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Step Three: Your Prescription for Naltrexone 103 injection. However, the long-term effects of the slow-release prep-arations have not been fully examined.52 Continual administra-tion also prevents the use of naltrexone selectively to weaken only alcohol drinking and not other behaviors (discussed in chapter 9), as well as preventing pharmacologically enhanced learning of healthy alternative behaviors. During Step Three, you begin thinking of drinking alcohol while on naltrexone as being “good for me” or at least “necessary for me
to get better.” At first, it may feel strange, but you will soon get
used to it. Remember, the combination of the two—Naltrexone +
Drinking—is your medicine, your ultimate cure and freedom from
your addiction. But doing either alone—drinking without taking
naltrexone or taking naltrexone without drinking—will do noth-
ing to help reduce the craving and break your addiction.
Here are some reminders. Naltrexone + Drinking alcohol over • Decreased craving for alcohol without having to stop cold • Reduced interest in and obsessive thoughts about drinking. • Drinking reduced to within normal safety limits—no more than twenty-four drinks per week for men and no more than five drinks on a single occasion or no more than sixteen drinks per week for women or four drinks on one occasion. (Upper limits are set by different agencies; these limits are derived from the World Health Organization.) • The ability to choose to abstain totally—but only after an average of three to four months on the Sinclair Method. • Automatic and gradual withdrawal and detoxification from • Setting your own goals—total abstinence or drinking within What Does It Feel Like to Drink While Taking Naltrexone?
If you took naltrexone without drinking, you would feel about as
much as you would if you took a multivitamin—virtually nothing.
Fewer than 10 percent of patients reported temporary nausea in
clinical trials in which it was given to abstinent patients. It pro-
duced even fewer side effects in patients who were still drinking.
The medication is not psychoactive, and it will not make you feel
high or low. Naltrexone does not bring relief from alcohol craving
like a painkiller relieves a headache. Some patients report they
do not get a “buzz” from the first drink when they begin drink-
ing while taking naltrexone. However, even when you do take it
together with alcohol, you do not subjectively feel it working in
your system.
One of the nice features of naltrexone and other opioid antago- nists is that the endorphin system they block is relatively unim-
portant most of the time. Endorphins are involved in many forms
of reinforcement, but usually as just a backup or shortcut sys-
tem. Their role as painkillers may be important in the wild, where
animals often have to function despite severe injury in order to
survive, but in our modern world, we are seldom faced with such
challenges. Other neurochemicals that modulate behavior, such as
dopamine, serotonin, and epinephrine, are critically involved in
the regulation of vast numbers of activities, and one must be very
careful with drugs that alter these systems. With the endorphin
system, however, most people can’t even tell if it has been blocked
by an antagonist such as naltrexone. Indeed, that has been tested
in some of the double-blind clinical trials in order to demonstrate
that the patients really could not tell if they had been given an
opioid antagonist or a placebo.53
Remember, naltrexone by itself will not reduce the craving or de-addict you in fifteen minutes, fifteen days, or fifteen years. You
should be aware of false claims on the Internet that naltrexone
can abolish your craving within fifteen minutes. As we saw in
chapter 3 on the scientific evidence behind the Sinclair Method,
naltrexone is only effective if combined with drinking over the
course of at least three to four months. Extinction takes time and
requires active drinking together with naltrexone before full de-
addiction can happen.
Step Three: Your Prescription for Naltrexone 105 Alcohol Abuse and Addiction Are Not Rational
Some people have questioned whether patients would actually take naltrexone. If naltrexone blocks the “pleasure” from drink-ing, a rational patient would simply stop taking the medication in order to get pleasure again from drinking. First, let’s start with an established fact. Compliance has been extraordinarily good with the Sinclair Method. More than 85 per-cent of the alcoholics being treated with naltrexone do indeed take their medication, even though they have been told that it blocks initial euphoria from alcohol. That is not rational, you might complain. No, it is not, and the reason is that alcohol abuse is not a rational behavior chosen logically for its ability to produce euphoria. Studies of human so-cial drinkers show that euphoria is only occasionally increased by alcohol.54 If you are in a melancholy mood, red wine will make you bluer. If you are in a party mood, you will fly through the air on bubbles of champagne. If you are feeling frustrated, you may become aggressive—hence, the violence associated with drink-ing and crime. If you are in a hospital gown in a stainless steel laboratory at nine o’clock in the morning with nothing to eat or drink, alcohol will not produce euphoria—as was demonstrated in one PET brain scan study in Finland on the effects of alcohol.55 The study demonstrated nicely some of the immediate effects of alcohol on the brain, and it showed that an opioid antagonist blocked these effects. The researchers had hoped to measure if it was blocking euphoria as well, but failed because the alcohol did not produce any significant increases in euphoria under stark laboratory conditions. Among alcoholics, there is very little—if any—pleasure ob- tained from drinking, and certainly not enough pleasure to com-pensate for all the pain they get from their continued abuse of alcohol.56 Alcoholics drink because they have become wired to drink. There is no rational reason for choosing to drink because they do not “choose” to drink, any more than you choose to lift your leg when the doctor taps your knee. You are wired to produce

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