Hi Dr. Eskapa - I've seen several people ask this question so thought I would post it here.

If we take Nal and then later on don't really have the desire to drink, is it better to drink or is it no determent to the treatment if we don't drink that time? I thought I read somewhere that originally someone (may or may not have been Dr. Sinclair) had his patients taking Nal every day and drinking whenever they wanted to, but he found the pills were just as effective if the patients only took the pills on drinking days. By suggesting this instead of taking the pills everyday, it allowed the treatment to be much more cost effective.

So for those people who have taken the pill with the intention of drinking but then find the craving gone, do you feel it's just as good for them to abstain on that evening and enjoy the lack of craving or will they benefit more (advance their treatment) if they do in fact have a drink?

Thank you!

Taking naltrexone followed by abstinence will not hurt you if you do so occassionally.

However, taking naltrexone continuously with abstinence leads to something called 'receptor up-regulation' - making your opioid system more susceptible to reinforcement coming from the endorphins released when you do drink especially if you have been on naltrexone + abstinence then drink without naltrexone coverage. In other words, if you take naltrexone with abstinence then stop taking it and drink you will get a super jolt of reinforcement to the opioid system thereby increasing subsequent craving:

See this from The Cure for Alcoholism:

Pharmacologically Enhanced Reinforcement of Healthy Alternative Behaviors

Patients should be told that, while they are on naltrexone, they should avoid behaviors other than alcohol drinking that release endorphins. Otherwise, these other behaviors can also be weakened, which would be detrimental. Instead, we would like to have the other behaviors strengthened so they can compete with alcohol drinking and help fill the void as drinking is extinguished. This is made possible by practicing these alternative behaviors during pauses in naltrexone treatment.
The body reacts to having the opioid receptors blocked by naltrexone by increasing the number of these receptors, that is, up-regulation. This has now been shown in various species, including human beings. So long as the naltrexone is present, there is no effect, but for a period of several days after stopping naltrexone the patient is super-sensitive to endorphins. Behaviors that release endorphins will produce enhanced reinforcement during this period. It is very important that patients do not drink alcohol during pauses in naltrexone treatment. Although there should be pauses in naltrexone administration, patients should practice healthy alternative behaviors that release endorphins during these pauses.
In practice, patients at the beginning of treatment are asked to make a list of behaviors that they find pleasant, and then avoid tak﷓

ing part in those that release endorphins while on naltrexone. The physician can help identify which behaviors release endorphins. Then, after a few weeks of drinking alcohol while on naltrexone, the patient is advised to have a weekend without naltrexone and without alcohol, starting on Friday evening. (If the patient then finds the craving is too strong, the pause should be postponed and naltrexone resumed immediately.) Saturday is a washout day. On Sunday afternoon, still with no alcohol and no naltrexone, the patient actively chooses to take part in one or more of the healthy alternative behaviors. Usually, patients report that doing so is extremely pleasant. On Monday, the patient can go back to naltrexone and drinking.
Subsequently, this procedure should be repeated over and over, with the number of days off of naltrexone increased progressively, and the variety of alternative healthy behaviors expanded. Eventually, the periods off of naltrexone and drinking expand to fill most or all of the week.
Naltrexone should not be administered with a specified fixed time limit. If naltrexone is provided, say, for only three months, most patients will improve for that period of time, and then afterward relearn the drinking behavior. Within a few months, they will be back to where they started. Having just a short pause in drinking may be beneficial for the liver, but otherwise has little impact on the health of the individual. Naltrexone is a lifetime commitment. The commitment consists generally, however, of just carrying the pill around all the time just in case the patient drinks.

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Yes this is the recommended way however I couldn't stop some of the 'pleasurable' activities you list because they form part of my vocation.

I can say just carrying on as normal with other activities did not harm my success in any area one bit.

Thank you.

I agree with UKB, I don't think you have to give up any normal activities. I don't have much appetite, but when I have good food, I still enjoy it, and I haven't noticed any difference in how I feel about going for a bike ride; I'm quite motivated to put positive things back in my life. Maybe I wouldn't attempt a day-long hike or sky-diving until I can put a couple of AF days together. Unfortunately, since I'm not involved with a partner right now, I can't speak to the sexual aspect.