The Sinclair Method of Alcohol Extinction
The Sinclair Method is a treatment for alcoholism that involves the use of antagonists such as naltrexone or nalmefene in order to decrease the craving for alcohol over time, while the person continues to consume controlled amounts of alcohol. It relies upon a mechanism called pharmacological extinction, where involuntary impulses are reduced through the introduction of a stimulus without the subsequent reward.
Taking naltrexone, at least an hour prior to drinking, results in the medication passing through the brain barrier, showering down on the neurons in the neuclus accumbus (thinking part of the brain) and attaching and coating the neurons. Once coated, the neurons cannot fire when stimulated by alcohol, thus removing the reward system stimulus.
History and Theory
In the 1970s, Finland’s National Public Health Institute developed a breed of Wistar rats called the AA line, which were more prone to alcoholism.  The research facility determined that this tendency was caused by an increased reactivity of the endorphin system to the consumption of alcohol. Both human and rat biology reacts to the presence of alcohol by releasing endorphins, and these rats produced more endorphins in that event than a typical rat.
Endorphins are part of they body’s reward system for performing healthy behaviors. Sex, exercise, eating, thrill rides and risk taking generally result in the release of endorphins. The endorphins “teach” the body that the behaviors that were performed prior to the endorphin release are behaviors that should be repeated. The link between the more active endorphin system and alcoholism in rats suggests that the release of endorphins by alcohol teaches the body to believe that drinking alcohol is an activity that should be repeated.
Classical conditioning suggests that, should you perform a behavior and be rewarded (through the release of endorphins), then the urge to perform that behavior becomes stronger. Furthermore, if you perform a behavior and are not rewarded, then the urge to perform that behavior gets weaker. This effect is referred to as the extinction of that behavior.
Based on Pavlovian classical conditioning, a substance abuser must perform the behaviors that they are attempting to extinguish and not be rewarded by the endorphins. Tests with the AA rats confirmed that this effect involved not only the actual consumption of alcohol, but also the sensory stimulus that the rats experienced while consuming alcohol.
Dr. John David Sinclair used these results to develop a treatment for alcoholism for humans. For it to work, the patients need to take a drug, which prevented endorphins from rewarding them for drinking. Naltrexone was originally used, although other drugs are now available for this purpose. The patients also needed to expose themselves to the conditions under which they developed their addiction. This means not just drinking alcohol, but consuming it in the same environment in which they developed their addiction. This is the compelling point of outpatient treatment for the Sinclair Method of Alcohol Extinction. Going inpatient for treatment is a false sense of security, in a non-threating environment and not the reality of life for most patients.
The best results should be garnered by completing the extinction process in a real world environment. Only those patients who indicate medical necessity should be treated as an inpatient, and then by convention detox protocols.
This results in an extremely simple treatment for alcoholics. A daily dose of naltrexone effectively blocked endorphins. Beyond that, it was just a matter of the alcoholics going about their life as usual. They drank when they had the urge, and the urge was extinguished over roughly a five-month period. Periodic psychological counseling improved the speed and effectiveness of the treatment considerably, although the frequency of this counseling varies more based on the budget of those paying for it than on the level of effectiveness.
Today, the Sinclair Method has been refined by additional clinical research to optimize outcomes. Neurotherapeutic Addiction Associates uses a twenty-week protocol, which allows one drink per day (usually at dinner time), with the addition of Campral (acamprosate) another FDA approved medication for alcohol dependency after the seventh week of treatment.
It’s impossible for any treatment for alcoholism to have 100% effectiveness because some alcoholics really do not want to stop drinking. Clinical studies of the Sinclair Method achieve a success rate where 78% – 87% of treated patients reduce their drinking below the level where cellular damage occurs. About a third of treated patients completely stop drinking (i.e. they extinguish their craving for alcohol).
The end result of the treatment is a patient that can take or leave alcohol. They have no particular craving for it. The patient must still take their antagonist drug an hour before consumption of alcohol, but besides that they can drink normally without the fear of relapse. This treatment also has the advantage that the patient does not need to undergo detoxification before treatment. In fact, detox can decrease the effectiveness of the treatment because it can change the alcoholic’s drinking patterns.
Naltrexone may not bevtolerated by some people. Roughly 3% of alcoholics cannot take naltrexone because of prior liver damage. A standard test for liver damage can determine this so that patients who pass the test can take naltrexone safely. Other alternatives to naltrexone, such as nalmefene, have been developed that are safer to take, however, it has not yet been approved by the Food and Drug Administration (“FDA”) for use for alcoholism in the United States.
Treatment using naltrexone was approved by the FDA for use in the US in 1994. Since then, its adoption has been slow and spotty. Dissemination of information of the treatment has been blocked by all of the existing treatment organizations largely because their existence depends upon the continued use of the treatments that they provide. Most treatment centers rely upon inpatient treatment for funding, and would cease to exist if widespread adoption were to occur. Alcohol Anonymous opposes the treatment on two fronts – the use of drugs and the continuation of drinking.
Project Combine, the largest controlled clinical trial in the alcoholism treatment field, published in the Journal of the American Medical Association in May, 2006, has shown “that while naltrexone was effective in its own right, combining it with the specialized counseling added no more effectiveness than naltrexone by itself” according to Dr. Raymond Anton, the coordinator for the trial. Naltrexone had been approved by the FDA for use within a comprehensive program of alcoholism treatment. This confirms findings from earlier smaller trials with naltrexone in Australia and with nalmefene in Finland. Of course, other forms of integrated services may still add benefits, but the pills do work alone. The medical community has been largely unconvinced of the effectiveness of this cure because of the extreme shift in mindset necessary to accept a treatment for alcoholism that involves continued consumption. To further cloud the matter, many studies have been done involving using naltrexone to help enforce abstinence – a purpose for which it is poorly suited at best. Although their “failure due to relapse rate” has no bearing on the Sinclair Method, most doctors see a “this drug failed” result and do not look to see how it was used.
The consultant to Neurotherapeutic Addiction Associates was one of the early patients of a treatment program in Sarasota, Florida in 1998. It worked so well that he felt that it could work for anyone who had a genuine desire to quit drinking (this is a key principle to overcoming the craving for alcohol).
Those patients with moderate to severe underlying stressors greatly benefit from the various therapies available at the Center and led to the development of the current comprehensive protocol of medication management with individual/group therapy that is integrated with acupuncture, exercise and nutrition to create the best possible therapeutic opportunity for success.
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