The Sinclair Method: a revolutionary treatment for alcohol abuse
Sobriety without abstinence
The Sinclair Method is a unique treatment for problem drinking. It does not rely on enforced abstinence maintained by willpower, 12-step programs, aversion therapy with Antabuse and/or behavioral therapy. It does not involve a period of detox and there are no withdrawal symptoms. The Sinclair Method is also not a method to achieve controlled drinking through willpower. It uses a drug called naltrexone, which is used to treat other forms of addiction. Naltrexone cancels out the patterns established in the brain of an alcoholic by an extended period of alcohol abuse. These patterns are responsible for the cravings that are experienced and provide positive reinforcement each time alcohol is consumed. When naltrexone is used, with time, the desire to drink excessively becomes extinguished. Some people who succeed with the Sinclair Method ultimately decide to become abstinent. Others continue to drink alcohol periodically, but remain within the generally accepted safe limits for drinking.
Conventional alcohol treatment programs and their results are described below. This is followed by an account of different approach taken by the Sinclair Method and the advantages this brings. Finally, possible reasons why the Sinclair Method has not become more widely accepted are discussed.
Pattern of conventional alcohol treatment programs
Mainstream alcohol dependency treatment takes the following course. The alcoholic is asked to stop drinking immediately and abruptly. This is the period of “drying-out” (detoxification), during which alcohol is eliminated from the body. Many people experience unpleasant and even dangerous withdrawal symptoms during the detox phase, which may last for up to two weeks. Patients frequently stay in detox centers during this first phase. They are monitored and, if necessary, are given barbiturates, benzodiazepines or both types of drugs together to help them through the process.
After this, the person is told to remain abstinent for the rest of his or her life. Cognitive behavioral interventions or other psychosocial support, such as the 12 step program of Alcoholics Anonymous is used to support abstinence. Medication is frequently prescribed as well.
The three main types of medication, which can be used to assist abstinence, either alone or in combination, are:
Disulfiram (Antabuse) is taken for its deterrent effect. Alcohol is metabolized to acetaldehyde. A liver enzyme called aldehyde dehydrogenase breaks down the acetaldehyde further so that it can be excreted from the body. Disulfiram works by inhibiting the activity of aldehyde dehydrogenase. As a result, high levels of acetaldehyde accumulate in the blood. The acetaldehyde dilates the blood vessels and acts on heart, which leads to a number of unpleasant symptoms. The person becomes flushed and nauseous, feels his heart race, experiences dizziness, headache, palpitations and shortness of breath. A severe reaction may include vomiting and even unconsciousness and can be life-threatening.
Acamprosate (Campral) is used to relieve withdrawal symptoms and craving. Alcohol increases the action of a neurotransmitter in the brain called GABA and decreases the effects of excitatory amino acids such as glutamate. The net result is a depressant effect. Over time, the body adapts by increasing the activity of the glutamate system and decreasing that of the GABA-ergic system. When alcohol is withdrawn, the depressant effect stops, but the neurons keep on being hyperexcitable. On its own, the brain needs many months to readapt. Acamprosate helps to restore the activity of these two systems to normal levels.
Naltrexone is used in the treatment of drug addiction as well as alcoholism. It blocks opioid receptors in the brain, but its mechanism of action has not yet been fully clarified. It is thought that naltrexone decreases the reward effect felt after consuming alcohol.
Results of conventional alcohol treatment programs
There is certainly no doubt that the strategies involved above can be successful in some cases. However, the level of success is fairly limited.
Success rates for the 12-step program of Alcoholics Anonymous are hotly disputed. Critics estimate that as few as 5% of all people starting with AA achieve long-term abstinence. What is evident from personal testimonies on the Internet is that while many are strong supporters, the structure of the organization does not appeal to all, with some considering it to resemble a cult.
The drastic effects provoked by drinking while on disulfiram result in a high drop-out rate. Some alcoholics, under pressure from medical professionals or families to take the medication, resort to elaborate measures of deception to avoid swallowing the tablets while feigning to do so.
Acamprosate and naltrexone produce a modest level of success when abstinence is used as the criterion of success.
A meta-analysis by Srisurapanont and Jarusuraisin comparing the results of 24 studies on a total of 2861 subjects showed that in the short-term, naltrexone gave a 36% decrease in the relapse rate. After 12 weeks, naltrexone was superior to placebo only in the time to the first drink and intensity of craving. Furthermore, 36% of subjects stopped taking the drug in the first 12 weeks. All subjects were also receiving some form of psychosocial support during the studies.
A meta-analysis by Rösner and colleagues compared the effect of acamprosate with that of naltrexone. The authors concluded that while acamprosate was better in preventing a lapse (having a first drink), naltrexone was better in preventing a lapse from turning into full relapse (resumption of the drinking habit).
Kiefer and colleagues found that the rate of success in maintaining abstinence was slightly increased in subjects who received combined therapy with acamprosate and naltrexone.
Roy Eskapa: The Cure for Alcoholism
A detailed description of the Sinclair method and how to apply it.
The Sinclair Method: how does it differ from conventional alcohol treatment programs?
The Sinclair Method is fully described in a book by Dr Roy Eskapa, The Cure for Alcoholism.
David Sinclair developed his method following observations that when rats with experimentally-induced alcoholism were given opioid antagonists together with alcohol, they showed a progressive decrease in alcohol consumption. Giving an opioid antagonist during enforced abstinence not only did not reduce subsequent drinking but tended to increase it.
Interview with David Sinclair - Part 1
He hypothesized that drinking alcohol at the same time as taking an opioid antagonist will block the reinforcement that a drinker gets from alcohol. This reinforcement is something that has been learned over a prolonged period of alcohol abuse (no one becomes addicted to alcohol after a single drink). Over time, both drinking and the craving for drink will become extinguished and the pattern of excess drinking will be unlearned.
The Sinclair method is based on the subject taking naltrexone only on days when he or she intends to drink. One tablet is taken approximately one hour before drinking. In this way, an alcoholic can be helped to regain sufficient control to continue drinking within safe limits, even if he or she does not choose to move to full abstinence.
Sinclair is currently claiming that the results of 76 studies have shown a 78% success rate over 3-4 months. One extended study gave a 50% success rate after 3 years. Success is defined as a subject reaching a level of controlled drinking within safe limits or choosing to progress to full abstinence.
Sinclair is adamant that continued success of the method is dependent on naltrexone being taken each time the subject wishes to drink, no matter how infrequently this might occur. Drinking without naltrexone would result in an even greater level of reinforcement than previously experienced and restore the previous pattern of alcohol abuse and dependence.
Interview with David Sinclair - Part 2
Advantages of the Sinclair Method
Drinking is not stopped abruptly. The gradual decrease in drinking that sets in as a result of the extinction process means that subjects do not experience withdrawal symptoms. Costly stays in detox centers are therefore avoided. In addition, there is no requirement for supportive treatment with barbiturates and benzodiazepines, which can themselves cause addiction.
Sinclair believes the method may possibly succeed without reliance on psychosocial interventions. Some practitioners still choose to use them, however the cost of rehab treatment may potentially also be avoided. The reason for this is that the method does not rely on forced conscious changes in behavior, but on pharmacologically-driven unlearning of behaviour at the same physiological level where the pattern of alcohol abuse was established.
Naltrexone is no longer under patent protection. Cheaper generic formulations are available. With time, many people find that they no longer with to drink daily. Since naltrexone is only taken on drinking days, this further reduces the cost of their medication.
Interview with David Sinclair - Part 3
The subject alone decides if and when to drink. No compulsion is exerted at any stage and abstinence is seen as a matter of free choice. Autonomy and dignity are therefore supported by the Sinclair method. People are finding it possible to drink socially in a controlled manner. One participant on an Internet forum describes his relief at being able to attend social functions without drawing attention to himself either by forced abstinence or by drinking to excess.
An article in The Times (UK) cites the experiences of two people on the program:
“Oh yes, I still enjoy good wine. I savour wine. But there's no craving.”
“With naltrexone, it's weird. You drink and you feel the effect of the alcohol but it doesn't have the magic.”
Interview with David Sinclair - Part 4
Why is the Sinclair Method not in widespread use?
Following Sinclair’s move to Finland, his method has found widespread use there among mainstream practitioners. Elsewhere, it has gained little acceptance. Paradoxically, its advantages may be among the factors contributing to its limited uptake.
Since naltrexone is no longer under patent and since it use gradually decreases over time, there is no major drug company that would find championing the Sinclair method particularly advantageous to its profits.
Elimination of the need for detox, and possibly also the need for rehab, is a threat to the highly profitable alcoholism industry.
The autonomy of people on the Sinclair method, and the fact they are left with a free choice when and how much to drink rather than compelled to full abstinence does not fit with the philosophy of Alcoholics Anonymous and other 12-step proponents.
Nevertheless, the success reported by Sinclair raises the question of why his method is not being investigated more widely. A quick review of alcoholism forums on the Internet showed that many, for whom mainstream methods have failed, are desperate to find a practitioner willing to let them try this controversial method. Where such help is not forthcoming, some people are deciding to go it alone. They are buying naltrexone on-line, despite the risks of self-medication and the further risks of purchasing from potentially dubious suppliers. They should be given the opportunity to try in the safest possible way a method that may help them to find freedom from the prison of alcoholism.
References and acknowledgements
M. Srisurapanont and N. Jarusuraisin
Naltrexone for the treatment of alcoholism: a meta-analysis of randomized controlled trials
International Journal of Neuropsychopharmacology Vol. 8, pp. 1–14, 2005 full text
S. Rösner et al
Acamprosate supports abstinence, Naltrexone prevents excessive drinking: evidence from a meta-analysis with unreported outcomes
Journal of Psychopharmacology, Vol. 22, No. 1, pp. 11-23, 2008 abstract
F. Kiefer et al
Comparing and Combining Naltrexone and Acamprosate in Relapse Prevention of Alcoholism : A Double-blind, Placebo-Controlled Study
Archives of General Psychiatry, Vol. 60, pp. 92-99, 2003 abstract
Naltrexone: can a pill cure alcoholism?
The Times, January 12, 2009
J. D. Sinclair
Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism
Alcohol and Alcoholism, Vol. 36, No. 1, pp. 2-10, 2001 full text
vipin09 on Deviant Art (prisoner)
yanivba on Flickr (whisky)