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.
The Sinclair Method is currently being administered at The ABC WELLNESS on 12 Mile Road just West of Northwestern Highway by Dr. Diane A Culik MD
And doctor Culik has been listed as one of our verified TSM providers for several years. I just double checked and her office is still listed on our provider map.
So when using this method do you take the naltrexone daily even if you dont plan on drinking? Or only when you want to drink that day?
The Sinclair Method protocol is one 50 mg pill of naltrexone (or one 18 mg pill of nalmefene) a minimum of 1 hour prior to the first alcohol drink of the day. If no alcohol is being consumed, then no medication is required.
Is this treatment evidence based or approved by FDA??
“Evidence based” is a term reserved for treatments that have gone through a very specific process and been approved through a specific committee. You can read more about why we do not call TSM an “evidence based” treatment in our blog post ‘Open Letter to SAMHSA.’
The FDA does not approve “treatments,” per se. They approve medications for specific uses. So yes, the medication used in the United States, naltrexone, is FDA-approved for a variety of uses, including alcohol addiction.
The evidence that the Sinclair Method is built on includes both research-based results and clinical practice. We have an entire section on our website that talks about the science behind TSM.
My problem is that when I start to think about drinking, I hadn’t taken the 1 hour gap before. So I ‘d take a pill but also start having wine. Is this going to help me at all? I’ve only had 6 pills daily so far. The problem comes in that when the craving hits, I take the pill but can’t wait one hour. Pathetic, I know. But do I still get any benefit from that?
Unfortunately, there is no benefit as far as TSM is concerned to taking the medication and not waiting the full minimum hour. The reason is that, like most medicines, your body does not process the medication immediately. Naltrexone is a very well researched medication. It takes an hour to be effective.
TSM has a very high rate of success (about 78%), but most of those who don’t significantly reduce their drinking are not successful because they do not take the medication and wait the full hour every single time. As harsh as it might sound, if you don’t wait the hour, you will not succeed.
I have been a TSM’er for almost 2 years and it has changed my life. I am not an alcoholic per se, but I wanted to reduce my alcohol consumption and was never able to reach my goal. My biggest TSM obstacle was my doctor, who refused (and still refuses) to give me a prescription for Naltrexone. I contacted the Telemedicine network on this website and after a 10 minute consultation with the tele-doctor, LITERALLY had a prescription for Naltrexone in my hands two hours later. Within 3 days, I found myself drinking significantly less and have stayed compliant with TSM ever since.
I’m beginning this journey as soon as I can see my doctor. It’s the first time I’ve felt any hope of overcoming this brain disease!! I will be one of the successes … And So It Is
Thank you for this site. Blessings!!
I started TSM journey in April of 2014 and was meticulous about taking the medication an hour before drinking. I had drank alcohol for about 30 years – mostly binging on weekends. My drinking binges diminished considerably in the beginning but I would often drink through the medication to get drunk, i.e. doing shots. It took about 4 years to get to the point where the thought of alcohol actually made me sick. I have had a couple occasions in the last year where I was barely able to get one drink down because it tasted so awful. I have had a couple of other occasions whereby I did not even drink after taking the naltrexone because I could not bring myself to drink because my stomach was already getting upset at the thought of consuming. Trust me, this is the complete opposite of my old drinking patterns of being triggered by just watching people consume red wine and then my cravings would kick in. Now I get a quick nauseous feeling when I see people drinking. I have no cravings whatsoever. Has anyone else experienced a full extinction whereby I don’t really want to be abstinent, but found that I have no desire to drink anymore. I feel a bit like an outsider even though I can drink if I want to. However, I would never drink without taking my naltrexone and go back to where I was. It’s just such a strange experience to fully feel the cure of TSM and not even want to drink anymore. I almost have to talk myself into wanting to drink and then I just really don’t want to even feel the buzz and taste that nasty alcohol. The buzz isn’t even worth it because it is so blunted by the lack of reward. It just feels like I am drinking this terrible poison and it feels and tastes nasty.
I tried TSM a LITTLE bit a few times with tablets. I have recently received the Vivitrol shot, somewhat because of pressure from others to move forward, but also thinking that it would have a similar effect when I drink. I have not experienced the ‘dulled’ effect that I did when trying TSM with tablets an hour before. Was I wrong to think that it might? Should I stop the shot and try TSM again? More importantly… Is there danger in taking naltrexone tablets (one or half) while on the Vivitrol shot???? Thank you for having this site!
While only your medical provider can give you direct medical advice about what medication you should or shouldn’t use, the time release injection is meant to be used with abstinence. It is not meant to be used along with alcohol. That is why it does not have the same effect.
TSM is a commitment. There is nothing in the protocol or the research to support a claim that success will happen for those who dabble. “a little bit” or “a few times” isn’t sufficient for the Sinclair Method to work. The research supports one pill, a minimum of one hour prior to the first drink of the day, every single time alcohol is consumed. That’s for life. Addiction can be relearned if a person begins drinking without following the medication protocol.
Just a note to thank you for your desire to help people who often have no hope about their drink. I’m the father of 3 sons and one daughter, my youngest son has been drinking for the past 23 years, my family and I have tried to help him without success. By watching your video and reading the book THE AA EFFECT, we have new hope about my son Tony giving up the poison he’s been drinking. I started letting some friends of mine know about YOU and the good news you are spreading. Thank You so much for being the kind of human being you are, God bless you !
Thank you for this post.
I have been taking Naltrexone for 2 weeks and my doctor prescribed it to me as a way to reduce cravings and NOT for TSM. I was fine with that because I thought, why continue drinking with the goal of pharmacological extinction if this medication simply reduces my cravings? Well, it reduced my cravings for 24 hours (placebo effect?) and I freaked out when I wanted to drink the next day thinking that this pill, my last hope, wasn’t going to work for me. After more research on your website, I realize it will take some time and commitment. I will keep at it and I continue to have hope
Hi. I’ve been taking Nal in the morning for over a year now, a protocol my doctor prescribed because I was a daily drinker and trying to curb my need for alcohol.
I’d like to try the Sinclair Method, but I’m worried that the use of Nal first thing in the morning for such a long period will be a detriment to my success with the new approach. Can you tell me whether it will be an impediment to trying TSM now?
We are not aware of any science that would suggest your past use of naltrexone daily would make it more difficult to switch to the Sinclair Method.
Yes, Claudia, you’ve been saving another life and don’t even know it. Isn’t that special? If it weren’t for your Ted I would have never heard about TSM. As well as the doctors I had been to here in Brazil. They are totally unaware of the method. I’m in my third month now and can see considerable progress. Thank you so much. You are a very special person. Thank God you are in this planet.
I’m not a daily drinker but have been prescribed Naltrexone after three months of abstinence. I’m confused at to how often to take it to avoid cravings and reduce consumption if I choose to drink. . Do I take it every day or just an hour beforehand? I’m confused about this.
We are not doctors, so we cannot give medical or dosing advice. The Sinclair Method is a specific (off-label) way of using naltrexone that consists of taking an opiate blocker (naltrexone or nalmefene depending on the country) one hour prior to the first alcohol-containing drink of the day. It sounds as though your doctor prescribed naltrexone according to the label, which was approved in 1994 when the FDA considered abstinence the only measure of success for an addiction medication.
I’ve been a heavy drinker (mostly wine) for over thirty years. The only time I stopped was when I was having children. I have recently stopped drinking. (29 days). When I decided to stop I realized that I was solely relying on the Naltrexone and not using any other supports to help me not drink. Even taking the Naltrexone, I would often over drink. I don’t know if it was the timing and the added supports, but I have reached a monumental point that might lead to extinction. By supports I mean listening to sober podcasts, reading sober blogs, having sober treats (this all comes from Belle Robertson – Tired of Thinking About Drinking, just Google it if interested) Around 10 months of taking Naltrexone, I started to use sober supports and I am now free of the monkey on my back that was alcohol.
I took 50 mg for two months – then upped it to 75 mg (1 1/2 pills) for the remainder of the time, one hour prior to my first drink.
Good luck to you all, and thank you Claudia for everything that you do!
I wish there was a way to “LIKE” each of these comments and responses because they are all so refreshing, hopeful and full of compassion. Congrats to CThree for all your hard work in spreading the word on TSM. Looking forward to June 12th, TSM Awareness Day.
I received my prescription two weeks ago. I’m used to taking a pill and waiting as I’ve been trying N-acetylcysteine (NAC) for months before getting Naltrexone. I’m a binge bourbon drinker and I’m worried if the Naltrexone is working or if I’m one of the unlucky ones that it doesn’t work for. I am still drinking until I get drunk although the “drunk” does feel different. Is this normal? I’m still getting buzzed and I haven’t felt any desire to stop once I’ve started.
Pharmacological extinction happens gradually and you won’t notice much in the first month. Some take 3-4 months, others take upwards of a year. If the “drunk” feels different, as you put it, then it’s doing something. It’s likely you didn’t reach this level of binge drinking in 2 weeks…so it’s unlikely that you will be able to “fix” it in two weeks.
A person plans to have a bloody Mary or mimosa at brunch and take natrexone 1 hr before. This person then plans to have drink at “happy hour”- Should this person take a second naltrexone before the evening cocktail?
Thank you. Very improtant treatment for alcohol mis-use and dependency.
Thanks for this question. This is exactly the sort of question I had. I’ve been on the Sinclair method for about three weeks and am lucky that I’m already seeing results. My question is similar to the one above which I hope someone will answer. Is there a problem if you take the Naltrexone more than an hour before you drink? Occasionally I will take it anticipating my first drink but as my cravings have diminished I might not have my drink until an hour and a half to two hours after taking the pill. I don’t want to mess up my progress so I’d really like to know how to handle situations like mine and the one mentioned above.
This has been life changing for me.
On average, naltrexone’s peak absorption time is an hour. That said, 60-120 minutes after you take it seems to be the “sweet spot” for most people.