If you took naltrexone without drinking, you would feel about as much as you would if you took a multivitamin—virtually nothing.
Fewer than 10 percent of patients reported temporary nausea in clinical trials in which it was given to abstinent patients. It produced even fewer side effects in patients who were still drinking. The medication is not psychoactive, and it will not make you feel high or low. Naltrexone does not bring relief from alcohol craving like a painkiller relieves a headache. Some patients report they do not get a “buzz” from the first drink when they begin drinking while taking naltrexone. However, even when you do take it together with alcohol, you do not subjectively feel it working in your system.
One of the nice features of naltrexone and other opioid antagonists is that the endorphin system they block is relatively unimportant most of the time. Endorphins are involved in many forms of reinforcement, but usually as just a backup or shortcut system. Their role as painkillers may be important in the wild, where animals often have to function despite severe injury in order to survive, but in our modern world, we are seldom faced with such challenges. Other neurochemicals that modulate behavior, such as dopamine, serotonin, and epinephrine, are critically involved in the regulation of vast numbers of activities, and one must be very careful with drugs that alter these systems. With the endorphin system, however, most people can’t even tell if it has been blocked by an antagonist such as naltrexone. Indeed, that has been tested in some of the double-blind clinical trials in order to demonstrate that the patients really could not tell if they had been given an opioid antagonist or a placebo.53
Remember, naltrexone by itself will not reduce the craving or de-addict you in fifteen minutes, fifteen days, or fifteen years. You should be aware of false claims on the Internet that naltrexone can abolish your craving within fifteen minutes. As we saw in chapter 3 on the scientific evidence behind the Sinclair Method, naltrexone is only effective if combined with drinking over the course of at least three to four months. Extinction takes time and requires active drinking together with naltrexone before full de-addiction can happen.
Alcohol Abuse and Addiction Are Not Rational
Some people have questioned whether patients would actually take naltrexone. If naltrexone blocks the “pleasure” from drinking, a rational patient would simply stop taking the medication in order to get pleasure again from drinking.
First, let’s start with an established fact. Compliance has been extraordinarily good with the Sinclair Method. More than 85 percent of the alcoholics being treated with naltrexone do indeed take their medication, even though they have been told that it blocks initial euphoria from alcohol.
That is not rational, you might complain. No, it is not, and the reason is that alcohol abuse is not a rational behavior chosen logically for its ability to produce euphoria. Studies of human social drinkers show that euphoria is only occasionally increased by alcohol.54 If you are in a melancholy mood, red wine will make you bluer. If you are in a party mood, you will fly through the air on bubbles of champagne. If you are feeling frustrated, you may become aggressive—hence, the violence associated with drinking and crime. If you are in a hospital gown in a stainless steel laboratory at nine o’clock in the morning with nothing to eat or drink, alcohol will not produce euphoria—as was demonstrated in one PET brain scan study in Finland on the effects of alcohol.55 The study demonstrated nicely some of the immediate effects of alcohol on the brain, and it showed that an opioid antagonist blocked these effects. The researchers had hoped to measure if it was blocking euphoria as well, but failed because the alcohol did not produce any significant increases in euphoria under stark laboratory conditions.
Among alcoholics, there is very little—if any—pleasure obtained from drinking, and certainly not enough pleasure to compensate for all the pain they get from their continued abuse of alcohol.56 Alcoholics drink because they have become wired to drink. There is no rational reason for choosing to drink because they do not “choose” to drink, any more than you choose to lift your leg when the doctor taps your knee. You are wired to produce the knee-jerk reflex, and the alcoholic has become wired to produce the drinking reflex.
So, yes, naltrexone may partially block the pleasure—if any— from drinking. But pleasure is not why alcoholics continue drinking. Consequently, the blocking of pleasure from alcohol has stopped few patients from taking their naltrexone. If they had been told to abstain from drinking, compliance would have been much more difficult. Alcoholism, by definition, is difficulty in abstaining from alcohol. And clinical trials that have instructed patients to abstain have met with more problems with compliance. However, being told to take a pill before drinking is an easy command to obey.
The pleasure from alcohol may be unimportant for the alcoholic, but the overall pleasures in life are important. Many behaviors are reinforced by endorphins, and we would not want to lose these other joys in life. As a solution for this problem, the Sinclair Method uses a process called selective extinction that removes the behaviors related to alcohol craving and abuse but supports and strengthens the other behaviors reinforced by endorphins. (This will be discussed in chapter 9 in the section titled Selective Extinction: How to maximize Your Results.)
Your subjective sensations, feelings, and emotions hardly change when you drink while taking naltrexone. However, the pathways controlling your drinking are incrementally weakened each time you do it. This occurs at the microscopic level of trillions of connections between neurons in the brain.* Just as you cannot feel the metabolic processes in your liver or kidneys, you do not feel the de-addiction process as your nervous system is restored to normal.
As you drink on naltrexone, you will not be aware of the neural super-highways being weakened and cut back into their original condition. The process amounts to the gradual but steady weakening of the addictive circuitry wired throughout your brain and nervous system. As you proceed to drink while taking naltrexone, your brain is no longer being reinforced by endorphins. This produces pharmacological extinction—Sinclair’s amazing discovery—which automatically weakens the wiring causing your addiction. De-addiction happens slowly but surely with the research showing that the more often you drink on naltrexone, the more you weaken your addiction.* One could not ask for an easier, more elegant, or dignified solution to addictive drinking—you literally “Drink Your Way Sober.”