Not sure if this is the right place for it but here goes.

Just been to see my GP today (that's like your own personal Dr here in the UK). Now she is new to Nal, hasn't prescribed in the past because Nal is something only really used by the Drug and Alcohol team. So she's learning as much as I am. I'm 6 months in and I consider myself in control of my drinking so we now have a few questions;

Do I have to take Nal before I drink, for the rest of my life?
Can I cut back the dose to 25mg, or will this put me at risk of a binge?
Are there any long term side-effects of using nal?

I'm currently taking 50mg 3 or 4 days a week, basically when I feel I might want to drink. Sometimes I do, sometimes I don't. Since regaining control I also have started to be able to identify a definite depression the day after using nal. It's not a problem because just being able to live without drink controlling me is great, however I am having to exert a lot of motivation during these periods to just keep on doing things. I am not suicidal by a long way though, even despite a few very series worries on my plate at the moment.

Some answers and or references would be great.

Hi UK:

Some of the vets will reply as well but here's what seems clear from this board and from the research:

Yes, you take Nal for the rest of your life before drinking.

Dosage is a grey area. It is different for each person. You'll have to experiment. There's relatively little robust research on the subtle issues involved in TSM.

Long-term effects, see answer #2. This is an under-studied drug. That's likely due, in part, to the fact that it is generic and drug companies/researchers have little incentive to do big studies. That said, there are addiction researchers out here doing smaller studies of Nal. That said, we know what the long-term effects of heavy drinking are and they are likely more damaging and catastrophic than taking Nal. I've read that the liver toxicity problems with Nal are at higher dosages and 100mg.

Anyone else please feel free to correct, amend or amplify on these thoughts.

I think going down to 25mg might be fine. I would try it out and see what happens. But as far as I understand, yes you need to take nal for the rest of your life. I think it is probably possible to stop taking nal and control your drinking through sheer behavior modification, since your behavior will have changed over the course of TSM, but it would be much more difficult and put you at the serious risk of a binge.
As for the slight depression after nal...I've noticed it too. For me it's not really a depression per se but everything is juts kind of BLAH and I have no energy. It's not ideal, and that's why I also try to stick to nal 3-4 a week, max.
Good luck.

You need to take Nal for the rest of your life as long as you are drinking. If you stop using Nal and continue to drink, you will go back to Pre-TSM levels within a couple months and need to start over again. I, among others, have experimented with the dosage. 25mg has worked for me for over 6 months now with the added benefit of effectively doubling my Nal supply. I have also tried 12.5 and it worked less effectively, my numbers/craving crept up. A couple weeks back on 50 mg then a return to 25mg put me back on track. Once you are confident in your baseline performance on 50mg, try 25mg. Don't fret if you have a big day here and there, monitor whether your craving returns in an obvious manner.

Read chapter 10 of Eskapa's book re: staying cured for reference.
The long-term effects of low-dose Nal (Under 300mg (pg 63)) appears nil (from my internet searches). Every medication should be approached with a cost/benefit analysis, even aspirin. When you factor in the fact that you will only take a single dose perhaps a couple times a week, the odds of doing any harm (especially compared with alcohol consumption) are miniscule. Furthermore, when you consider the benefits of up-regulation of opiate receptors, low-dose Nal could have positive benefits on your feeling of well-being and enjoyment of vigorous exercise. Nal on.

Confirming, for the most part, what others said:



That is the today's consensus. Long terms studies (5-15 years) are non-existent so this is not 100% but still seems likely. This fits the commonly accepted concept of "once an alcoholic, always an alcoholic" - i.e., brain rewiring by alcohol is near-irreversible.



Optimal dosage is not going to be the same for all people. 25 mg might be plenty for some and 50 might not be enough for others. You'll have to experiment to find out. There is no other way.



No one knows for sure. It is pretty obvious that Nal is safer than alcohol abuse. My guess is that the biggest fear is if the known upregulation of opioid receptors turns out to be permanent and, worse, progressive. In this case hypersensitization condition might develop and one of it manifestations is a lower threshold for an overdose (an issue with opioids for pain management). Note that this is pure speculation! Another concern, more vague and biochemically uncertain, would be long-term alterations of mental function (after all, chronic Nal would be constantly changing the way brain works). These almost equally well may turn out to be positive (e.g., better cognitive function) or negative (e.g., earlier onset of dementia) - with just about everything in between and a potentially huge variability in response between different people. Of course, not a shred of data exists on any of this either. It's just this: taking any action in life carries some risks

Do you experience the slight depression even when you take Nal and don't drink? I'm new to Nal but curious about your experience. I have always noticied a slight depression (sometimes major) the day after drinking.

I rarely take Nal now and don't drink. I do get a bit of 'flatness' with it the day after if I haven't drunk, but it's heavier - more like depression if I do.

Obvious solution is not to drink really!

By the way I have tried 25mg instead of 50mg, and yes it still works so may reduce to this level permanently.

Just wanted to report that yesterday I decided I wanted to get drunk. Bought a bottle of wine but couldn't stand it, poured half the second glass away, half of the bottle remained even after that - so I probably had 3 units total. I'd taken 25mg Nal 3 1/2 hours before this, did feel depressed this morning BUT no comparision to being hungover and sick. Oh I did have some food with my drink, not sure if that helps. I think it does.

Very pleased whatever, also know some of the tired depressed feeling is because I've been battling a few personal things lately, plus have been working very hard. I'd say 50% nal, 50% me on that score!

That's great news! Congrats, UK.

Thanks, I've a night out planned tomorrow and already I'm thinking I simply won't bother to drink. If I don't then the few units last night will have been the only drinks I've had in a whole 7 days, and without any effort - well apart from thinking "hey I don't actually want to drink, so I won't force it!".

Yippee I think I could be heading towards voluntary abstenance. Blinking miracle if I am.