I feel the same way about the 78% number possibly being high. It appears as though the 3-4 months to the cure number is inaccurate, so why then couldn't the 78% be as well. Glad I didn't run you off. I guess you meant that people doing TSM and trying to just blindly have faith in the process despite understanding it fully was like AA? Anyway, unlike AA, questioning is encouraged here and I'm glad you raise these questions. Many of these have been raised before with no answer. I hope you can find some answers but more importantly I hope you get cured.

I've seen a significant decline in numbers but nearly 7 months in I am not cured. the numbers have decreased by around 40% and have stayed there (with one peak) for months. I may ask my shrink about bumping up to 75mg after another month. At this point I'm kind of wondering if Nal is just working for me as an anti craving drug. Keep posting and thinking.

James, I welcome a healthy dose of skepticism. I have a slightly different take on some of your observations. First it doesn't matter how you measure your drinks as long as the unit is consistant and you report it. So if your glass of wine is 7 or 8 oz instead of 5 oz that's ok just keep it the same as you report your results so you can track changes. Secondly, I spent quite a bit of time reading through the articles back in July when I started TSM. I have access to MEDLINE and can get the full text versions of the articles for free. Project COMBINE is probably the strongest evidence that TSM is effective but it is indirect evidence because the researchers did not set out to test the Sinclair Method. CORD in India is using TSM in it's program to treat alcoholism but they have not published results that I can find yet only progress reports. I doubt we will see any US based research testing or comparing TSM to other methods coming from academic institutions. There is little incentive for them to do so. The prominent alcohol researchers in the US seemed to have moved on from Naltrexone to the next thing.


I agree that the exact role that opioid receptors play in AL dependence is not clearly understood. That said, it's not fair to compare heroin and alcohol opioid receptor responses to naltrexone. Naltrexone displaces heroin directly from opioid receptors and sends people into acute withdrawal but naltrexone is probably acting indirectly by blocking first drink effect and reducing the pleasure from alcohol partly by blocking opioid receptors and partly by modulating dopamine so giving it after you've already taken alcohol shouldn't be expected to have any effect. The horse has already left the barn and reinforcement has already occured. We also know that alcohol response and reinforcement doesn't even have to include alcohol if we've associated alcohol with something else (e.g. the smell of alcohol, the sight of it or even your drinking buddies or the bar where you drink) can all trigger reinforcement. You can give people non-alcoholic drinks and if they think there is alcohol in them they will start to act drunk.

As far as vivitrol, I personally would not want to take this drug because it blocks all opioidergic activities and if TSM does work and you abstain while on vivitrol you could be setting yourself up for a major binge due to receptor upregulation and alcohol deprivation effect.

As far as medications in the treatment of alcoholism I agree they are grossly underutilized. If you think about it most of the addiction treatment is done by psychologists and psychologists make their living talking to you. (CBT etc) they can't prescribe med.s and need to work with a psychiatrist or other type of physician to get you med.s. If med.s alone are effective there is not much reason for them to be involved in addiction treatment except to help you undo all the emotional trauma of addiction to you and your loved ones. I do enjoy discussing these aspects of addiction because it helps pass the time so keep asking the tough questions. I'm very curious to see what your AL use looks like in 3 months. Take care

Thanks all for the thoughtful replies. Due to work and sleep deprivation, it will take a few days to adequately consider them and gather a response.

Please do not let my musings and half-hearted "analyses" affect whatever anti-AL efforts you have in place now. Keep in mind that I am still an alcoholic.

Week 3 :

Still craving the 1st drink. For example, this morning I wanted a glass of wine but waited until 2 PM. (On my days not working it is not uncommon for me to start drinking early.) My biggest trigger seems to be boredom.

The biggest change I have noticed is that I feel the effects much more, thus making it easier to stop after 3 or so. Another encouraging sign is that last week after a particularly unpleasant and stressful conflict with a colleague, I only had 2 drinks afterward as opposed to the 5-8 bender I usually do to deal with my anger and anxiety. Of course after just 2 1/2 weeks on TSM I am not going to extrapolate much.

I am not advocating this for anyone else, but I am going to deviate somewhat from the TSM as described in Eskapa's book. First, next month, I am going to consciously decrease my drinking. I think many TSM beginners already cut down just from reflecting on their alcohol dependence. My absolute intake isn't sky-high, but I find it difficult to believe that deliberately trying to limit intake to say 30 units/week will detract from extinction compared with 50-60 units/week. This does not mean any attempt at abstinence.

Second, I am going to try to address my non-alcohol issues - self psychotherapy if you will. I know that according to TSM, and non-TSM NAL studies, this may have no effect on my AL intake at all. However, though treating my AL dependence is my number 1 goal right now, addressing anxiety +/- depression can't be bad as a separate endeavor. I am going to give computerized cognitive therapy a try. There are multiple sites around, but one freebie which looks good is http://ecouch.anu.edu.au .

Best wishes to everyone.

Hey St. Vincent and Elfern,

I enjoy your posts discussing the studies associated with NAL.

I read the COMBINE study, since JAMA allows free access to its archives. "The Cure" referenced this study several times, implying that it supports TSM and emphasizing that NAL use does not require psychotherapy. As I said in a previous post, the study reports equivalent efficacy of NAL and Combined Behavioral Therapy (CBT) with no additive advantage. Either one is modestly better than placebo. Thus a patient could just go the CBT route rather than NAL, though the former is much more time-intensive and expensive.

The use of NAL in COMBINE is the traditional abstinence lead-in and encouragement of abstinence during the course of the study, which is completely different from the TSM approach. There is no subset analysis of those who drink during the study. In fact, that would be invalid since days to first heavy drinking is one of the primary end-points. Thus no conclusion about TSM can be drawn from COMBINE.

Ironically, CBT in this study includes "facilitation of 12-step participation", and in the "Conclusions" section the authors thought that this may be why their CBT results are better than most previously reported studies of cognitive-behavioral therapy.

Given the above, I think it disingenuous that COMBINE is quoted to support TSM in any way.

About Vivitrol, I mentioned it mostly because the manufacturer stands to make huge profits if TSM works with it, and thus may be willing to fund a TSM study.

Since starting TSM, I have read a bunch of AL studies, both because of curiosity and direct personal relevance. One more interesting thing which I was not aware of and I find surprising, is that the self-remission rate is so high. Depending how liberal the definition (no big benders, no AL-related arrests, overall moderate drinking or less), the rate is 20-50% for 1-3 years!

Thanks for the discussion. I think I will throttle way back on introducing these topics. Most people have little interest in them, or take them the wrong way - at least with the way I have posted. Plus, I don't want to discourage folks from their attempts at a method which may or may not work for them. And I certainly don't want to have anyone sink into despair because of theoretical discussions of scientific papers.

I'll mostly just stick to my personal experiences from now on.

Hey James, Glad to hear ya..Sounds like you are doing good..I am having similar results..I also decided to deviate a bit this week by purchasing less beer..I want to see if I am drinking more because it is there or because I need it..So far so good..No mad dashes to the store,just a passing thought..As to your depression..My doctor put me on 100mg of vitiman B1 a day..Seems to be helping..No Ideas about the anxiety..Mine seems to be less severe with the decrease in alcohol..Have a good night James:) Goodman

james,
i commend you on taking the initiative and making what effort you feel is right for you. i will check out the cbt link you posted. i think that in general working to get issues resolved for oneself, however that happens is always a good idea. i have years and years of hard work, on my own and with therapists under my belt. not perfect yet, never will be, but i'm still working on making me feel and be better

i also appreciate your desire to post in a way that won't dishearten folks, but i for one am interested in what you have to share and hope you continue to make informative posts even if they are challenging to the conventional wisdom here.
thanks, and best to you!
path

By all means post what you want. I appologize if I dissuaded you. Seems you are discovering legitimate beefs with the book, as many of us have. This information being brought to light here is helpful to future TSM'ers, for instance, most of us agree that the 3-4 month claim in the book is absurd. and your take on the COMBINE study is interesting. I really don't think the book is well written at all. It is sensationalistic and comes off quack-ish. BUT, TSM works. I've seen it, and though I am not cured, I appreciate the fact that TSM has cut my intake in half. Hope it keeps extincting further

Hi James,

I've really stopped worrying about whether it'll be naltrexone or baclofen or some other concoction that will finally give me some respite from this damned monkey on my back. The bottom line is that finally, there is an alternative to the dogma of AA, which needs me to acknowledge that I'm a weak-willed victim whose total lack of responsibility has led to this dependence problem. Now we're beginning to see that it's actually a chemically-based dysfunction, and that its progression can be halted by addressing the opiod bindings that lead to addiction. Perhaps naltrexone won't be the ultimate answer, but the knowledge that it's not a character flaw or a product of a damaged psyche not only makes me feel much less guilty about how I arrived at this place, but give me a great deal of hope that finally, there'll be a way out of my dependence. If it's not naltrexone, it'll be something else. But I finally have hope that my drinking will eventually have an end point, where I'll have the choice of continuing as a social drinker or just stopping completely.

Thanks Joe and Goodman,

I appreciate your optimism and support in your posts , which is important for most of us. I mean, whatever our AL intake, we still have to get up in the morning (or afternoon), go to work, interact with colleagues and family. Having support makes things go smoother.

I think NAL works, which is why I am taking it. But, for reasons I gave in other posts, I just cannot believe that it works in 78%. But I will take any advantage. I am not wedded to NAL, and if in a few months I don't see objective progress, I will try other medications.