diary you can easily carry with you.
In the United States, one drink unit is defined as having one-half ounce of pure alcohol, such as the following:
- 10-12 oz of beer (4-5% alcohol) = 1 drink
- 8-12 oz of wine cooler (4-6% alcohol) = 1 drink
- 4-5 oz of table wine (9-12% alcohol) = 1 drink
- 2.5 oz of fortified wine (20% alcohol) = 1 drink
- 1.25 oz of 80 proof distilled spirits (40% alcohol) = 1 drink
- 1 oz of 100 proof distilled spirits (50% alcohol) = 1 drink
- 1 bottle (330 ml) beer (4.7% alcohol content) = 1 drink
- 1 mug of beer (4.7% alcohol) = 1.5 drinks
- 1 bottle strong beer (6% alcohol) = 1.3 drinks
- 1 mug strong beer (10% alcohol) = 2 drinks
- 1 glass (12 cl) wine (10% alcohol) = 1 drink
- 1 bottle (75 cl) wine (10% alcohol) = 6.5 drinks
- 1 glass (8 cl) fortified wine (20% alcohol) = 1 drink
- 1 bottle (75 cl) fortified wine (20% alcohol) = 9.5 drinks
- 1 shot (4 cl) spirits (40% alcohol) = 1 drink
- 1 small bottle (50 cl) spirits (40% alcohol) = 12 drinks
- 1 bottle (70 cl) spirits (40% alcohol) = 17.5 drinks
Wines include champagne. Fortified wines include sherry, port and vermouth. Spirits include vodka, gin, whiskey, rum, cognac, and liquors.
Upper Limits of Moderate Drinking
- Men: Twenty-four units per week or five units during any single drinking session.
- Women: Eighteen units per week or four units during any single drinking session.
For assistance in counting drink units, visit this Web site: www.knowyourlimits.info
Measuring Your Cravings
Craving goes hand in hand with excessive drinking and addiction. You should assess your craving levels on a weekly basis. The Visual Analog Scale of Alcohol Craving (VAS) is a simple instrument to help you chart your craving levels as they decline over the course of treatment. You will actually be able to plot the reduction in craving over the next few weeks and months. If you are working with a trained counsellor, you may wish to share your weekly VAS results with him or her as you progress through treatment.
Visual Analog Scale of Alcohol Craving (VAS)
Imagine that you are in a situation where you would typically be drinking. How badly would you want to drink? Determine the point on the line below that best describes your level of craving for alcohol and draw a clear vertical line at that point.
Begin Your Drinking Diary
Now that you have your supply of naltrexone or nalmefene, what do you do? You should immediately begin your Drinking Diary and continue drinking on your medication. One patient aptly described this process when she said, ‘I no longer simply go drinking. I go Nal-drinking so that I can Null my drinking’.
Begin by taking half the normal dose, 25 mg, for the first two drinking sessions. You can break your 50 mg tablet in half or ask your pharmacist to do this for you. After the first two doses, you move to the full dose of 50 mg, which is the official recommended dose.
The Drinking Diary is an integral part of your treatment plan. It serves as your roadmap, guiding you toward the cure. If you drink only on weekends, that is fine – you will be able to plot your weekend drinking. If you drink every day, you will be able to plot your daily drinking pattern as it declines. At first, you might not notice much of a difference, but as time passes, you will experience a steady decline in your consumption. Most people notice an observable reduction in craving and the actual number of drink units per week within the first six weeks.
When you begin treatment, you should not be perturbed if you find yourself drinking well over the safety limit of even far more than you like. After all, this is why you are on the Sinclair Method. Some people drink many times over the safety limit – twenty four units per week for men and no more than five units on one occasion and eighteen drinks per week for women and no more than four units on one occasion – every week. Knowing how much you drink is essential. (Please note that many restaurants serve ‘a drink’ equivalent to two or more units.) This way you can accurately plot how much you are drinking and this monitor your progress on a weekly basis. Clinics have found that the Sinclair Method brings drinking down to an average of fewer than nine units per week after three or four months.
A couple of cautions are in order. First, you must be particularly careful not to drink and drive or use machinery. Naltrexone can actually increase some aspects of intoxication. Sinclair found an increase in motor impairment from alcohol in rats. Later research found increased problems from alcohol related to the divided attention needed in driving. Second, do not drink more in a session than you are used to. Naltrexone or nalmefene will not block alcohol poisoning.
What Should You Expect to Happen?
The answer is that no two people are alike. Some people respond to treatment more quickly than others. Generally, naltrexone and nalmefene side effects are rare and include symptoms like mile itchiness or transient nausea. Compared with the side effects of addictive drinking, most patients report they are both minor and temporary – well worth the effort. The majority of patients taking naltrexone or nalmefene report few or no side effects.
Be alert that, even very early in your treatment, you may occasionally experience a surprising ability to stop after only a couple of drinking. However, this decrease in drinking and craving is merely an artefact of the treatment. The naltrexone or nalmefene is blocking some of the effects from the first drink and from stimuli that have become conditioned to release endorphins; this helps block the ‘first-drink effect’. It is a beneficial but weak effect. The powerful effects from pharmacological extinction develop much more slowly and cannot cure you in a week or two. It took you a long time to reach your current craving and drinking levels, and it will take at least three to four months to reverse the addiction. Some people take longer before the neurological scaffolding – the addictive wiring in the brain – is brought down, reduced, and restored to it’s normal, healthy, pre-addicted state.
Of course, each of you will be progressing through treatment at your own pace. But everyone has to follow the formula: Naltrexone or Nalmefene + Drinking = Cure to be successful. You should expect success – like the seventy-five patients in Figure 8 who showed reduced craving over three to four months.
You can also expect your actual drinking to go down to about fifteen drinks per week within three to four months and eventually down to nine drinks per week, as shown in Figure 9.
You set your own treatment goals. Only 3% of the patients originally treated by Sinclair’s group chose total abstinence as their original goal, but about a quarter of them were abstinent after three months of treatment. Before treatment, it may be difficult to imagine a life without alcohol, but by the end of treatment, your craving will have decreased so noticeably and dramatically that total abstinence becomes a matter o personal choice. You will no longer fear alcohol. You will not be in its vice; you will not be it’s servant or puppet. You will find that you no longer obsess or think about it and it will become more or less irrelevant in your life. However, the ultimate goal is to break the addiction so that you control your drinking instead of it controlling you.
Some people may wish to drink two or three times a year – for instance, at Christmas or on New Year’s Eve. This is fine as long as you always take your medication before you do so. The point is that the Sinclair Method allows you to cut back or stop altogether without the nagging feelings of deprivation and threat of relapse associated with traditional abstinence-based treatments. You will not have to attend regular support groups – unless you choose to do so.
If you choose to continue drinking, the treatment will result in a massive decrease in your desire for alcohol and also the actual amounts you drink when you do. You will find yourself simply losing interest in the party. Because de-addiction occurs at the microscopic level of opioid (endorphin) receptors and synapses in the brain, you will not know why the voice in your head suggesting ‘I could do with a drink’ or ‘I need a drink’ simply seems to have disappeared. Your rescue from the bottle happens as if by magic. It is not magic, of course, but the fruits of the Sinclair Method are astonishing indeed.
Most likely, others will also notice positive changes – you no longer get drunk, depressed, hung over, out of hand, or aggressive, and you don’t lose your judgment and control. Drinking + Naltrexone or Nalmefene produces a state of permanent physiological de-addiction.
Selective Extinction: How to Maximize Your Results
Selective Extinction is a technique you can use to enhance your resistance to alcohol while encouraging competing positive, desirable behaviours. After a month or two of treatment, you will find that your craving for alcohol has progressively decreased with each Naltrexone or Nalmefene + Drinking session, so there are days when you will simply not want to drink. Selective extinction means that on these days you do not take naltrexone or drink but instead do things that you normally find rewarding.
If possible, before you start naltrexone or nalmefene, you should make a list of healthy, positive behaviours that you find rewarding – or found rewarding before alcohol began negatively interfering in your life. Typically, in clinics, the physician will point out which of these behaviours are probably reinforced by endorphins, but you can do it yourself. For instance, you may include sex or some vigorous exercise such as hiking, sailing, jogging, tennis, yoga, or aerobics on your list of pleasurable activities. Maternal and paternal activities, such as the warm ‘Ooh! The baby!’ feeling you get from cuddling children or pets, almost certainly produce endorphins. So do thrilling behaviours (for example, amusement part rides), novel experiences, eating highly flavoured foods, especially sweets and spicy meals. Sensual pleasures usually involve endorphins. Performing, singing, presenting, and acting all involve endorphins.
In general, activities that are stimulated by a little alcohol, such as an appetizer before eating, are opioidergic, that is, they are reinforced by endorphins. On the other hand, behaviours that involve long periods of high attention and holding still, like target practice, are probably not opioidergic. Of course, there are unhealthy opioidergic behaviours like high-risk behaviours, gambling, or taking opiates and other drugs, which obviously should not be on your list.
Make sure you do not participate in the healthy opioidergic activities while you are on naltrexone or nalmefene – save them for your ‘No Drinking – No Naltrexone or Nalmefene’ days.
On naltrexone- and drinking-free days, the opioid system in your brain will be more sensitive to reinforcement from endorphin release because of a phenomenom known as receptor upregulation, which causes receptor supersensitivity. The naltrexone or nalmefene causes the upregulation, but so long as it is in the brain and blocking the receptors, there is no effect. When you stop taking naltrexone or nalmefene for a while, however, there is a period of a few days when the naltrexone or nalmefene is gone and the extraordinary large number of opioid receptors are now free, producing more reinforcement whenever endorphins are released. You can take advantage of opioid receptor supersensitivity because endorphin-related activities are more rewarding than normal. In this way, you begin replacing ‘bad’ endorphin activities such as drinking with ‘good’ ones such as vigorous exercise. You will find your interest and enjoyment will increase progressively for the healthy activities, helping to fill the vacuum as drinking decreases.
Naltrexone or nalmefene offer a window of opportunity for pharmacological enhanced learning of healthy behaviours. If you last took the medication of a Friday afternoon, Saturday is a washout day, when the medication is being removed from your body. Starting Sunday afternoon, roughly two days since your last dose of naltrexone or nalmefene, you are in a state where patients report that doing those alternative behaviours is especially reinforcing. A highly flavoured meal tastes great. Even the first bit of chocolate is fantastic. Sex is more rewarding. Exercise feels marvellous. The supersensitivity gradually disappears over the next few days, so it is wise to make an effort in the healthy activities during this window while you get more reinforcement.
At any time, you can return to drinking; just make sure you take naltrexone or nalmefene an hour before you take the first sip of alcohol. Typically, patients start by having only a weekend with naltrexone or nalmefene and drinking – and with practicing a healthy behaviours on Sunday afternoon and evening – then return to Naltrexone or Nalmefene + Drinking, and avoiding the other opioidergic behaviours. Subsequent periods without alcohol and naltrexone or nalmefene become progressively longer. Eventually, drinking while on naltrexone or nalmefene was occurring only once a week or less often, and the periods without alcohol and naltrexone or nalmefene were six days or longer.
Follow Up, Follow Through, and Therapy
You should see your physician from time to time – at least once a month – even if you have a renewable prescription that does not require regular visits. However, in situations where it is not feasible to see your doctor more frequently or you simply do not wish to, you can still be successful on your own. You can follow the Sinclair Method as privately or as publicly as you choose. But you must follow the Golden Rule now and after you complete the program: always take the naltrexone or nalmefene before you drink.
The Sinclair Method requires personal motivation to take your medication consistently before drinking. You do this for the rest of your life – but only when you drink. Once you have started the program, there is absolutely no point in stopping and starting.
Stay with It; It Takes Time to Work
Research shows that the minimum time for obtaining most of the benefits from the Sinclair Method is three to four months’ worth of treatment. Don’t fool yourself – the addictive wiring in your brain became super-strengthened over years, not overnight. The addictive circuitry will not be sufficiently de-activated after a month or two of the Sinclair Method. If you do not complete the minimum three to four month treatment period, you will be like a half-baked cake – a cheesecake without the cheese – and because your treatment will be incomplete, you will still be addicted to alcohol.
Actually, the treatment never stops, although after the three to four months, most of the time it consists of only carrying the medication around with you. There never comes a time, however, when you drink without taking the medication. If you did, even after you are cured, you would start relearning the addiction to alcohol. Being cured does not mean you cannot develop the disease again.