The Sinclair Method with Amy Mok

Foreign.

I want to introduce Amy Mok, nurse practitioner out of Washington. You want to give a little bit about your background in nurse practitionering, Amy?

Yes. Hi, I'm Amy Moak. I am a psychiatric mental health nurse practitioner. I have a doctorate. I started later in life in nursing. I got my BSN in 2012. I was 51. And then a few years after that, then I worked for the state, state of Minnesota and got board certified as a psychiatric registered nurse. And then after that, in 2014, I moved to Seattle, Washington, and obtained my doctorate as a nurse practitioner with a psychiatric family mental health track, and I graduated in 2017. I've worked in community behavioral health, worked with a lot of people with and also in the state when I lived in Minnesota, a lot of individuals with serious and persistent mental illness and chronic substance use issues. And most recently, I work in the prison system. I worked for the Department of Corrections in Washington state, and I actually worked in reception. So I saw all of the guys that just came in from county, came in from jail, you know, had to get them assessed before they went to their parent facility.

We're gonna talk today about. Okay, sorry if I cut you off. And it's Dr. Mok talking about. This is my sister. So we're talking today about something Amy and I've been talking to about a while, which is, you know, reducing the recidivism of people who are alcoholics or other drugs, drug abuse, and kind of how we've approached alcoholism or alcohol use disorder for the past maybe 100 years or so. And some of the new opportunities are out, which is we're gonna discuss is called the Sinclair method, which is using a medication to block the euphoria that goes along with drinking and other drugs as well, that leads potentially to extinction of the alcohol use disorder. So I'm gonna give a brief background from my understanding, Amy, and you kind of explain how you can see this working in clinical practice.

Okay.

So the reason it's called Sinclair Method, there's a European, English, Dr. Sinclair, who thought that perhaps we should be approaching alcoholism a different fashion right now. It's either all or none. Either you, you know, keep drinking if you have a disorder, or you go into AA and completely cease drinking, which definitely works for some people, but it has a high failure rate as well. Otherwise we'd have no more alcoholism. And with the Sinclair method, it's using naltrexone, which is a drug designed to block the euphoria receptors, might be used for narcotics. And the person takes this at least an hour before they drink, they go out and continue drinking. And over time, usually a month to six or eight months, that crave for alcohol starts drying up a little bit and the euphoria from alcohol doesn't happen. So they lose the psychological interest and the, in the physical interest in drinking alcohol and then that interest extinguishes over time. Now this is something that if somebody did it, they might go to where they do totally stop drinking. And some people might do this and just use it as a way to substantially cut down their drinking but be able to continue to drink socially once in a while, but they would have no interest in say drinking at home anymore. That's the idea. I want you to take, take from there, Amy, how you see this potentially affecting your patients.

Okay. Well I also to just to kind of add on what your explanation is, is another way to look at it is if you thought of it actually over time, actually reverts your brain back to before you started drinking too much. Like if you looked at, you know, a common expression people use if they go into treatment or AA is you can't turn a cucumber back into a pickle. Well, it seems like maybe you can. So when I work with prisoners that are getting ready to leave, you know, we call it getting close to the gate. Typically I, we try to like discharge them or I try to discharge them on Vivitrol, which is the long term acting of naltrexone. And so because my feeling is, well, I bet you could stay out in prison if you stayed clean and sober. But to answer your question, the way I could see it working is educating the individual before they leave rather than taking this injection once a month. Like Dr. Mok said, it's a lot more effective if you take it just before you drink. So you're able to remove the stigma. And also if you're faced with like, historically it's been abstinence or nothing. And I'll tell you what, forever is a really long time if you have to tell someone you can't drink anymore. So what you do is that if you educate someone, just take this an hour before you drink and what's going to happen is you're going to find eventually that craving or that dopamine you get is going to be negated. So you're going to find that you can either drink like say occasionally, maybe not at all. And it's also effective for, you know, for other drugs. Like Dr. Mokz said, the only one you have to be careful of is if you're Taking opiates because it just, you know, blocks that receptor. But that's a whole nother discussion. But we have found it's effective for other behaviors such as stimulants like methamphetamines, gambling, you know, all of these activities or substances that create a great dopamine hit, like this feeling of euphoria. So it's effective for all of that. So it's very cost effective, which is huge. It's very like user friendly. Know you don't have a lot of side effects like you do, like most people with alcoholism. I shouldn't say most people. But in addition to abstinence, you know, drugs that we tend to use is like an abuse which you just become profoundly ill if you take it. And you can actually drink around it if you need to. But with an abuse, you have to be careful. If you use mouthwash, you know, hairsprays, you just have to be careful of everything. And this actually helped. It's like more of an organic way to stop drinking. It takes away all of that stigma, feeling of shame. We're also removing this whole idea of, oh, you're relapsing, you know, you have to stay abstinent, you're relapsing. And so it can just help people in like a non shameful, holistic way. And it's in their control. So it's a matter of they could either, like I said, stop drinking altogether or just drink. They would find that they could just become someone that just drinks occasionally. The trick is, or the caveat is, is that you have to remember that forever. You're going to be, you want to take Naltrex about an hour before you drink forever. So it's something that you just would want to keep with you. Just like if you think of someone that has to have, you know, is prone, say to heart attacks, they have to keep nitro or heart pain, they have to keep nitroglycerin on them. You just would want to make sure that you just had naltrexone as a safety net.

Getting back to that, you said something about you want to be careful if you're on opioids. Now, if somebody's on chronic opioid use, which would be like Vicodin or oxycodone.

Right.

They should be using this because it'll block the effect of the opioids. Would it be pretty much 100% blockage? They'd get like withdrawal.

You go on instant withdrawal.

Yeah. So fortunately, opioid withdrawal is not dangerous, but it's Horribly painful. So somebody's got an addiction to narcotics or is on chronic narcotics, this is not for them. If you were not on narcotics and you took a naltrexone and you broke your leg and you took a Vicodin an hour after you took naltrexone, it wouldn't really work. But if you took it the next day, it would still work. So it's, it's. The danger is just that you would. Somebody who's addicted to narcotics or who's on them chronically, this is not for them. And I want to get back to the, you know, you've been really focused on addiction for a long time. And we have in this country, particularly this all non, non mindset that you either go to a and cease drinking forever or you have a problem forever. And obviously some people have gotten off alcohol addiction or use disorder and manager drinking, but it's not common. Usually a slippery slope. What is your thought about when we talk to healthcare providers about suggesting something other than all or none? It seems Dr. Sinclair wrote in his book that doctors are very biased against this. They do feel all or none, even though all or none fails. What's your take on that?

Well, that's very true. When I first graduated, one of the first places that I interviewed at to practice it was a substance use center in Oregon, Astoria, Oregon. And when I said to them I was getting. You had to get a waiver at that time to prescribe Suboxone, which is for opiate use disorder. And I said, oh, I'm getting the waiver for Suboxone, you know, medically assisted treatment. And the director said, oh, we don't use medications. We just go by the 12 steps. And that is just destined to fail. You know, they had a lot of people in and out of the program all the time. But I know just my personal experience is that.

Just back up and explain what the 12 steps are for. People are not familiar with it.

Oh, I'm Sorry, that's with AA. AA has 12 steps. It has to do with basically taking personal responsibility, changing your behavior. It talks about having as a result of the 12 steps, you have a spiritual experience. And it's the AA and the 12 steps. And the 12 steps are. A lot of other recovery programs have just emulated the 12 steps. You know, the first one is, you know, accepting your palace over alcohol. And so that it's talking about abstaining totally getting a sponsor service meeting with other people. You know, you go to meetings, you talk about, you know, certain areas of the steps. You know, you make.

I just want to be clear that Amy and I have spoke this lot offline is we're siblings. We have no bias against AA or Narcotics Anonymous. Nothing at all. In fact, that's been a wonderful program. And we don't want to suggest that you shouldn't do that by any means. There's no possibility. We're suggesting that we're saying is that there potentially is something else besides all or none. Not that you should go that first. So if you think abstinence is good for you want to join aa, we have a hundred percent support of your decision. So just to be clear, I don't want any way bash something that's been the most successful alcohol cessation that we know.

Yeah. Actually it's right for a long time. It's the only thing that we had. And I will say this, just kind of jumping on that. I was probably in. Probably practicing in nursing for probably five or six years before I realized, oh, not everyone had to get sober using aa. You know, there are other alternatives. You know, I think if you looked at, you know, harm reduction is something that's relatively new probably in the last 10 or 15 years. So. Yeah, so absolutely. But my personal experience is like, as an example, when I would in the. In the prison system meet with individuals that were getting ready to be discharged and if they had. Not everyone. You know, we use Suboxone a lot, but not everyone uses opiates usually now, today it's in fentanyls, like in almost everything. Fentanyl even more so than heroin. But if the underlying problem was alcohol, even meth, I would do a trial. You know, just give them a pill of Naltrexone for maybe two or three days, make sure they tolerate it, and then send them out with an injection of Vivitrol, because you get it once a month. And so my feeling always was, hey, let's give you a fighting. Let's give you a fighting chance, you know, let's at least put you on a level playing field. And so some of the other providers that I worked with had the feeling of once throughout, in the community, it's not our problem anymore. And my feeling always was when meeting with my patients was, how can we reduce recidivism? You know, how can I keep it from you coming back in again? Because to me, that just seems to be the whole point. You know, it'd be great to keep, like I said, if you could. Most, I'm going to say probably 80% of our population, I'm Just grabbing this number from my personal experience, if they could, if they were able to remain clean and sober, they wouldn't be, they wouldn't be re incarcerated. Almost every single one did their crimes and sometimes very violent ones under substance use. And when I said Suboxone, Suboxone for opiate addiction, that seems to get all of the glory and that has to do with all the grants and everything that we, that we get from the US government and it. And with Suboxone there doesn't seem to be an end plan getting them off of it. And also that's not the only thing people are addicted to. Like we just completely forgot about alcohol. And like Dr. Mokatt said, it's. And I would tell people this is the thing, you feel like you're going to die if you're withdrawing from opiates. You're not going to, but you feel like you are. But you know what, if you withdraw from alcohol, that can kill you.

That's going to dig into that. So you're dealing with a totally different population. I am. So Amy deals with mostly men in the prison system.

Right.

And I deal with women, average age in the mid-40s that are coming into our clinics for wanting to look and feel better, doing cosmetic procedures, hormone replacement. So totally different groups of people. Your patients have much more complexity than mine do because we don't have the, the narcotic involvement. And that's why you have to be more careful. And when she's talking about Vivitrol, that's just a long acting form of naltrexone. So for alcohol use disorder in the standard population, we're talking more about an oral pill. And this is again want to recap? Since this is a verbal trail, we're talking about something called the Sinclair method where people take a, a pill of naltrexone. Naltrexone is blocks box narcotics, but it blocks the receptors that cause euphoria about an hour before drinking to get the psychological and physical connection between drinking and feeling good kind of gone. And over time that that habit extinguishes. And the practical case, it takes months, typically three months to six or eight months for the person to see a gradual reduction or alcohol. And it has a huge benefit that Amy really elegantly pointed out. If you're an alcoholic, you can't just go cold turkey. Actually got to wean off of it. Now somebody is abusing alcohol even they're drinking it every day. But they're, they're at a point where they can try to stop and not feel terrible, they're not going to go through withdrawal. But the person that can't go 24 hours without a drink is going to have significant withdrawal symptoms. And there's a medical way to work some people through that. So I don't want to get into that so much as to say we're not going to really see that with this method. Because with the Sinclair method you're really supposed to continue resume your normal drink drinking and let your habit of wanting to desire drink just sort of dry up. And over time people find they're just not reaching for the glass of wine or the vodka or wherever it is in the evening and maybe they can still do it on the weekends with their friends and eventually they're just losing their taste for it overall. Another point that Amy had pointed out is that is this something you kind of would maybe, maybe make a lifetime habit? Because the concern is, which has been shown, if it's a year or two and you haven't drank and then you start drinking again, you have the same ability to get that attachment back and then like ricochet back, but it'll come back. So you just keep a pill in the pocket, you're traveling on vacation, bring up, bring your bottle with you. And some people will drink every week one or two glasses. And some people will drink every few months. Some people just decide they're never going to drink again. But the idea is to get that addiction down. And Amy and I are trying to get the word out because in healthcare we have an iron grip on the past. In any new breakthrough, I mean there's a kind, there's a quote. I don't know who said it, I can't find who said this. But for every pioneer in medicine, there's a thousand self appointing guardians of the past. And Dr. Sinclair proposed a Sinclair method. He's passed. He was in England and he was trying to get the word. I wrote some books called Cure Alcoholism and it wasn't accepted in the United States, it was accepted in Europe and it was quite common to do clinics that would prescribe naltrexone for people with alcohol use disorder. Has a caught on the United States because we have such a bias in our medical community because your doctor's got to prescribe it. You can't just go and get it. And I tell you, I know somebody very close to me that had been cured from alcoholism with the Sinclair Sinclair method. And he switched doctors really pretty much stopped drinking, but asked for a prescription, a refill on his naltrexone because he was out, but he hadn't drank in a year and his doctor refused to give it to him. He says, this is for something you got to take every day and you got to be absent. He said, well, I am abstinent. Well, you don't need it then. So there is this bias built in for a pill that's very, very safe, very, very cheap. So this is an inexpensive way to cut down your drinking or eliminate drinking. I mean, when you treat the prisoners, do you guys interact with Alcoholics Anonymous and Narcotics Anonymous?

No, we did. I started just a couple months before COVID hit. So meetings used to come into the prison. They stopped during COVID and they never picked up again. But I'm in receiving. Okay, so I'm in reception. So that's where you know, the whole goal is. You're going to just be there temporarily. We do have some long term living units, the long term prisons, which is called your parent facility. They do have more interaction with AA and na. I've worked in other like lockdown treatment facilities and AA and NA do come in and meet with. So the general thought is still it's going to work with AA and na. And so when I started answer when I just talked about people in the, the some other providers in the prison that were like, ah, don't send them out with a long term injectable. I know that still the thought was if someone is on naltrexone and or vivitrol, you have to work in conjunction in the community. You have to be involved in some kind of substance use treatment program for it to be effective. And we have found that is simply not true. It can help. And I am not down, I am not downgrading debt at all. But the fact is the 12 steps don't work for everyone. And the fact is substance use treatment just, it just doesn't work for everyone. It just doesn't take for everyone. And this is another alternative that, another thing to put in your tool belt to even use in conjunction with that or instead of it. And I just wanted to add in the big book, if people are familiar with the Big book of Alcoholics Anonymous, one of the things that it says is they talk about the 12 steps and they said we thought we could find an easier, softer way, meaning abstinence, but we could not. Not. And the fact is maybe we have. So it's just.

Let me go back to that because a very important point. So we have the 12 steps. AA, narcotics, now this and Alcoholics Anonymous that has a failure Rate because of the difficulty of separating. And we have the withdrawal syndrome too.

Right.

But the American studies looking at naltrexone, they tried to do an all or none study. So what they do is they have people that were alcoholics and they put them on naltrexone and tell them don't drink completely abstinence for a month and then take another group and they put them on a placebo and tell them not to drink. And both groups would fail at the same rate. This is the opposite. This is where telling somebody no counseling, I'm not recommending against counseling in these methods. There's no counseling. You simply use a medication to break that, that, that connection between drinking and feeling good. And eventually. And again, it's not a month, it takes several months, you lose your interest. So going back to that, that the studies in America have shown that has suggested that naltrexone doesn't work because they were trying to mix it with aa, which has got a failure rate that's significant. And the naltrexone does not work acutely like that. So taking naltrexone does not decrease your drive for drinking or cravings drinking, but taking naltrexone and keep drinking cause you to extinguish that habit. So it's really quite. It's difficult to study because of that because we have such a bias towards rnn. But that's where the suggestions have been that naltrexone doesn't work for alcoholism because they designed experiment to fail. So I think that's a great point. And another drug that we've been using, a semaglutide, which is used for diabetes and weight loss. There's a large published report showing that people using semaglutide with or without diabetes, so they're using it for weight loss or diabetes. They actually had a 50% reduction in alcohol use disorder in the group that used it. So that's something that if somebody has a weight problem and they're wanting to drink, you can use the drugs in combination patient. They could use semaglutide to help with their weight, which also reduces other cravings. And use naltrexone along with. And both of them we're seeing using them usually four to six months. So that's, that's something synergistic. These. It's been more observational studies than actual studies. So they just observe people drink less when using semaglutide. So I think now we're crossing a threshold. Amy said is that there was A time that we had one thing, which was abstinence. And that was the best thing for people who could not stop drinking. And now we have something to give you a little help with or without counseling. But the semaglutide, I'm sorry, the Sinclair method specifically, is not a counseling program. It is a. It is a pharmaceutical program.

Right. You could consider it like medically assisted treatment.

Yeah, medically assisted treatment.

And also, I just want to clarify. It absolutely can work in tandem with AA or a treatment program if you're in that. And I will say this. So, yeah, so like Dr. Moak had said, we're all so, you know, there's this whole idea of all or nothing. And, and the fact is, if you actually read any of the historical literature on Bill Wilson and Dr. Bob, those are the two founders of AA. If nelt, if this information had been available when it was formed, they absolutely would have embraced it. Yes, and they absolutely would have embraced it and used it to help their. I will just call their. Their alcoholic cohorts.

Oh, we brought up this semaglutide. Now here's a parallel. So we have obesity, which is a problem in the United States that leads to cancer, diabetes, heart disease and just unhealthy lifestyle. And we were doing bariatric surgery, which is a surgery like a stomach stapling surgery, helps people lose weight. We're telling people to eat less and exercise. And these drugs have meaningfully changed the health span of humans. I had a big and really relatively new. These are drugs develop for diabetes and they've changed the health span in humans. We're seeing less cardiovascular disease, less development of diabetes and reduces obesity. And doctors at first were very biased against it. They didn't want to prescribe it. You can do this on your own. You can just diet and exercise. Well, it's not working. And we have so many pressures that we have no control over that are causing us to get heavier. The food availability, probably our microbiome, all these other things. And it's meaningfully changing people's lives and it's going to extend human lifespan. If we look at naltrexone, we're all in the same way. We have this bias. Yes, you can quit drinking on your own, especially if you don't have a severe problem. That's because people with severe problem have the probably the most to gain, but people just realize it's drinking too much. This is a very simple method to allow you to keep drinking, eventually lose your interest, get that habit improved and get control your Drinking, which nobody wants to say that word, but this is the potential to control your drinking for real. And it's a pharmaceutical option. And just to be clear, there's naltrexone. People talk about microdosing. This is just a standard dose of 50 milligrams taken one hour beforehand. It's not the microdosing that's used for different conditions such as fibromyalgia. So this is a prescription medication, is made by big pharma. It doesn't have to be compounded, it's readily available and it's inexpensive. And you need a prescription.

Right.

So, Amy, what should people do if they want to consider this? How do they talk to their doctor about it? You practice in the state of Washington, correct? In Michigan and the Carolinas. But what somebody is in California, in.

New Mexico, Mexico, if they want to talk to their doctor about it. Actually, the book that was written, the Cure for Alcoholism, they actually have some good scripts to talk to their doctor, but they could just say, you know, I've been like, reading this literature. It helps, like, block the, you know, the receptors so that, you know, I won't get that favorable hit, that dopamine hit. And to be honest, you might find that you're going to have to shop around and talk to more than one doctor that's going to be open to this. Because there is, like, a lot of thought out there that it's all or nothing. You know, it's like, well, if you don't think you have an alcohol problem, then why do you need it? And if you do need it and need an alcohol problem, you need to be going to treatment inpatient or outpatient.

And getting back to just from, you know, I've employed a lot of doctors, work with a lot of doctors. Doctors have the same preservation of their time as everybody else does. So if you bring something totally new to your doctor, that means they've got to look it up and it takes time and they're better off saying no. And unfortunately, that is the truth.

Truth.

So doctors typically do not change behavior until there's overwhelming pressure to do so, either by the community, by insurance companies, by the patients. There's. There's a slow change. So that's one of our missions, is to get more doctors aware of this very safe option. This is an incredibly safe drug. It doesn't have side effects that are significant and is very inexpensive. And it is way safer than having a drunk driving ticket or killing somebody on the highway or driving your life in the wrong direction, ruining your family. So a lot of things. And you don't have to be that bad. It could just be something where I just don't want to drink four nights a week. It could be any stage can use this medication. So I appreciate you talking to us. Maybe we'll do a recap on this down the road. See, your patients do. And I'd really want to really focus on getting the word out and really educating doctors as well. Say this is okay. It's a very safe drug that your patients can use.

Absolutely.

Keep spreading it. So thank you so much.

Hey, thank you for having me.

Bye.

Bye.