Alcohol Rewards and the Sinclair Method

When most people think about the reward from drinking alcohol, one of the first things that comes to mind is the “buzz” or intoxicating effects. With that in mind, some people new to the Sinclair Method (TSM) begin with the expectation that they will take their medication and it will keep them from getting drunk. Unfortunately, that’s not true.

Although the beginning stages of intoxication may be pleasurable, what you are actually feeling is your body reacting to rid itself of what it views as a poison. The reward that TSM targets is more subtle, yet incredibly more powerful than an intoxicating buzz.

Understanding Alcohol Rewards

The reward system in our brains is complex and nuanced. It is also as difficult to control as holding your breath. Sure, you can make a choice not to breathe for a limited amount of time. Eventually, though, your body will compel you to inhale and exhale.

This may be why addiction treatments that focus solely on abstinence through cognition and behavior fail for so many people. It’s like trying to hold your breath indefinitely, then being told you didn’t try hard enough when you ultimately give in and savor that sweet oxygen your body desperately needs to function.

The First Sip vs. the Last Drop

To understand the rewards TSM targets, first we must understand that where our brains are concerned, not all alcohol is created equal. While it’s obvious that beer, wine, and liquor are all different, that’s on the surface.

This concept can be applied to anything we crave, not just alcohol. Imagine you are almost finished mowing the lawn on a hot summer day. You’re dehydrated. Thirsty. You’ve only got two more passes before you are done, but all you can think about is the tall glass of ice water you are going to gulp down. You want it. Your body needs it. Every step you take makes you thirstier.

In those moments when you begin putting ice and water in the glass, your reward system is already firing. The first sip sends endorphins rushing through your brain. ‘This is exactly what I needed’  you think. By the time you get halfway through the glass, your anticipation has been satisfied, even if your thirst hasn’t been.

The overwhelming craving is gone, and while your body enjoys the rewards of proper hydration, your brain is not being flooded with the same level of endorphin rewards as that first sip. It’s the same glass of water. Same ice, same physical need. Yet the reward your brain gets is not the same.

 

Targeting Alcohol Rewards with TSM

The Sinclair Method is a treatment for alcohol use disorder that specifically targets the reward system’s response to alcohol. It consists of taking an opioid antagonist (50 mg of naltrexone or 18 mg of nalmefene, depending on geographical location) one to two hours prior to the first alcohol-containing drink of the day.

TSM works through a process called pharmacological extinction, which can be simplified as using medication to unlearn a previously conditioned response. In the case of TSM, the combination of medication and alcohol teaches the brain not to abnormally crave and anticipate alcohol.

Ivan Pavlov’s dog learned to salivate because the sound of the bell meant food. This was a conditioned, involuntary response brought on by repeated sessions of pairing a ringing bell with food. At first, the food was the reward, similar to how the initial reward from alcohol can be the buzz or feeling relaxed. But over time, the dog salivated at the sound of the bell — even without the presence of food. The sound of the bell became a trigger for a desire that needed fulfilled and the dog was powerless to stop its reaction.

For a non-addicted drinker, the connection between alcohol and the endorphin rewards is weaker than for someone with alcohol use disorder (AUD). Situations and stimuli do not cause the same type of involuntary response of triggering intense cravings as in someone with AUD. That is why a “normal” drinker is better able to self-regulate consumption than those with AUD.

The concept of extinction is also credited to Pavlov and is often referred to in TSM circles as “Pavlov’s dog in reverse.” In controlled studies, pharmacological extinction of hyper-reactive alcohol cravings occurred in three to four months. In general use situations, extinction generally takes six months to a year.

Minimum Hour Wait Time and Targeting Rewards

To ensure the effectiveness of TSM, the greatest reward must be targeted, and that reward comes from the first sip of alcohol. That’s why the minimum 60 minute wait between taking the medication and the first drink are critical to the method’s success.

Think back to the bottle of water. The endorphin reward from the first sip in this example is much higher than the reward from the last one in the glass. This happens in spite of the fact that the water and ice are chemically identical throughout the drink.

The alcohol reward cues that the Sinclair Method targets are not always easy to detect. They are complex and involuntary. That’s why some of the earliest signs of progress are often not obvious. To read more about the science of TSM, visit our science page.