Can a person’s craving for alcohol be reduced by blocking opioid receptors?
The following is a transcription of a talk I gave for the C3 Foundation 2021 conference, “Stronger Than Your Drink.” The C3 Foundation is dedicated to educating doctors and the public about the harm reduction method of treating alcohol use disorder with medication-assisted treatment. To listen to the full video of my talk at the virtual conference, please click here.
It can be difficult to identify a gray area drinking problem and when you have crossed that line from moderate drinking to alcohol abuse. The gray area is defined by a social drinker who sometimes engages in binge-drinking. The alcohol consumption involved will vary from one person to another.
Is this sort of problematic drinking an actual addiction? If you are concerned about where your drinking life is headed, you may want to consider seeing a doctor and a gray drinking health coach.
Is controlled drinking possible for someone with alcohol dependency?
Alcohol dependence is a learned behavior that involves a complex interaction between the pleasure of alcohol intoxication and the resulting endorphin cascade that floods opioid receptors.
Advanced alcohol dependency can be prevented by slowing down gray area drinking early on. Consider attending more sober events socially rather than social situations focused on heavy drinking. There is no shame in addressing gray drinking before it gets out of hand.
The Sinclair Method is an alcohol treatment that uses the opiate blocker, naltrexone.
Naltrexone, and similar medications, such as nalmefene, are used in addiction treatment for opioid addiction and to treat addictive behavior related to alcohol use. The idea is that engaging in habit erasing behaviors, such as regular TSM practice, will eventually lead to abstinence for many people.
What does an opioid antagonist have to do with helping someone to reduce their alcohol drinking? It turns out that endorphin reinforcement is a significant component of the habit forming behavior process of developing an alcohol addiction.
The need for inpatient treatment can be avoided by providing treatment early while still in a pre addiction state.
Many substance abuse problems start this way, and some can be treated with similar protocols that may involve naltrexone treatment. While it may seem like a break from traditional treatment, using naltrexone to reduce a person’s craving for alcohol and other substances is well established.
One issue that comes up with traditional abstinence based treatment is what is known as the alcohol deprivation syndrome. Patients who have had prior detoxification and are alcohol-free may start developing an alcohol craving issue months after their alcoholism treatment.
The Sinclair Method helps the problem drinker to avoid the alcohol deprivation syndrome. In the documentary, One Little Pill, people who practice The Sinclair Method are interviewed and followed as they discover that this form of pharmacological extinction for alcohol addiction really does work for a large percentage of the people who try it.
Below is the transcript from my C3 Foundation 2021 talk. Please visit my official page about The Sinclair Method with links to books by Claudia Christian and Dr. Roy Eskapa.
What is gray area drinking?
Gray area drinking is a level of drinking that is below that of a severe case of alcohol use disorder. And, it is above the level of an occasional, casual drinker who rarely drinks and never gets intoxicated.
A person who has an occasional sip of wine or champagne, not finishing the whole glass, is not a gray area drinker. Having a sip or two of champagne on New Year’s Eve is not gray area drinking.
At the other extreme, a person who drinks to get drunk every single day is probably beyond being a gray area drinker. Having blackouts, where you forget where you were the night before or waking up with people you don’t know is beyond gray area drinking. Driving drunk and getting charged with drunk driving is a sign of someone who is beyond gray area drinking.
Gray area drinkers typically don’t drink in the morning to get rid of a hangover. They are more likely to try other remedies and suffer through the hangover, wishing that they had not had so much to drink the night before.
Are gray area drinkers just alcoholics in denial?
Of course, as the name implies, there is a gray area where it is hard to define where a person is on the spectrum of alcohol use or misuse.
Addiction is characterized by denial. People do not want to acknowledge that they have a problem until the problem gets bad enough that they have no choice but to get help.
There are certainly people who fit the definition of alcohol use disorder who do not see themselves as alcoholics. They may admit to drinking too much on occasion, but not to having a problem with drinking to the extent that they need outside help. They believe that they have the problem under control.
A gray area drinker does have control over their drinking much of the time. They do not drink every day. They control whether or not they are going to drink, but when the drinking starts, they have a tendency to get out of control until the night is over.
Gray area drinkers are at risk for progressing to becoming alcoholics. While not all will develop alcohol use disorder, many will eventually, as they continue to drink excessively on occasion.
The progression may begin when they start going out to drink one extra night during the week. Maybe the partying starts on Thursday night instead of Friday night. One day, with a particularly bad hangover, they may decide to finally try having a morning drink to see if it really gets rid of the headache and sickness.
A traumatic life event may lead to more drinking and more life problems associated with drinking alcohol. A death in the family, a breakup, or loss of a job can lead to anxiety and depression. For someone who already has a tendency to drink excessively on occasion, they realize that they can self-medicate with alcohol.
Eventually, the level of control that the gray area drinker has over when they decide to go out drinking starts to fade away. Yet, if the person identified themselves as a gray area drinker for many years, they will still believe for some time that they still fit in that category, even after they have progressed into the realm of alcohol use disorder.
Is gray area drinking a problem?
Gray area drinking is common in college age young adults and even with many young working adults. On college campuses where alcohol is allowed, students drink to unwind from a week of hard school work.
They go to campus parties and let go, drinking as much as they want on weekend nights. Young healthy people in their early twenties have a sense of invincibility. They see their peers drinking to get drunk and they see no problem with doing the same.
Drinking may seem fun in the beginning and lead to exciting unpredictable outcomes. Couples may meet on campus after a night of drinking at a party. New friendships may begin during a drunken night partying together.
But, is gray area drinking a problem for these young adults? As we know, there is no amount of alcohol that is healthy. Alcohol is a toxic substance that strains the body and leads to irreversible damage.
The American Cancer Society recently announced that there is no safe amount of alcohol. Even young and healthy college students would be better off not drinking at all.
Alcohol use affects performance. If a college student is concerned about not keeping up in class and not having the grades they want, they should first look at their alcohol intake, and drug intake as well if that is a factor.
While most gray area drinkers in college will not become alcoholics, their drinking may have long-lasting consequences. Drinking too much on the weekends has an effect on studying and performance in class during the week.
A student may dream of going to a graduate program, such as law school or medical school. Or they may look forward to a good job with a specific company after graduation. Either way, they may have to change their plans along the way because they are unable to achieve their goal, or they downgrade their expectations.
Poor grades and changes in life plans are often justified and explained away as being because, either the person was not capable of achieving the goal, or it was not really what they were meant to do.
But, what if gray area drinking is what killed their dream? These days, people are often looking for a magic pill that can make them perform better academically or at work to be more successful. It turns out that one of the greatest superpowers a person can have to succeed at making their dreams come true is to remain alcohol and drug free.
Gray area drinking can go on for a lifetime. If the problem never progresses, then it never gets to the point where help is definitely needed. No one is going to be confronted with a family intervention because they have a few too many drinks at dinner occasionally.
A person may arrive at the age of 50, 60, or 70 and realize that their life dreams slipped away and they never reached their true potential. Even as mature adults, they may still not attribute their life failures to occasional excessive drinking.
On the other hand, the alcoholic may get help along the way and go into recovery. Being alcohol and drug free, they discover that they are able to do anything they want in life. The recovering alcoholic has that advantage over the gray area drinker.
In fact, people in recovery from alcohol use disorder often start to notice that family and friends around them are gray area drinkers who regularly have too much to drink.
Do gray area drinkers need medication to help them stop drinking?
Should gray area drinkers take medication to help them cut back on drinking? Most gray area drinkers would probably say no to medication or medical treatment. Why should they get treatment when they don’t have a problem?
Yet, gray area drinking is a problem and all gray area drinkers would benefit from cutting back on drinking. It is possible to stop gray area drinking without medication.
There are many coaches that will work with clients to talk them through slowing down and stopping their excessive drinking.
These coaches work with their clients by pointing out all of the things in life they can enjoy and accomplish without alcohol. They show them how alcohol use is really not fun at all.
Suggesting medication for a problem that can be solved without medication may seem excessive. Yet, we take medication all the time for things like headaches, allergies, upset stomach, and more.
Anti-inflammatories, antihistamines, and antacids. Are these drugs safer than a drug such as naltrexone? Why would we think taking a few Advil gel-caps is fine, but taking a naltrexone tablet before going out to a party is bad?
The problem is the general lack of understanding of what naltrexone is and how safe it is for most people. Of course, it is not right for everyone, but neither is Advil, Claritin, or Tums.
Is The Sinclair Method appropriate for a gray area drinker?
I believe that the gray area drinker is a perfect candidate for The Sinclair Method. The medication is safe for most people and it works well to help people reduce their alcohol intake.
In a perfect world, no one would drink and no one would feel the need to drink. We would all realize that enjoyment of life is better found in other ways than going out for a night of drinking.
On a cruise ship, people sit at the dinner table and have one drink after another. Then, they go to the various ship bars and have more drinks. Cruise lines sell drink plans that allow vacationers to have as much alcohol as they can consume.
But, wouldn’t it be more pleasant to walk on deck and enjoy the sea air and peacefulness of the open ocean? On a ship at sea, you can enjoy beautiful sunrises and sunsets. And, there are many other fun activities to do onboard that do not involve any alcohol.
Unfortunately, people still drink too much on vacation and when they go out to nightclubs and parties. What if they had a prescription for naltrexone and were able to take a pill before going out? What if people on a cruise ship could take a pill to help them naturally keep the drinking under control?
When it comes to alcohol, less is always better. Naltrexone is safe. Instead of thinking in terms of a person being either an alcoholic or non-alcoholic, we should think more in terms of harm reduction.
While not everyone will choose to take the pill, if we made it more available, there would certainly be people who would make the choice to try the treatment and see how they feel with less drinking.
College students would be more productive. Vacationers would enjoy their vacations more. Workers would get more work done and feel better going into work on Monday morning. No one has ever woken up in the morning, wishing that they had gotten drunk the night before.
How well does TSM work for gray area drinkers?
My clinical experience in providing TSM to gray area drinkers is that it works incredibly well. The results are dramatic and almost hard to believe.
There are people who call my office, inquiring about TSM, who are clearly gray area drinkers. They only drink on occasion, but when they do, they tend to go on one-night drinking binges.
In my experience, the typical gray area drinker patient has their consultation and gets their prescription, and then I don’t hear back from them right away. When I finally do get in touch with them, they report back that the results were better than expected.
In a short time, the gray area drinker loses interest in alcohol. I have, on multiple occasions, had patients who ask if they need to continue with the treatment after a few sessions. They would rather not drink anymore at that point. They quickly lose the desire to drink alcoholic beverages.
A large formal study on the efficacy of TSM on gray area drinkers should be done, and I believe that the results would reflect my experience that gray area drinkers respond very well and quickly to TSM.
The most common question I get from gray area drinking patients on The Sinclair Method is if they need to keep going on with it. That is a good question. Is further pharmacological extinction beneficial when the patient does not want to have another drink?
I don’t believe that a few sessions of TSM will completely end a person’s alcohol use for life, even if they are a gray area drinker. However, the treatment is certainly beneficial and should be continued or restarted as needed going forward.
Should gray area drinkers have to go to a doctor for a prescription of naltrexone?
If naltrexone is so safe, why do people need to go to a doctor to get a prescription? Why are some medications over the counter and others are not?
The kinds of medications that are OTC vary from one country to another. In many countries, people have the freedom to purchase more types of medication and then decide if they want to see a doctor to guide their treatment.
In the US, the FDA is conservative in making decisions to allow a medication to become OTC. In some cases, special interest groups lobby the FDA to keep a medication from becoming over-the-counter.
For example, there was an asthma rescue inhaler that the FDA was going to approve to be OTC. The reasoning for approving the inhaler was that it would be far safer than the existing OTC inhaler, which has a serious cardiac risk associated with it.
Allowing people to make the choice to buy the safe inhaler would have been a form of harm reduction. Of course, it’s always great when people go to see their doctor for guidance, but in the real world, people self-treat with what they can find on the shelves of their local pharmacy or grocery store.
If the only asthma inhaler that is OTC is the more dangerous one, people will choose it simply to avoid having to sit in a doctor’s waiting room to ask for a prescription and then wait in line at the pharmacy.
The safer inhaler was never approved by the FDA because a group of pulmonologists lobbied to prevent the approval. Why would they want to prevent the public from having a safer OTC choice?
Their argument was that if people with asthma can get the good inhaler without seeing a doctor, they might choose to not see an asthma specialist and get proper full treatment for their asthma.
There is some justification to their decision in that lung function should be measured and asthma is often best treated with a combination of medications.
However, they did not take into account the concept of harm reduction. It would be great if everyone with asthma would see a pulmonologist. But, unfortunately, many people are not going to go to see a doctor if they know that there is an over the counter medication that they can purchase and use as needed.
If there was no asthma rescue inhaler available over the counter at all, then asthma patients would have no choice but to see a doctor for a prescription. But, since there is a dangerous inhaler currently on the shelves, and there exists much safer inhalers available only with a prescription, the proper decision that should have been made by the FDA is clear.
In the end, people will choose to buy the more dangerous inhaler that is over the counter because it is the only one available without a prescription. By choosing harm reduction over the greedy lobbying of a group of specialists, the FDA would have, without a doubt, saved lives.
Should naltrexone be approved for over the counter use?
Should people be able to purchase naltrexone tablets without a prescription and without speaking to a doctor or pharmacist? The most important consideration is safety. Over the counter medications are typically relatively safe to the extent that members of the general public can be trusted to read the instructions and take them in a safe manner.
Naltrexone does have side effects and contraindications. Not everyone should take naltrexone. Yet, it is very safe for most people. It is on par with the safety profile for other drugs available without a prescription, such as ibuprofen, acetaminophen, and aspirin.
Why wouldn’t the FDA approve naltrexone to be an over-the-counter drug? Clearly, gray area drinkers everywhere would benefit from the drug being more easily available.
Many doctors are already refusing to prescribe the drug without good reason. Their patients often have a better understanding of naltrexone than they do.
Imagine if naltrexone were available at the checkout counter in the grocery store? Or at the cash register at the gas station.
What if universities could hand out packets with one or two naltrexone tablets? Schools already give away free condoms to students, why not naltrexone tablets?
Imagine if you could buy naltrexone in the bar from a vending machine. They already sell a variety of medications in bathrooms, such as aspirin, ibuprofen, or naproxen. Why not naltrexone?
How can TSM for gray area drinkers improve people’s lives?
TSM can clearly make the lives of gray area drinkers better. By not drinking, they are able to enjoy and appreciate the things in life that are truly rewarding.
Imagine spending an evening with your children, watching a movie or playing a board game? Or, getting to bed early to enjoy a peaceful walk in the early morning. Life is much better without alcohol, or at least with a lot less alcohol. How can society be improved by using TSM for gray area drinkers?
It is impossible to measure the lost productivity from gray area drinking. The problem is so prevalent and pervasive in society, that its effects extend to all areas of modern life.
When your phone doesn’t work because the new update you downloaded has bugs, is it because the software engineers had a few too many drinks at the bar to unwind on the weekends?
When your child’s teacher puts on a video for the class to watch Monday morning instead of providing an inspiring lecture, is it because they have a hangover from the night before?
It’s hard to imagine how much better things might work if there was less drinking. It’s likely that gray area drinking is a much larger problem than alcohol use disorder and drug addiction.
People in recovery often point out that the drug that brought them down the fastest was what got them into recovery so they did not have to linger in active addiction for too many years.
Gray area drinkers are essentially lingering in a low level of functional active addiction that can last many years, or even a lifetime. There are likely many more gray area drinkers than there are alcoholics and drug addicts. It’s time for us to start thinking about how we can address this potentially much larger problem.
Should doctors offer naltrexone to all of their patients?
Naltrexone is not an over the counter medication and it will probably not be approved any time soon. I don’t know who would lobby against its approval, but probably someone will have something to say against it. Maybe the makers of Vivitrol.
In the meantime, it is the responsibility of doctors to decide who should get a prescription for naltrexone.
Of course, there are limitations to who should get a prescription for naltrexone. People who are prescribed opioids cannot take naltrexone. Pregnant women and people with liver problems should not get a prescription.
Otherwise, who should doctors offer naltrexone to? Should doctors carefully screen patients for gray area drinking?
Doctors are currently expected to screen patients for alcoholism. There are various questionnaires and screening questions that can help a doctor to determine if their patient has alcohol use disorder.
Realistically, it is not a problem that doctors especially want to discover. If the doctor asks if you wear your seatbelt and you say no, the solution is simple. They tell you to wear your seatbelt.
Alcoholism is more complex. Your doctor can’t simply tell you to quit drinking and expect that to work. They should at least refer you to an addiction specialist. They may also recommend peer support meetings.
But, what if you are a gray area drinker visiting your doctor for a yearly physical? You will most likely pass right under the radar of the alcohol screening questions, if they are asked at all.
There is an old joke that an alcoholic is defined as someone who drinks more than their doctor. Your doctor may also be a gray area drinker. If the doctor does not see your drinking behavior as a problem, why would they offer treatment?
There is a similar medication to naltrexone that is freely prescribed to patients for the purpose of harm reduction. In fact, there are situations where doctors are legally required to provide a prescription for this particular drug.
Narcan nasal spray is the rescue drug that can reverse an opioid overdose. Doctors are expected to prescribe it to people who take opioids, whether prescribed or obtained from the streets. They are also expected to prescribe narcan to people who live with opioid users.
Narcan is a brand name for the drug, naloxone. Naloxone is an opioid receptor blocker, just like naltrexone. If a doctor is doing their job, they are freely prescribing and recommending Narcan nasal spray. It is possible to justify prescribing or recommending Narcan for nearly anyone.
We all have the potential to come in contact with someone who uses opioids and is at risk for overdosing on opioids. The more Narcan out in the world, the better. It is a safe drug and has the potential to save lives.
Doctors might want to consider looking at naltrexone in the same way. Naltrexone and naloxone are both very effective harm reduction medications.
Naloxone can save a person’s life from an accidental opioid overdose. Naltrexone can save a person from a lifetime of excessive drinking.
Rather than looking for excuses to not prescribe naltrexone, doctors should instead look for more reasons to prescribe the medication to more patients.
The instructions for following The Sinclair Method are fairly easy. They can be described in a few sentences. Doctors give out diet sheets that are more complicated than The Sinclair Method.
A prescription for naltrexone and a short instruction sheet will be helpful to any adult patient who is a drinker. The patient may choose not to fill the prescription, or they may fill it and choose not to take it at first.
Still, treating gray area drinking as a condition that deserves medical treatment will signal to the patient that their drinking is a problem for their overall health, even if they are not an alcoholic. At some point, that person, before going out to a party or dinner, may look at the naltrexone bottle and start to think about the benefits of cutting back on alcohol intake.
By discussing the issue, writing the prescription, and providing an informational sheet about the benefits of TSM, the doctor will be planting the seed in the mind of their patient. That patient may then talk to family and friends about gray area drinking and how there is medical treatment that is easily obtained from their family doctor.
In busy clinics where patients come in for vague complaints or general physicals, and hurried doctors go in and out of exam rooms every few minutes, there is often a pattern to how these brief medical visits go.
The patient states their chief complaint, the doctor asks questions and then performs a physical exam. Then, the doctor makes recommendations. They may recommend a healthy diet and exercise program, and safe sex practices, and wearing a seatbelt while driving.
If the patient has a health condition, such as the common cold, the doctor will recommend supportive therapies to feel better while the cold runs its course. Sometimes the patient has a condition that warrants a prescription for medication and sometimes not.
However, there is often an expectation from patients that a medical visit should end with a prescription. The patient may ask for an antibiotic for their cold, even though it will not help. They may ask if there is something they can take to give them more energy or to sleep better.
Usually, the doctor must disappoint their patient in explaining that there is no prescription needed, only education. The doctor educates their patient on sleep hygiene, eating less, exercising more and so on.
What if the doctor offered a prescription for naltrexone and told their patient that this medication could change their life. They will get to sleep easier on weekend nights, wake up refreshed, lose weight (because they’re not drinking), have more energy, enjoy life more, and be more productive in creative projects and in school or work.
Life can improve dramatically when even occasional excessive alcohol use is taken out of the picture. Doctors can provide their patients a prescription that has the potential to help change their lives for the better, giving them a better and brighter future.
The Sinclair Method is an excellent solution to the problem of gray area drinking. Hopefully, more doctors will learn about this harm reduction protocol and start to have this conversation with more of their patients.