With controlled drinking using naltrexone, is the goal always total abstinence?
Alcohol addiction is a condition that was always treated in the past by programs preaching complete abstinence. The Alcoholics Anonymous 12-step program has been used as the foundation for alcohol dependency treatment since the mid-20th century.
The belief is that out-of-control heavy drinking can only be controlled by full alcohol abstinence. AA members frown on the idea that alcohol consumption can be controlled by an alcohol abuser.
Abstinent individuals who have struggled through alcohol withdrawal symptoms and alcohol deprivation syndrome take pride in their many years of sobriety. Unfortunately, the fact is that they are in the minority of people who attempt quitting alcohol with complete abstinence.
The Sinclair Method is an alternate form of alcohol treatment that helps individuals to engage in moderate drinking. Their alcohol intake is carefully measured and limited to one or two alcoholic drinks daily.
TSM addresses alcohol dependence with a process known as pharmacological extinction. Over time, the habit of wanting to drink is extinguished from the reward centers of the brain.
TSM should be viewed as a form of harm reduction.
By seeing it from this perspective, doctors should feel comfortable discussing this form of treatment for alcohol abuse.Traditional treatment with total abstinence from alcohol has a fairly low success rate. The chance of repeatedly relapsing is high. Joining the long-term abstinence group is not easy.
TSM patients quickly learn that they are able to control and minimize drinking alcohol with the treatment. They also learn about the process and how it works.
One question that comes up often is what it means to reach extinction. They wonder if they will reach a point where the habit of drinking is gone, and if they will never have an alcoholic drink again afterwards.
It is hard for a heavy drinker who engages in frequent binge drinking to imagine reaching extinction of their drinking habit. In traditional addiction treatment, addictive behavior is not treated with pharmacological extinction, but with abrupt abstinence.
With abstinence treatment, relapse often occurs because of the intense cravings that arise within months of quitting. The dreaded alcohol deprivation syndrome leads many people back to active alcoholism.
Yet, the goal for many people who use The Sinclair Method is to achieve complete abstinence from alcohol. After putting their heavy drinking days behind them, they look forward to the day that they can be fully abstinent individuals.
Often, the desire to be fully abstinent involves pleasing loved ones and family members.
There is pressure from people who are concerned about your alcohol problem that want to see you reach a point where you no longer drink. After staging a dramatic family intervention, they do not want to hear about you having a drinking day when you are allowed to consume an alcoholic beverage. They keep bringing up their concern about “the other shoe dropping.”
With TSM, the treatment goal is for a treatment outcome where drinking is controlled. For some people, that will mean eventual complete abstinence, and for others, it will mean continuing to have an occasional drink.
Drinking alcohol is an integral part of modern society. Drinking is part of religious ceremonies, major life celebrations, and holidays, such as New Year’s Eve. Being marked as an alcoholic with a substance abuse problem brings unwanted attention, due to the stigma surrounding addiction.
How do you know when you have reached extinction?
One day, after practicing The Sinclair Method for anywhere from several weeks to several months, or in some cases, a year or two, you may realize that you have no interest in ever taking another sip of alcohol. Even if pure alcohol was put in front of you, it would be no different from looking at a glass filled with dirt.
When the desire to drink is gone, you have reached extinction. Does that mean that you are cured of alcohol use disorder? AUD is a chronic condition that can go into remission, but is rarely gone for good.
It is possible to reach extinction, and then, by drinking without following the TSM protocol, to develop alcohol dependency again. Just because you have arrived at the alcohol habit extinction does not mean you are cured for good.
There are some people in the TSM community who argue over the meaning of extinction vs. abstinence. It is an academic debate that has little meaning in the lives of real people who are finding success with TSM.
Does extinction mean that you no longer drink? Does abstinence mean you have reached extinction?
I believe that it is best to think of these concepts as being completely independent. To visualize it better, think of the source of the idea of pharmacological extinction, Pavlov’s dogs.
In the TSM literature, there is often a reference to Ivan Pavlov’s landmark experiments with conditioning dogs to salivate with the ringing of a bell. As Dr. Pavlov continued to ring the bell without feeding the dogs, they salivated less.
The habit of salivating to the bell was extinguished by withholding food. Blocking opioid receptors with naltrexone is seen as analogous to not feeding the dogs, and ringing the bell is having an alcoholic drink.
After the experiment was complete, did Pavlov’s dogs never salivate to the ringing of a bell ever again? If the experiment was repeated with the same dogs, it would be fairly easy to take them out of the state of habit extinction.
They would go right back to salivating when the bell rang within a short time if the scientist were to feed them with the bell ringing repeatedly. Yet, if the bell was never rung in the presence of food, they would not develop the habit again.
Similarly, a person can be in the state of pharmacological extinction with TSM and still have an occasional drink after taking naltrexone. The drink might be enjoyed for the flavor, such as a fine wine with dinner. Or, it may be for the experience of fully enjoying a holiday with family and friends, such as a sip of champagne on New Year’s Eve.
Therefore, it is certainly possible to reach extinction and remain in that state while still having an occasional alcoholic beverage.
Yet, other people may prefer abstinence. For people who have grown up surrounded by the doctrine of Alcoholics Anonymous, it can be satisfying to finally put down alcohol for good. Or, regardless of the AA program, some people enjoy the feeling of being abstinent and no longer drinking.
It is possible for a person to use The Sinclair Method successfully and then commit to abstinence even before they have reached full extinction. They may simply decide that they have had enough, even though there may still be those lingering thoughts about having one more drink.
There is nothing wrong with committing to total abstinence. If someone decides they are done with drinking, there is no need to give in to societal pressures to have a drink.
Abstinence often occurs with TSM after arriving at full pharmacological extinction, but it does not depend on it. Alternatively, extinction does not necessarily imply a need for abstinence.
Abstinence and extinction are not the same thing.
There is flexibility with TSM that makes it ideal for different people with different goals.
Some people are concerned about their liver and the risk of liver disease, or the increased risk of various cancers, so they aim for complete abstinence. They may go through an intensive inpatient detox, where they are given sedatives, vitamins, and acamprosate to help with the alcohol withdrawal.
Or, they may use TSM to achieve abstinence over a period of time. Both options are available.
Other people simply have the goal to getting their drinking under control. Whether they are alcoholics or gray area drinkers, they have tired of binge drinking, but they are not ready to give up the occasional enjoyment of an alcoholic beverage.