I am on day 24 of taking Nal, so almost 4 weeks in. I have been reading and posting on this board, and I thank God that you guys are here to guide me along.

I had all the side effects (nausea, insomnia, bad dreams, heightened taste, clear headed drinking etc.), and I went from drinking 8-11 beers a night, immediately down to 3-4 beers a night. I was never getting a buzz, and I didn't miss it. I was going to sleep completely clear and sober, and despite the insomnia and weird dreams, I was basking in the absolute joy of leading a, for the most part, sober life.

But now, just as many of you have reported, the side effects have all worn off, and the "Honeymoon Period" seems to be coming to an end. I have climbed from 3-4 beers per night, up to 5-6 beers per night, and even had an 8 beer night not long ago.

This was predicted by many of you on this board, and most people seem to experience this honeymoon period, and then an increase back to pre-TSM levels of Alcohol intake. And then gradually, over 4-6 months, the intake dwindles (as if by gradual magic) down to hopefully a level where you can pronounce yourself "CURED!!!" Well you guys have been right about everything so far, so I am not about to start contridicting you or doubting you now.

But, I do want to ask about will-power and therapy. My therapist is an addictions counselor from way-back and is well schooled on the AA, white knuckling/sponsors/abstinence/willpower methods. This whole Sinclair Method stuff has been a lot for him to adjust to. He has been great, in that he did agree to let me try this method without him judging it or advising against it. He is open to learning new techniques basically. But now that I got down to 3-4 beers a night, he is saying that I should try to use willpower to stay at 3, and then in a few weeks we can step down to 2 beers per night, and then 1 and then be off it eventually.

Well, I know that with TSM, I am about to spike back up to 6-8 beers a night, like I was Pre-TSM. But I feel like I could maybe over-come that with willpower. I'm pretty confident, that with Naltrexone, I could resist, and drink only 3 beers a night for a month, and then step down to 2, and so forth.

But is that the best thing? Should I literally just sit back, and not try to will anything, and just drink whatever, and how much of whatever I want? And let the Naltrexone bring me down gradually like everyone else. Or should I try a combined approach of Naltrexone to help with cravings, but use will power to step myself down much faster without the "traditional" pre-TSM spike?

I don't think that statement is the opposite of using willpower. Using willpower to me is not drinking even though the cravings are very high - "I would do anything for a drink right now ... must ... resist... argh! It's all I can think about!"

To me that's a very different thing than, "Man, another drink right now would be great! Hmm, let me sit on it a moment and see if I still feel that way in five minutes - if I do, I'll have one. Maybe I'll sort my loose coins or go check email or something to take my mind off this for a moment."

Pre-TSM no way would any project take my mind off anything other than pouring that next drink. Post-TSM, no problem, the strong desire for a drink passes in a minute or two, and I am merrily engaged back with my TV program, or changing light bulbs, or cleaning a closet, or whatever. As time goes on, the craving-wave seems shorter and less intense.

When I drink something sweet and tasty (I love Honest Tea Pomegranate Blue, for instance) it ALSO tastes great and I think, "Man that's delicious. I could just guzzle another one!" But I follow that thought with, "Dude, the calories start to pile up if you do that. Aren't you trying to stay on top of your weight? Maybe switch to sparkling water, eh?" And I do. I don't consider this using willpower; it just seems like common rational thought. I don't just drink "whatever" or "as much as I can" just because I can. Why should drinking alcohol be any different? Sure, I think to myself "I could easily pound these awesome beers until they're gone!" followed by, "Dude, isn't there something else beside alcohol that would taste good right now? Try a Pomegranate Blue - it's a fraction of the calories!"

All that said, it took me forever (well, actually 16 weeks) to reach the point where I suddenly felt like, "Maybe tonight might finally be AF!" - and it did catch me by surprise.

At the risk of contradicting a professional addiction counselor, I will offer an opinion and my experience, which of course is not intended to be advice.

Using willpower at this stage of treatment would no longer be TSM. It would be somewhat of a hybrid method which may or may not work. In my personal experience, I used absolutely no willpower post-honeymoon and my units did rise and stayed there about two months before destabilizing and "roller-coastering" down to moderate levels. It took me almost 5 months of treatment before moderate drinking levels were reached and all without any willpower.

In months since then, I have used what you may consider "willpower" at these low levels I am imbibing now (about 4/week). The reason I don't like the term willpower at this stage of treatment is because the cravings are almost non-existent and it's more of a decision not to drink, than it is willpower. I remember willpower from my AA days; it was like "how long can you hold your breath?" Post-cure, the decision is more like "should I be in the center lane or the right lane on this highway."

I can't imagine trying to use willpower before TSM extinction has occurred. It seems as if it would be needlessly difficult. But, of course that decision is yours. Who knows. You may come up with a hybrid treatment that works!

EDIT: Cross-posted with PV, who stated the same point about willpower vs. decision far more eloquently.

Bob

Eskapa responded to this in a post on his thread. he said there's nothing wrong with using a little willpower to reduce intake as long ass the cravings are manageable. In his book, Eskapa says, "De-addiction happens slowly but surely withthe research showing that the more often you drink on naltrexone, the more you weaken your addiction." (p. 107, emphasis his). Eskapa says in a footnote to this comment that Sinclair insists that, while frequent drinking is beneficial, consuming large quantities per session is not beneficial for TSM and of course can be dangerous.

Eskapa reports that Sinclair found that reinforcing positive opioidergic on non-drinking/non-nal days is important to TSM progress. "If you last took naltrexone on Friday afternoon, Saturday is a washout day, when the medication is being removed from your body. Starting Sunday afternoon, roughly two days since your last dose of naltrexone, you are in a state where patients report that doing those alternative behaviors [e.g. sex, exercise, a gourmet meal] is especially reinforcing." (pp. 121-122)

Some here who have pronounced themselves cured found that alcohol-free days came spontaneously. Others report exerting some effort. Of those who used effort, some report that progressively less effort was required subsequently. This is also true of reduction in consumption. One member, a binge drinker, reported forcing Alcohol Deprivation Effect in order to create and drink through an important trigger. Sinclair responded here that doing it this way probably was a good idea [for binge drinkers; daily drinkers don't have the trigger of ADE to extinguish because we never deprived ourselves ].

You are very fortunate to have an open-minded addiction specialist. This method is so counter-intuitive (i.e. you MUST drink vs. you MUST NOT drink) that I'm not surprised you are getting encouragement to use some willpower. If he has read the book you might remind him that here in the field, TSM is taking longer for most than the 3-to-6 window in the book.

If you choose to use effort, there is a balance to be achieved among the factors I've mentioned here. The main thing is being exposed to triggers and naltrexone-drinking through them.

Edit: To finish the thought about ADE and to say I cross-posted w/ PV and bob3d and what they said goes double for me. I like the effort/willpower distinction. I'll leave the ass as-is for your reading pleasure.

lena makes me laugh sometimes!

Bob

Here is Sinclair's answer, which I copied from a post by Eskapa:

From David Sinclair - reply to this question. His response was quick and I appreciate it. I should state that almost everything I have learned about addiction science has been since I met Sinclair in 1990. The rest came from reading and working with people facing addiction issues. Here is an explanation for SpringerRider hot off the press from Helsinki, Finland:

What you describe is actually one of the basic processes in the nervous system. Learning is caused primarily by the synapses between nerve cells becoming stronger (reinforced), and thus making it more likely that you will make a response or think a thought or feel a craving again.

We know, however, that the opposite process - the weakening and eventually complete burning out of synapses - is at least as important. (Extintion) For example, most of the changes in the nervous system that occur in the first few months after birth are the removal of synapses. It is sort of like sculpting: removing all the other synapses (and thus breaking all the other neural pathways) until just the one correct one is left.


You may call this "deep in your psyche" but causing it is a real physical event.

The dissolving of the relationship to craving is the burning out of the synapses that previously had made you think about alcohol. It is not the relationship between craving and its satisfaction that is being removed, however. That relationship, or rather that between craving and reinforcement, is blocked as soon as you take the first naltrexone pill, and it is blocked so long as you have naltrexone in your brain, but it is completely unconscious. It just is a fact that if you happen to have endorphins released, they will not be able to cause any reinforcement (strengthening of synapses), but you cannot feel this. At most you will notice the lack of something when you do have endorphins released, after drinking alcohol, or by eating sweets, jogging, etc.

The really important factor is what happens after alcohol drinking causes endorphins to be released and then the expected activation of opioid receptors from binding their endorphins does not happen. At that part, the nervous system starts the mechanism of extinction. The synapses that had just been used, e.g., ones triggered by the sight of a drinking friend, or the smell and taste of your favorite drink, or by the mood when you drank, become weaker. These synapses are now less capable of making other neurons fire. Some of these neurons that are less likely to fire now are the once involved in thinking about drinking and in craving. Others that are less likely to fire are ones causing the drinking behavior itself.


There was a new report last week at the ESBRA meeting here in Helsinki. You may have heard of the MRI machines that can show when parts of the brain are active. The new report, from Germany, showed how alcohol-related cues (e.g., pictures of beer bottles) were able to stimulate strong firing in various parts of the brain in people who had become alcoholics because of reinforcement of synapses by endorphins. And these were the people who responded very well to naltrexone.


I found your description of how the craving grows with alcohol deprivation very interesting. This phenomenon, which I named "the alcohol-deprivation effect" is what got me started doing alcohol research over 40 years ago. It is a very powerful thing. It also is contrary to the ideas people had back then about what causes the motivation for alcohol. In particular, it was generally accepted that the motivations was logically caused by withdrawal from physiological dependence on alcohol: that people were drinking just to avoid withdrawal.

Consequently, the treatment they gave was detoxification and forced abstinence, long enough for the physiological dependence to be gone. Indeed, a misleading euphemism for alcoholism still used today is alcohol dependence. If they were right, detox would have been the cure for alcoholism. Of course, it was not. We found that the alcohol-deprivation effect does not disappear as physiological dependence is removed. Instead, the increased craving produced by the alcohol-deprivation effect grows stronger and stronger, week after week, and never went down in several months of deprivation.

Now to your question of whether you should intentionally deprive yourself of alcohol. The way you are doing it sounds good. It is a good idea to extinguish all of the various forms of drinking you had learned to do. You should drink alcohol (with naltrexone) in the same locations where you previously learned to drink, with the same people, and with the same moods.

One situation in which you previously had learned to drink was probably after a period of alcohol deprivation. Consequently, the synapses connecting the deprivation-induced feelings of craving to the act of drinking have become reinforced; and they now need to be weakened by extinction.


Naturally, there are certain cases in which you must try to limit your drinking: you must be particularly careful not to be drinking if you are going to drive, etc. The naltrexone may even make some aspects of intoxication worse.
There is another reason for have pauses in your drinking as soon as you can manage to do so: in order to strengthen healthy alternative behaviors.

It is a good idea make a list of things other than drinking that you enjoy doing and then noticing which ones are probably reinforced by endorphins. They include eating sweets, spicy, salty and other good tasting foods; jogging, sports, and other forms of strong exercise; cuddling with babies and pets; some forms of sexual activity. These behaviors will also be weakened if you do them while you are on naltrexone - but we do not generally want to have them reduced. Therefore, first, you should avoid as much as possible doing those other behaviors while you are on naltrexone and drinking. Second, when you are able, have a weekend without alcohol and without naltrexone. Saturday is a washout day in which the naltrexone is removed from the body. On Sunday afternoon you should reward yourself by doing one or more of these other opioidergic behaviors.

We have discovered a really nice thing about this. When you do the other opioidergic behavior, you will get enhanced reinforcement of it. Patients report that the first bit of chocolate, on that Sunday afternoon, is the best they have ever tasted.
The main reason for this is that while naltrexone was blocking your opioid receptors, your brain tried to compensating by making more of them. This is called "up-regulation". We have actually measured the increase; it was almost a doubling of the usual number of opioid receptors.

So long as there is a surplus of naltrexone in the brain, the increase in opioid receptors has no effect since they are all blocked. But when the naltrexone has been washed out, this huge crop of opioid receptors is standing, begging to be filled by endorphins from that chocolate, or from jogging, or from any of the other behaviors.

The increase only lasts a few days, but during this window of opportunity you have supersensitivity to endorphins and an enhanced ablility to develop other behaviors to fill the vacuum as alcohol drinking becomes less important in your life.
This also leads to the long-term solution for the drinking problem. In our three year follow study, we found that the patients drank progressively less often over the months and years. In other words, the deprivation periods became longer and longer. Some quit completely. Many others were down to drinking at most once a week - it was sauna night in Finland and they wanted to have a sauna beer, like everyone else around them. The rest of the time they were just carrying the pill with them, in case a drinking occasion arose. It costs nothing to carry it. And there is no risk of weakening any of the healthy opioidergic behaviors.

Just remember to always take the naltrexone before drinking, because this enhanced reinforcement has another part to it. If, during the time of supersensitivity you drink alcohol without taking naltrexone, there will be enhanced reinforcement of alcohol drinking. Done repeatedly, you would soon relearn all of the craving and drinking behaviors that had been extinguished.

David

That's a *really* juicy tidbit, I'm going to want to refer back to this one. Maybe a sticky thread for 'assorted letters from Drs. Eskapa and Sinclair' would be good

-Ned

At least she didn't say "as long as the ass cravings are manageable..." !!!

This is getting funnier and funnier! Thanks, RV!

Bob

I have to say I was always taking the NAL and drinking....Just doing what I always did. Didnt notice a major decrease in units. However I felt less compelled to drink. But did anyway. Recently I have been consciously trying to have more AF free days. To my amazement its not been difficult at all. Im now starting to lean towards the fact that once the overwhelming desire to drink lessens we need to increase the willpower to not drink. Im sarting to believ once again....will keep all posted.