Can We Take The Devil Out Of The Bottle? Evidence and personal experience with the Sinclair Method (naltrexone) for alcohol abuse.

Note that I am not a medical professional; just someone who took a medication and found it helpful. Nothing in this post should be contrued as professional medical advice.

Alcohol Use Disorder

The medical term for what most people call “alcoholism” is “alcohol use disorder” (AUD). There’s one surefire cure for alcohol use disorder: Not drinking. Not drinking works 100% of the time for people who follow through with the treatment! But there’s obviously one huge problem with the “not drinking” approach, which is that people who abuse alcohol like drinking, by and large, and many of them have a very difficult time not drinking
We’ve come up with various support systems that make it somewhat easier to not drink, like 12-step programs and rehab clinics. Unfortunately, these systems suffer from the same problem as “just not drinking” — problem drinkers like to drink, and that often makes them unwilling to comply with these programs.
Can problem drinkers just drink less? Enough less that it stops being a problem? Some certainly do. But here, too, we run into a problem: The list of symptoms that define alcohol use disorder is basically a bunch of different ways of saying “out-of-control drinking”, and it’s asking quite a lot of someone whose drinking is out of control to reduce it to a controlled level. In general, moderation seems to be especially difficult — relative to abstinence — for people for people whose drinking problems are severe.

That’s all very discouraging. But we call alcoholism a disease, right? If it’s a disease, how about we try giving people…I dunno…medicine?

There are several medications that seem to work somewhat well for treating alcohol use disorder, including disulfiram, acamprosate, and naltrexone. I’m not going to talk much about disulfiram and acamprosate in this post; briefly, disulfiram works by making even small amounts of alcohol horrifically unpleasant, whereas campral works by reducing craving — but seemingly only for people who abstain completely. This points to an important limitation these two drugs share: They work only for people who want to stop drinking completely. Problem drinkers like drinking, which makes these meds a tough sell for people who aren’t convinced they need to stop.

Extinction Therapy

Which brings us to naltrexone, the topic of this post.

Alcohol causes the brain to release endorphins, which in some people sets off a chain of processes that condition the brain to associate alcohol with reward, leading to addiction and cravings — Pavlov’s dog, but with booze instead of food and cravings instead of saliva. Naltrexone is an opioid antagonist that blocks endorphins from binding to receptors. Addiction research John David Sinclair proposed that naltrexone could be used as a therapy for alcohol addiction, using an approach based on classical conditioning and specifically on extinction.

If naltrexone is consistently administered before every time someone’s brain is exposed to alcohol, the association between alcohol and reward could be reduced and eventually eliminated, just as Pavlov’s dog will eventually stop salivating at the sound of a bell when the bell stops predicting food; this process is called psychological extinction. Sinclair’s therapy — now called “The Sinclair Method” (TSM) — calls for problem drinkers to take a naltrexone pill at least one hour before each drinking session, gradually extinguishing alcohol cravings and makes it easier to moderate or abstain. Unlike either of the other two medications I’ve mentioned, this therapy works least as well for drinkers who want to moderate as for drinkers who want to quit, and indeed requires that even someone who ultimately aims to abstain continue drinking for at least a while. In theory, anyway. Does it work in practice?

Extinction therapy works exceedingly well for problem drinkers who happen to be rats:

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brief note

I plan to write two follow-up posts on Picketty. The first, which I hope to write this month, will be a deeper examination of Picketty’s ideas on inequality. The second will be about Picketty’s theory of “educational reverse”, and I will probably wait for that until we have more data on the demographics of the U.S. presidential election results.

Book Review: “Capital and Ideology”, by Thomas Picket. Part 1, because hoo boy was it long.

Capital in the Twenty-First Century, Thomas Piketty’s #1 best seller about the economics of inequality, was in one sense a bit of a dud.  Supposedly, the main point of Piketty’s book was the following dry equation: When r, the rate of return on capital, is greater than g, the rate of economic growth, inequality of wealth increases.

For the most part, economists were not impressed.  Specifically, they were not impressed by the r > g thing; even Paul Krugman, definitely a Picketty fan in general, calls the book’s central thesis an “intellectual sleight of hand.”  If you’ve paid attention to nerdy online debates about Piketty, you’re probably familiar with the following irony: Piketty’s book about inequality was a runaway success because the 1% have been getting richer and people are upset about that; however, even Piketty himself admits that the r > g isn’t the reason the 1% are doing so well; r > g tells us the rich are getting richer because they’re accumulating ever-greater returns from capital, but in recent decades, what’s actually happened is that CEOs are pulling astronomical salaries.

If you’re not familiar with that debate, don’t worry; we’re moving right past that stuff.  The book was not a best seller because of r > g; the book was a best seller because it’s a comprehensive, data-driven, and engaging economic history of inequality in the United States and Europe during the past hundred and fifty or so years, and a warning that inequality is likely to keep increasing unless we do something about it.

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It Feels Like We’re Thinking?

Ezra Klein recognizes, in Why We’re Polarized, that the literature on political polarization and bias is deeply and personally disturbing.  “To spend much time with this research is to stare into a kind of intellectual abyss,” he says.  The research seems to show that people trick themselves into confirming their own biases, and that people with higher levels of political engagement and knowledge are more, rather than less, prone to doing so.


The implications should not be lost on the reader.  Chances are, if you’re reading a book by Ezra Klein, you’re a highly educated and engaged consumer of political news, exactly the kind of person this research says is most vulnerable to motivated reasoning about politics.  Everyone recognizes that other peoples’ political reasoning is motivated; in particular, they recognize that the other side’s political reasoning is motivated.  However, it’s incredibly difficult to admit that your own reasoning is political motivated, and even if you were to admit that, what would you do about it?

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Book Review: “Why We’re Polarized”, by Ezra Klein.

Mostly it’s because we’re humans and humans are dumb, tribal apes.  Also, America is in deep trouble because our constitution contains some serious mistakes that we need to get fixed.  That’s the short version of what Ezra Klein has to say about Why We’re Polarized.

But there’s a lot more to it than that.  Klein, one of the biggest names in modern journalism, co-founded Vox and along with Nate Silver, helped pioneer a new school of journalism that’s heavily influenced by empirical social science. Vox is also — much moreso than Silver’s FiveThirtyEight — unambiguously a publication of the progressive left, deeply confident that empirical social science supports left-leaning policy goals.  Conservatives have criticized the publication of being hopelessly biased and called its “explanatory journalism” schtick patronizing.

Why We’re Polarized gives a pretty good idea of how Ezra Klein thinks about the current state of American politics and American political journalism.  I’ll note that Klein thinks in terms of systems, not stories; rather than identify heroes or villains, or ask where things might have gone differently, he describes our polarized political system as if it were the engine of a car; each part supporting the totality of how the machine operates.  Of course, the difference is that no one designed this engine intentionally and most of us don’t like where it seems to be heading.  This reminds me of how David Simon treats the War on Drugs in The Wire, but that’s neither here nor there.

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Book Review: “Blueprint: How Our DNA Makes Us Who We Are,” by Robert Plomin.

You’d think that staying at home all the time would give me more time to write blog posts, but it turns out there were a few other projects I wanted to finish first.  Not doing so great at meeting my posting goals for the year, am I?  Anyway…

Blueprint: How Our DNA Makes Us Who We Are has two parts.  The first, “Why DNA Matters”, summarizes current scientific consensus on the influence of genes on human behavior.  The second, “The DNA Revolution”, explains how DNA works, summarizes the recent history of research into human genetics, and predicts the effects recent and future breakthroughs in genetic research will have on the field of psychology.  It’s worth noting that Plomin is a top behavioral genetics researcher, as authoritative as it gets on some of these topics; it’s also worth noting that (especially in the second part) that he’s not a clinical psychologist and his speculations about the future of that field should probably be taken with a few grains of salt.

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Conspiracy theories update.

It doesn’t seem to me that there’s actually much new evidence suggesting that the coronavirus came from the Wuhan Institute of Virology. There’s now a confirmed record of safety concerns about the lab. That evidence moves the dial a bit, I guess, but there’s nothing directly tying the virus to the lab.

What this news does illuminate is that the lab-accident theory has been plausible this whole time, while we’ve been calling people conspiracy theorists and banning them from social media for saying so. It is in fact deeply suspicious that a bat coronavirus started spreading among humans a few miles away from China’s top lab for studying bat coronaviruses and the threat they pose to humans.

Mind you, most of these people are sloppy – they drew overly certain conclusions from weak evidence, made unjustified claims about the virus being a genetically engineered bioweapon, and so on. But people make sloppy arguments all the time – should we really be deplatforming people for spreading a theory that might be substantially true?

One thing’s for sure: If at some point good evidence emerges that the virus did come from the lab, I’ll have to drop my claim that no fringe conspiracy theory has ever turned out to be right.

“Embracing Defeat”, by John W. Dower, and “Exorcising Hitler”, by Frederick Taylor

The Great Leveler starts its chapter on war by describing the American occupation of Japan after World War II; for Scheidel it’s the central example of how a mobilizing war influenced egalitarian policies in the following decades.  For me, it was a shock mostly because it got me thinking about a time and place I hadn’t thought about much before.  My thoughts were something like, “We defeated Japan and then forced them to adopt democracy at gunpoint, and it worked.  How crazy is that?”

Certainly one lesson many drew from the Iraq War was that you can’t impose democracy at gunpoint.  But clearly you can, some of the time; what are the conditions that make it possible?  And to expand on a theme I mentioned near the end of the previous book review: Is high modernism and top-down planning really as uniformly bad as its critics say?  With these questions in mind, I read John W. Dower’s Embracing Defeat: Japan in the Wake of World War II and Frederick Taylor’s Exorcising Hitler: The Occupation and Denazification of Germany.

This review, and even the readings, are a bit of an experiment for me: Social science is my thing, and while the books I read are often cite historical incidents, they’re usually about some generalized form of human behavior, not straightforward accounts of what happened in certain times and places.


Were these democratic transitions actually a big deal?

I want to touch briefly on a topic neither of the books I read spends much time on: The political systems of Germany and Japan just before World War II.  Both Germany’s Weimar Republic and Japan’s lesser-known Taishō Democracy were more-or-less functional constitutional democracies.  Given that, you might think nothing special happened in Japan or Germany after the War; they simply resumed democracy after an interlude of totalitarian insanity.

That’s a very misleading view: Democracy often takes many years and multiple tries before it sticks, and both the Weimar Republic and the Taishō Democracy were fighting for their lives from the moment they were born.  Common words to describe them include “fledgling”, “failed”, and “unstable.”  The Taishō Democracy, in particular, never had full civilian control of the military.  A return to “normalcy” for Japan or Germany could have just as easily meant a return to non-totalitarian military dictatorships, so the question of why post-War democracy took hold and survived in the long term is a real and important one.


Post-War Germany

There are two really important things to understand about Germany immediately after the War:

  1. It was divided into four zones, controlled by the Americans, British, French, and Soviets.  The Cold War hadn’t quite started yet, but it was about to.
  2. It was a huge mess, lots of war crimes were committed against Germans (especially by the Russians, who had been abused quite horribly by the Nazis during the War), and everyone was starving.

In the interest of not totally glossing over all the suffering and human rights abuses, I’ll at least provide links that describe two of the more notable events of the era: The ethnic cleansing of Germans from Eastern Europe and the neglect and starvation of German P.O.W.s.  But ultimately the “four zones” thing, and especially the rivalry between the Western Powers and the Soviets, was more relevant to the reestablishment of democracy.

The Soviets were strikingly efficient about setting up an occupation government, compared to the Western Powers; the Communist Party of Germany, controlled by Comintern, provided a ready-made party structure and a network of activists with knowledge of local conditions and politics.  And the Soviets suffered no doubts as to what exactly they wanted to do in Germany: Rebuild it as a Communist state controlled by Stalin.

The Western Powers, on the other hand, began the occupation with no clear plan other than not letting Germany rearm and start World War III.  The early Morgenthau Plan even proposed that Germany be permanently deindustrialized, allowed only an agrarian economy.  The political disputes around the plan are a bit hard for me to follow, but in general it seems that Roosevelt was quite sympathetic to the plan, very much to the objection of Churchill and to his own State Department.  Whatever the case, Roosevelt died before the end of the war, and the United States instead eventually implemented the Marshall Plan, which funded large-scale economic recovery programs aimed at strengthening Western European industry and rebuilding West Germany as bulwark against Communism.


Post-War Japan

The Japanese occupation, in contrast, was run by the United States alone, dominated by the personality of General Douglas MacArthur, who pretty much seems to have been the Team America: World Police song in human form.  Unlike his counterparts in Germany, MacArthur knew exactly what he wanted to do in Japan: Rebuild it as a liberal democracy.

Occupation and democratization in Japan seems to have had more than a hint of The White Man’s Burden to it.  Whereas everyone seemed to assume that democracy was the default state Germany would return to, many doubted whether the Japanese people were ready for it.  I’m not sure how ironic I should find that:

  1. On one hand, Germany and Japan each had just over a decade’s prrior experience with democracy; the Weimar Republic and the Taishō Democracy could be seen as parallel first steps toward democracy by previously militaristic societies.  So why should anyone have expected Germany to be better at democracy than Japan?
  2. On the other hand, it seems to me that despite superficial similarities, the Weimar Republic really was more democratic than the Taishō Democracy; Japan was still formally a monarchy and it it’s possible that democracy sprouted there only because Emperor Taishō had cerebral meningitis and couldn’t do much to stop it.

Whatever the case, MacArthur centered his strategy around the belief that it was necessary to keep Emperor Hirohito on the throne, as a defanged symbol of continuity between old and new Japan.  MacArthur essentially promised that the United States would play along with the ruse that Hirohito had been dragged into war unwillingly by his military advisors, so long as Hirohito consistently said nice things to the Japanese people about democracy and the United States.

The Japanese constitution is perhaps the most shocking example of how ambitious and high-handed the occupation was.  MacArthur’s office called upon Prime Minister Shidehara to draft a new constitution; Shidehara’s appointees suggested keeping the Meiji Constitution in place with only minor changes.  MacArthur rejected their proposal outright and instead assigned the task to…well, two dozen Americans who weren’t too busy that week.  And I do mean a literal, singular week — at less than 5000 words the Japanese constitution is one of the shortest in the world in part because the drafters simply didn’t have time to write anything longer.  None of the committee members knew anything about constitutional law, though several were lawyers and they did most of the writing; the only member who spoke decent Japanese or knew anything about Japanese culture was Beate Sirota, who had no specific formal qualifications but was well-educated and grew up in Japan.  The constitution was then presented to what Dower describes as “the completely unsuspecting Japanese government” for minor revisions.


Exorcising Hitler?

Even though “denazification” is in the title of Taylor’s book, he really doesn’t have all that much to say about it.  And perhaps that’s because there wasn’t all that much to say; denazification was generally a lackluster affair.  The top surviving Nazis in Germany and the highest-ranking militarists in Japan were tried, convicted, and executed, with the notable exceptions of Hirohito and his family.  A few thousand other Nazis and militarists were convicted of various war crimes and human rights violations; a vastly larger number were not tried or convicted for their crimes, and overall the process seems to have been pretty arbitrary.

A much larger number of people associated with the military regimes were banned from holding political office.  So far as I can tell these bans were temporary in Japan, but in theory tens of thousands of former Nazis were banned for life from holding office in Germany.  In practice, those bans don’t seem to have been enforced consistently.  I will note that most democratic transitions don’t involve this sort of ban — in Guatemala, for example, the former dictator’s party actively participated in democratic politics, and in Nicaragua, the former Sandinista dictator is now the elected president.  A similar and very controversial policy was implemented in Iraq.  Of course, one could argue that since these dictatorship never committed atrocities on the scale of the World War II totalitarian states, there was less justification for banning former officials from power.

I was a little disappointed by Taylor’s coverage of denazification — again, given that it’s mentioned in the title of the book — but he did clarify something that I had been confused about: Did Germans begin reckoning seriously with the Holocaust immediately after the War?  The short answer is that they didn’t.  The common German attitude after the war was firmly in “Hitler had some good ideas” territory; it wasn’t until more than a decade later, beginning with the Ulm Einsatzkommando trial and continuing with the Frankfurt Auschwitz trials, that Germans began to adopt the attitude of penitence we are familiar with today.


Are there lessons here?

As I mentioned, I mostly read and review books about social science and policy.  As such, I’m inevitably tempted to try to draw lessons from this sample of two, about what made the “democracy from above” a success in Germany and Japan but a failure in Iraq.  It’s probably a futile effort, but here are some disorganized thoughts:

  • On one hand, it’s clear that a country can successfully transition from totalitarianism to democracy with very little in the way of honest reckoning or consistent justice.  Germany took a long time to do that, and Japan has never really done it; both are considered full democracies.
  • On the other hand, banning high-ranking members of the old regime from participation in democratic governance might be a part of the recipe for success.
  • The Allied occupiers after World War II had almost unlimited legitimacy throughout the world, other than disagreements between Communism and the Western Powers.  This probably gave them freedom to implement controversial policies that the United States did not have while occupyingIraq.
  • Neither Germany nor Japan had a long history of democracy before the War; however, they did have long histories of centralized, effective state control, and neither suffered from major ethnic strife (other than Germans versus Jews, I suppose.)  Iraq, in contrast, had a relatively weak state and high levels of ethnic conflict.  One could argue, in fact, that democracy per se in Iraq has done just fine, and the main problem is that Iraq has not been able to achieve law and order.

The Great Leveler: Violence and the History of Inequality from the Stone Age to the Twenty-First Century, by Walter Scheidel

I can tell a straightforward, partisan story about inequality in the United States:

  1. The colonial United States was a remarkably egalitarian place ⁠⁠— for white people, at least.  But as the United States industrialized, from the Civil War through the Gilded Age and all the way until the Great Depression, the government made few efforts to redistribute wealth, and inequality grew and grew.
  2. Franklin Delano Roosevelt’s New Deal policies reduced inequality dramatically and established a bipartisan consensus in favor of egalitarian redistribution that lasted for decades.  Democrats controlled the White House and Congress for most of these years, and even the two Republican presidents elected during this time — Eisenhower and Nixon — basically accepted the New Deal consensus.  During this time, inequality remained low and even declined slightly.
  3. But backlash against the Civil Rights Act ultimately shattered public confidence in Big Government, eventually leading to the election of Ronald Reagan in 1980.  After this point inequality began to rise again, such that today we once again see levels of inequality we haven’t seen since the Gilded Age.

This is a common story — for example, it’s pretty much exactly the one Paul Krugman tells in The Conscience of a Liberal.


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Not Peer Reviewed in Review, 2019

By my count, I wrote six public posts of substantive length in 2019:

I also wrote two additional posts that I haven’t publicly published:

  • Personal experience and a literature review on the use of naltrexone to treat alcohol abuse.  I decided not to publish the post last year because I want to have a lengthier period of personal experience to draw upon.
  • A review of The Great Leveler: Violence and the History of Inequality from the Stone Age to the Twenty-First Century, by Walter Scheidel.  This is private simply because I’m still finishing it, and I hope to publicize it by the end of the month.

Some thoughts about my year in blogging:

  • I would like to roughly double the number of long-form posts I publish next year, such that I write one a month.
  • I’m satisfied with the range of topics and formats of posts I’m writing.  Reviews, data analysis, and argumentative essays all seem like areas where I have the skills and interests to write productively.
  • I think I can be more proactive about promoting my posts.  By far the biggest spike in my traffic was when I posted a link on r/slatestarcodex.  I was initially cautious about doing that sort of thing; it felt like it might be a violation of Reddit’s norms, but it seems that people don’t mind some judiciously applied self-promotion when the effort level is high and the topic is relevant.
  • I’ve scaled back the food photos.  I like the way they fit visually between the long-form posts, but I don’t know whether they contribute to other peoples’ experience of the blog.  For whatever reason, they do seem to get a lot of other WordPress users following my blog, but I’m not so sure those users enjoy my long-form content.