Hi all,

I started taking naltrexone on 9/9/10. I am going to chart my progress and I hope that will be educational for others.

My baseline is 30 units/week. This isn't much compared to what I have seen posted, but my alcohol consumption has severely affected my life, and cause legal problems.

I have read Dr. Eskapa's book, looked at some of the original papers, and know a bit about neurotransmitters. I have to say that I think the claims for TSM are way overblown. Fortunately, unlike AA, it shouldn't matter whether I am a true convert or not. Obviously I want this to work for me, but I am pretty sure that there is no placebo effect with me : ) .

Day 1 : 9 units (wine, pretty much all I drink). I figure: lets push the TSM to the limit, plus I was very anxious about my legal troubles. Basically passed out.

Day 2 : 3 units. Heavily hung over, so AL intake decreases anyways. There is general mild nausea and headache, but I don't know if it is the NAL or the hangover.

Day 3: 5 units. Wanted 1st drink. Didn't really enjoy 2nd. Went to restaurant and got AL with meal. Got more.

Day 4: 2 units. The nausea and disgust with AL continues. Stayed in my hotel room. Had a couple of drinks at dinner. Felt totally drunk.

Day 5: 6 units. Initial 2 with lunch. Felt slightly nauseated and actually only drank 1 1/2 glasses of wine. Checked into new hotel, sat in ornate lobby bar looking at beautiful women and people-watching in general. Ended up drinking 4 more glasses of wine. There is still a buzz., though the unpleasant effects - dizziness, detachment, loss of appetite - seems more pronounced.

Day 6: 2 units so far. Humongous hangover. Moderate craving by early afternoon. Likely will have 2 more.


My take so far for my 6 day experience: I get mild nausea and a headache, which decreases my desire for alcohol. This is trumped by the social cues. For example, alone in a fancy hotel lobby bar, it seems unnatural *not* to be drinking. The feeling of intoxication is achieved with less alcohol. The pleasure from AL seems about the same.

Welcome aboard. Your side effects so far sound pretty typical. Not everyone gets an immediate drop in consumption (or honeymoon) so keep taking your NAL and drinking in all the normal places and situations you are accustomed to drinking so you can extinguish as many triggers as possible. I look forward to future discussions about neurotransmitters, pharmacology, pharmacokinetics, psychology and pharmacological extinction. I too am mostly a wine drinker and high functioning alcoholic so you are not alone out there.

welcome jamesCT,
i look forward to any discussions about neurotransmitters, the brain, addiction, anything you can add to our knowledge here will be most welcome.
path

glad we have a science minded person around. yeah, some of the claims in the book are being found a bit over the top by many on this board. seems like it takes longer for most of us to be cured, but this DOES work. those side SE's should go away soon. I had then nausea early on and remember asking if this was a placebo, if it simply made people too groggy to drink, I said Eskapa and Sinclair looked like quacks to me etc...., in other words I was as much a skeptic as anyone, only to become a believer after seeing results.

Thanks all.

I really want to have this work. I've gone to AA (very briefly) in the past, and find it incompatible with my own believes. I have seen psychiatrists previously and been given meds for depression and bipolar, but they didn't seem to change my drinking long-term. And, on my own, I have gone abstinent for weeks at a time.

With my current (AL-related) legal and work problems, without NAL I suppose I would be knocking back 6-9 drinks a day instead of the lesser amounts I am actually drinking. I hope this honeymoon effect bodes well for an eventual cure.

My plan for the next 3 months is not to consciously limit the units/day that I drink, to allow extinction to set up. After that, I will probably try to cut down if my units are still high.

I appreciate all the info and support in these forums.

JamesCT,

I am three weeks in and the side effects are barely noticable but they were pretty crappy the first week. Hang in there, I also noticed an initial honeymoon reaction but that is ebbing and flowing. I guess it will take time to work through all the triggers. Welcome and I look forward to sharing the ride. BTDT

My doc, who had never heard of TSM before but put me on Nal anyway, told me that one of the main things I'd have to overcome were the social cues you mentioned, because the med works on the physical craving but not the mental/emotional component. He was right. Three months in, I'm having two or three AF days in a row, which is major. But if I watch Mad Men, where everyone seems to be holding a glass all the time, I immediately want a drink. So once the physical craving is gone, I guess we'll still have to work on un-empowering those cues. How that's done I'm not quite sure, but I'm open to suggestions.

My first week was marked by mild nausea and headaches which made AL unpleasant. This week, the SE's are gone, meaning - just like pre-TSM - I quite enjoy the 1st drink. The 2nd one still buzzed, but less so. By the 3rd and 4th ones, there is really no pleasure, just the strong desire to continue drinking until oblivion. So far this week I have resisted. This is only my second week, so the numbers are pretty much meaningless.

Some random thoughts, and no one else has to buy into them.

I have been equating one glass of wine=1 unit. But now that I scrutinize my drinks more closely, it is obvious that I get 1 1/2 or more per pour in places where I tip well or order several in a row. With that factored in, I likely was drinking more than 30 units/week. But I am not going to change my sig now because it looks like cheating if my numbers do go down in the future.

I tried looking up around 20 of the studies referenced in Dr. Eskapa's book. Almost all of them are abstracts with links to sites charging for the actual papers. I bought one (which I prob. will discuss in more detail in a later post): it cost me $35. I am sure they are all available for free in medical school libraries, but I don't live close to one.

The extinction effect of NAL and AL looks good in rats bred expressedly for AL studies. The translation into human relevance is tenuous.

Even on a theoretical level, it is uncertain how much of a role opioid receptors play in AL dependence. For example, giving NAL to chronic heroin users causes severe withdrawal, while NAL in alcoholics has little immediate effect. Plus, the painful experience in me and other alcoholics is that we drink not just (or mainly) for pleasure, but to escape .

All theory is gray (yeah, it is a quote), so what is the evidence?

The oft-quoted 78 % success rate of TSM is from a non-peer-reviewed collection of initial patient experiences from a Finnish clinic. This same clinic has a web-site wherein it showcases these results, but no follow-up current or cumulative results. The cynic in me thinks that, being a commercial enterprise, it would be eager to publicize good results if it has them.

Of interest is that its current program states that clients, while treated with TSM, will be given cognitive-behavioral therapy to decrease AL intake. This actually makes sense to me, but this goes against the recommendation in Eskapa's book.

Also in the book is a big deal made of the PROMISE study, and that it proved psychotherapy adds nothing to the use of NAL alone. True, but, the study showed that NAL has the same result as cognitive therapy - both with mild-to-moderate benefits over placebo; the equal claim would be that NAL adds nothing to the psychotherapy. Moreover, TSM was not utilized at all - it was the traditional use of NAL.

There were studies where NAL was taken before AL, and of course ones where participants on NAL drank when they weren't supposed to. These results should lead to further studies, but since TSM wasn't the study target, no conclusions can be made. As far as I know, there has been *no* peer-reviewed studies directly comparing TSM to traditional NAL use, or anything else.

From anecdotal reports - including those on this board, TSM works for some people. What is the success rate, and how does it compare to other medications? No one knows.

What about NAL as traditionally used - after a period of abstinence and meant to decrease craving? The main-stream-medical opinion, after considering peer-reviewed studies and meta-analyses is that it works, but its efficacy is moderate. But I think a moderate effect is great news, and certainly worth a try. It is scandalous that most physicians do not even consider medications in treating AL-dependent patients.

Lastly, Vivitrol - an extended-release form of naltrexone requiring monthly injections - was released some time ago as a treatment for alcohol dependence. The FDA approved it primarily because of one large positive study - which in fact was positive only in enrollees who were abstinent for at least 4 days; the benefits were greatest for those abstinent for 7 days prior and non-existent for those drinking immediately prior to Vivitrol.

Of course the long, slow decay of naltrexone levels with Vivitrol is different from the daily peak and fall of oral naltrexone, and TSM is not being studied here. But in my opinion, this paper reinforces the prevailing medical practice of encouraging at least a short period of abstinence prior to starting NAL and attempting to abstain while on the drug.

For TSM, the obvious step is to have a large-scale study (unblinded compared to no treatment or traditional NAL use). AFAIK, there is no current registered study to evaluate TSM. This may be because the reasons stated in the "Cure" book. Or because ambitious post-docs and assistant professors don't think there is much there.

For purely financial reasons, the maker of Vivitrol would finance such a study if it thinks that TSM is superior. The drug is $700 per shot ! If it thinks that, say, 6 - 12 months of injections followed by occasional cheap oral naltrexone , will cure 78% of alcoholics, the study would have been done yesterday.

What am I doing right now for my alcoholism? I just started TSM. The medical consensus is that NAL works, though only moderately. The evidence for TSM is sketchy from what I find, but it works for some people and it is easier to follow than the traditional NAL treatment. But, on the basis of one clinic report, I find it hard to accept that 78%, or even 50%, are cured within a few months.

I will continue with TSM. This month, I will drink as if I was pre-TSM. Next month, I will make a conscious effort to cut down, since extinction, if that is the actual mechanism, should work whether I am pleasantly buzzed at 2 drinks or sprawled on the sofa after 7.

The larger issue is that medications - NAL, acamprosate , Topamax, Baclofan - work for some people, and that though the efficacy of any one may be modest, given the devastating consequences of alcoholism, it is worth while to try them all serially in various protocols. Unfortunately, the medical community and the public at large is unaware of these advances.

So, that is my 2nd week progress report.

Hey James,I would like to appologise for my earlier rants..I was way off the hook..The whole AA 12 step thing just strikes a chord with me..I suffer from PTSD,sometimes I think that I am being attacked when I am not..I don't quite understand all your research?? are you saying that Sinclairs studies are over rated?? I am really curious because from a lay persons perspective,they seemed legit to me..but Im no expert,that is why I emailed the orange papers before I started all this..That guy seems to be an expert on interpreting studies..Anyhow,hope u can forgive me..Feel free to call me a caveman or neandrethal or whatever..still hope u do well here..I know,science is not based on hope..Hahaha...Goodman

Hello James , hello Goodman

I can see James you 're scrutinizing very closely research behind TSM . It's not an easy thing to do , not for me
at any rate to interpret . The bottom line is that alongside any research its a waiting game to see if and howmuch it'll work - For you / each person .
The fact that NAL has had some effect for you is in itself a goodsign .
As it happens my wife is bi polar and seemed to have shown common signs of alcohol dependance . She wisely packed it in about eighteen years ago and feels/ felt never any craving . I've read and known other people in the same boat , you're maybe aware of this . I say this because you also said you didn't drink particularly big quantities and yet it caused you behaviour problems . That too was very much my wife and old friends case .. The latter they thought was the life and soul of the party who'd jump on tables and dance and all manner of extremities . But he never shared the same view on it and
Perhaps you're both alcoholic and BP .
Any rate keep on posting and don't give up , above all til you recognize an extinction burst , and if that happens don't
ever give up , I'd say .
So what do you make of the project combine results as anotated in "The Cure " ??