Controlled Drinking Overview
Controlled drinking (CD) is part of the harm reduction approach to alcohol dependency, and also a type of Alcohol Dependence Treatment (ADT). The method of treatment has been around since the 1970s, and can be an effective method. However, even with repeated studies, the treatment has endured a controversial history among therapists, popular media, and in the research literature.
Clinical studies and peer reviewed research have demonstrated that controlled drinking is possible, and various moderation-based treatment could be preferred over abstinence-based treatment. Nevertheless, especially in the United States, zero tolerance has remained the treatment approach most popular among the public and professionals.
The History and Controversy of Controlled Drinking Research
The Sinclair Method is a treatment for alcohol dependency designed to implement a pavlovian technique called pharmacological extinction. This includes the use of an opiate block such as naltrexone which turns habit-forming behaviours into those which are habit erasing. The outcome is to reduce the urge to want to drink; thereby, returning the patient to a pre-heavy drinking state of mind.
The Sinclair Method requires a patient to take either naltrexone or nalmefene one to two hours prior to drinking. Naltrexone can be taken on a long term basis, but nalmefene should be discontinued after one year of taking it. Both are opiate antagonist receptors and disrupt the body’s reward cycle by causing the patient to want to drink less. According to studies, The Sinclair Method has a 78% success rate and has become a leading treatment method in Finland.1
Unlike treatment clinics that generally prescribe naltrexone or nalmefene to be taken on a daily basis, The Sinclair Method asks patients to take the medication 1-2 hours before consuming alcohol on any day that alcohol will be consumed. On any day alcohol is not consumed, no medication needs to be taken; thereby,allowing the patient to enjoy a natural release of endorphins from activities and life events. According to The Sinclair Methods’ cumulative research and opiate antagonist medications, including Selincro, are not anti-craving drugs and will not produce these kind of effects when used alongside abstinence.2 Users of the medications advocated by The Sinclair Method must consume alcohol after taking the drug in order for pharmacological extinction to occur. As treatment progresses, there should be a decline in alcohol consumption and an increase in sober days. The Sinclair Method also recommends patients to continue going to doctors appointments and counselling.
How Pharmacological Extinction Functions
When alcohol is consumed, the brain releases endorphins, chemicals that relieve pain and induce sensations of pleasure or euphoria. Repeated exposure to the endorphin release due to alcohol creates and reinforces the desire or urge to drink. According to advocates of The Sinclair Method, drinking is a learned behaviour, and one example of conditioning. Although conditioning is useful for survival, this mechanism can also reinforce behavior and habits which are detrimental to the health of the individual, including alcohol dependence (as well as additional anti-social behavior).
Pharmacological extinction as an outcome of treatment works because it assists in undoing, or reversing, the conditioning in the brain. When Selincro is taken prior to drinking, and alcohol is consumed, the brain will release endorphins, but receptors will block the endorphins from being able to bind to them. Like naltrexone, Selincro is prohibiting this connection. No reinforcement behaviour is used, nor is abstinence being forced upon an individual. Over time, without positive reinforcement, there comes a decrease in the desire to drink. When used over a period of 4-6 months, heavy or dependent drinking behaviour is extinguished. It’s important to note that pharmacological extinction does not change the drinking experience. If a person has a tendency to chase the thrill of drinking, such as going to parties, behavioural therapies may also want to be included in the treatment.
Abstinence vs. Controlled Drinking
More often than not, patients have mixed feelings about giving up alcohol, even if they are able to recognize the problem and how it is affecting their relationships, job, finances or health. The truth is that alcohol has become an integral part of a person’s life. Living without it might seem like an unattainable idea that is essentially out of the question. Thus, demanding abstinence may ultimately drive a dependent person away from dealing the issue.
This attachment and overall mindset of a dependent person may conflict with the current position and dominant view of Alcoholics Anonymous, rehabs and treatment professionals in that people with an alcohol dependency should remain totally and permanently abstinent from alcohol (and drugs). Controlled drinking is by and large rejected, with advocates of abstinence saying such a goal is detrimental and could enable denial as well as ignoring the need to admit there is a problem.
In several clinics, controlled drinking has become an alternative treatment approach when the patient does not wish to, or feels they cannot be, completely abstinent. Although controversial controlled drinking is a strategy which helps a person to reduce their alcohol consumption to a moderate level. Set over a period of time, often between 6 and 8 months, the idea is that by lowering the consumption of alcohol, the consequences produced by dependency can be addressed and minimized.
Studies of controlled drinking have been promising and suggests the treatment is successful for dependent people who have not experienced a serious addiction to alcohol, have a stable job, adequate social support, middle income and a good education. 3 In severe alcoholics, controlled drinking that may or may not include Selincro treatment was not as successful. These results showed a slow erosion in the ability to control alcohol consumption; thus, leading back into heavy drinking.
