Q: Do you follow the Sinclair method for treatment of addiction to alcohol?
A: Not strictly. I do prescribe the medication Naltrexone that is used in Sinclair method but I impose additional requirements to facilitate behavioral change.
According to the Sinclair method the patient takes Naltrexone one hour before using alcohol and over time the patient will drink less or not at all.
According to the Sinclair Method home page
“Certain medicines, such as naltrexone, naloxone and nalmefene, block the effects of endorphin and other opiates. I reasoned that if alcohol is drunk while one of these opioid antagonists is blocking endorphin reinforcement in the brain, the extinction mechanism would be activated, and it would then produce a small but permanent decrement in alcohol drinking and craving. The next day, the person would be slightly less interested in alcohol. Eventually control would be regained, and the person would no longer be an alcoholic; indeed, they no longer would be interested in alcohol.
The Sinclair Method is a passive approach. I prefer to prescribe Naltrexone to patients who are actively treating their alcohol dependence or addiction (According to DSM-V, alcoholism or alcohol addiction is now simply called Alcohol Use Disorder).
Active treatment requires that patients have a relapse prevention plan, so as to not to drink … or to drink within safe limits; … that they work with a counselor to identify triggers and avoid them, … and if those triggers can not be avoided then have alternative procedures in place to reduce the alcohol intake, for example … going late to the party, coming away earlier, carrying your own cocktail with reduced alcohol, hanging with a group that does not rely on alcohol to have a good time, etc.
My approach is to use the medication as an aid to treatment … not as the only mode of treatment. I believe addiction is not cured by a pill … it is a behavior problem and requires a behavioral approach to solve it.
Behavioral approach will also address issues like where to drink and how much, activity after drinking … so as to not to put yourself or others in harms way. Behavioral approach will also address the adverse effects of drinking on your health, your personal and family life, your social relationships and responsibilities. Behavioral approach will address the effects of drinking on work performance and employment, financial problems, and legal issues. Because your addiction not only harms you … it has the potential to harm your family and the society.
I have not had many patients with alcohol use disorder. I advise patients to get these medications through their PCP. These medications are not controlled substances and any PCP can prescribe them. Many patients start their treatment with me and then transfer to their PCP.
Some PCP’s do not wish to deal with addiction and related issues and may refer you to an addiction specialist who can also provide necessary counseling and other methods of behavioral therapy … especially if you have medical insurance.
The patients that come to my practice usually do not have medical insurance. I am willing to see those patients provided they have a PCP, because most patients also need lab tests and evaluation of other associated medical problems. My program requires that patients be well motivated and disciplined to give up or reduce their use of alcoholic drinks, be compliant, follow the recommendations.
My program does not have counselors, patients are required to enroll with an addiction counselor or behavioral therapist under their own arrangement, and attend at least one counseling session per month.
If you are looking for a cure in a pill … I don’t have it.
Other drugs that are mentioned in the Sinclair Method:
- Nalmefene is not yet marketed in USA; it is available in Europe, and is considered to be superior to Naltrexone as it has a lower incidence of elevation of liver enzymes as compared to Naltrexone. Nalmefene can be prescribed to patients who have elevated liver enzymes, while Naltrexone must be used with caution and discontinued if it causes a further elevation of liver enzymes.
- Naloxone is a very short acting opiod blocker and is not used in the treatment of alcohol addiction. Naloxone is primarily used to reverse opioid overdose.
Q: What is the dose of Naltrexone?
A: Usually 50 mg to 150 mg per day.
Naltrexone is commonly supplied as a 50 mg tablet, taken by mouth. Patients are started on 50 mg/day, that is one tablet once daily. Patient maintains a log of alcoholic drinks consumed, and compares it with pre-treatment amount. If there is noticeable reduction in alcohol intake then one can continue on this treatment. If not the dose is increased to 100 mg /day, that is two tablets once daily. Again the progress is monitored and the dose increased if need be. Maximum dosage of upto 300mg/day have been used. That is six tablets per day.
The change is made after observing the alcohol usage pattern for at least two weeks to a month.
Q: How long does the treatment last?
A: Usually three to twelve months … or however long it takes for the behavioral changes to be permanent.
Once alcohol usage is reduced to acceptable levels then the dose is reduced to a maintenance dose of 25 mg/day that is half a tablet per day … while the patient continues to work on solidifying the necessary behavioral changes. I have not heard of anyone using it beyond one year … most patients use it for three to six months.
If the patient does not see a benefit in three months then there is no point in continuing with Naltrexone, and should consult an addiction specialist.
There are some other medications that have been used but are not yet approved by FDA for treating alcohol addiction. There is some anecdotal evidence of success with these medications. These are not experimental medications … these are medications that have been approved for other indications and are being used in treating conditions other than alcohol addiction.
Q: Do you prescribe Vivitrol injection?
I get many inquiries about Vivitrol injection … due to the heavy advertising by the manufacturer.
Vivitrol injection has the same ingredient … Naltrexone. It is marketed in a long acting injection form. One injection is effective for four weeks, and it costs $1100 to $1300. Some insurances do cover it.
Naltrexone tablet costs $1 to $2 per tablet, same cost as one beer a day, that is a medication cost of $30 to $60 per month … as opposed to $1100 to $1300 per month for Vivitrol.
If you do not like the effect of Naltrexone tablet, or have some adverse effect … well you can stop taking it. If you do not like Vivitrol … sorry, once injected nothing can be done.
If one Naltrexone tablet is not enough for you … you can take two per day or even three per day. If the Vivitrol injection was not enough for you … most doctors will not give you any additional injection … and your insurance will not pay for it.
Important: Naltrexone does not block the effects of alcohol.
Naltrexone blocks opioid receptors, so patients derive less pleasure from drinking.
The problem is that patients who become alcoholic no longer derive pleasure from alcohol … drinking has become their habit.
Naltrexone does not block the effects of alcohol. Alcohol use will cause drunkenness, poor judgment, and facilitate inappropriate behavior. Naltrexone or not, alcohol use will cause slowing of reflexes, blurred vision, slurred speech, loss of balance and in-coordination. Naltrexone will not prevent DUI, accidents, and legal problems. Naltrexone will not protect against the toxic effects of alcohol on stomach, liver, brain, and heart.