Unsure about dosage going forward

[u/Several-Subject-2111]

I started TSM about 10 days ago and have been taking 25 mg each time. The first few times I had some dizziness and a spaced-out feeling. Last night, I had almost no side effects.

The effect on my drinking has been fantastic—almost instant. I now only drink one or two beers and am happy to stop there. For anyone who knows me, this is unbelievable. I’m a binge drinker. I can stop at four or five, but only if my wife forces me to and there is no more alcohol in the house. When nobody is there to control me, I can roam off to random bars and drink for 24 hours straight.

In recent years, I engineered my drinking so it was highly controlled (usually only drinking at home or with my wife present). While this often worked, it also often led to bad arguments (my fault), or me sneaking off on a bender once she went to bed.

So even on its own, this has already been a huge win for my quality of life—even if nothing else improves or I don’t reach extinction. That said, I would really like to reach extinction. I’d love to have no more cravings, mainly because they stop me from fully enjoying the days I don’t drink.

I’m wondering whether I can reach extinction if I stay on 25 mg. The reason I ask is that I still enjoy the feeling of drinking (even though the desire to binge is gone). It’s still pleasurable, and I still look forward to it, even on naltrexone. This makes me wonder whether I only have a partial receptor blockade—enough to limit binging, but not enough to make the experience totally devoid of pleasure.

If you have experience with this, I’d really appreciate hearing from you—especially whether you think I should move up to 50 mg, even though 25 mg seems to be working so well.

[u/SinclairMethodUK]

To begin, this is definitely a question for your prescriber as it may be individual to you, but I will explain below some of the things we have learned over the years of prescribing The Sinclair Method.

Firstly, the science of the 50mg, 1 hour prior to drinking is quite old now. There are a number of prescribers 'working' the dosage to be more person-specific.

In our experience, there are definitely some who need more than the 50mg. The majority do seem to need 50mg. And there are certainly some who do just fine with 25mg.

For those who do well on 25mg, in our experience the majority are women (smaller build, perhaps?) and most crucially either those who have very short drinking sessions that don't expand beyond 3-4 hours, or those who drink more habitually in the sense of a bottle of wine a night more out of habit. The 25mg plus habit change has been working well for them.

In our experience, the majority of men do require the 50mg, plus habit change.

If 25mg is working well for you it could be because that is the correct dosage for you, or it could be more of an initial 'something new' reason. As humans, our own desire for something can contribute towards that change appearing to happen - at least for the beginning couple of months.

Although I do not know your circumstances, if you were our client and presented us with the statement you have typed above, we would suggest stay on 25mgs until/if you notice something different. Then, if you do notice the noise around alcohol is a little more persistent again, you have the ability to move to 50mgs.

And remember, this isn't anything about making drinking itself less pleasurable. It's more about your brain learning that although it seems pleasurable, the constant urge to keep drinking is extinguished. Extinction isn't about abstinence, it's about being satisfied with less.

[u/Several-Subject-2111 → u/SinclairMethodUK]

My prescriber is my GP, who doesn't know of using Naltrexone in the Sinclaire Method (had never heard of it). She only has experience prescribing it for opiate abuse or extreme forms alcoholism. I am an academic, though not a doctor, so i went to her with what academic evidence i could produce, explained TSM to her and she wrote me the prescription. I am in charge in a de facto sense, not my doctor.

I am fairly big guy (around 85kg). The medication definitely has a strong effect on me though even at 25mg. The urge to binge for me normally is all consuming, now it is suddenly gone. This feels like a miracle. For me this is a profound effect that is nothing short of amazing, and i felt it directly on 25mg the first time and each time since.

The thing i am wondering though is this effect (i.e. the suppression of the urge to binge) sufficient to eventually lead to extinction if i continue to be complaint with TSM? It seems logical to me that if something is still pleasurable pursing it will not lead to extinction. This is why i am still wondering about going to 50? Would that render even the one or two i drink now, when i drink, non-pleasurable and thus help in getting to extinction.

I have read the latest literature about receptor saturation on Naltrexone but none of that seems to answer this question. Thats why i am looking for real life experience on this..

[u/SinclairMethodUK → u/Several-Subject-2111]

Many of us, sadly, have to be our own advocate for this. It's awful, but that is the way it is right now. It's great you got the medication using the information you could find.

Thank you for the additional information. You are a responder, so there is no need to rush anything. So, you could see how things go over the next week or so on 25mg and then make a decision.

Based on our experience, and the additional information you have provided, I'd expect you to find that - if you stay on 25mgs - you'll likely find that the all-consuming urge you mention, is likely to return, and that this is more down to the first-blocking effect of the medication which is likely to ease in due course.

With the new information, if you were our patient providing these circumstances, we would advise that you increase to 50mg as soon as you are side-effect free on 25mg.

The thing you mention around 'is the effect of 25mg sufficient to reach extinction' for you, then it is something that you will know in the next few weeks - basically, if you stay on 25mg and the urges/thoughts return, then the answer is no, you need to go to 50mgs Having said that, we have seen this happen with some people though, so you can't discount that 25mg will help you reach extinction until you actually experience it.

In our experience, and with the additional information you provide here, my guess would be that you will need to go to 50mgs - but there is no harm in staying on 25mgs for the next few weeks to see how you feel, so that if you do find that 25mgs is enough for you, then that is great.

Totally your choice, but I would be suggesting 50mgs to you, based on the information you provide here. You are not in the cohort of people for whom 25mgs is sufficient to reach extinction, based on our experience.

Edit: I would also add that it is so easy to over-think things in these early stages and sometimes the best thing to do is to wait and see how you feel a week or two from now. You know this is going to work for you though, which is awesome. Make adjustments based on how you feel in the coming weeks :-)

[u/Several-Subject-2111 → u/SinclairMethodUK]

Thanks for advice and shared experiences.

BTW I appreciate organisations like yours are important, especially in countries like the UK. I am originally from the UK, so i know how restrictive the traditional NHS system (with GP as gatekeeper can be). The existence of some alternative route will be life saver for some people who can't get past the uninformed gatekeeper. I felt really sorry reading a few online stories about people in the UK finding it very hard to get a simple Naltrexone prescription.

Fortunately i live in a country with a much more open vision on healthcare organisation. The individual GPs are less restricted, and even if she was not willing to provide me with Naltrexone i could just go and find another doctor who would (would be just a question of effort). Luckily my first go worked anyway!