The End of My Addiction

produce kidney stones, and it carries a small but significant risk of triggering glaucoma, leading two eye specialists to write in an article in JAMA that “blindness is no less of a problem than alcohol dependence.” Early in 2008, the FDA warned that topiramate may double the risk of suicidal thoughts and behaviors. 4
    The bottom-line measure for any treatment approach for a serious illness is a decrease in mortality and morbidity—meaning that fewer people are both dying from and being afflicted by the disease. In contrast to medication-induced reduction of high blood pressure, which is strongly correlated with a decrease in the mortality and morbidity associated with hypertension, medication-induced craving reduction has not been shown to decrease in any way the mortality and morbidity associated with addiction since the approach was introduced nearly two decades ago.
    Anew anticraving medication on the horizon, vigabatrin, will likely not change the picture. Marketed under the brand name Sabril, vigabatrin was fast-tracked for phase three human addiction treatment trials by the FDA in 2008. Vigabatrin has been shown to reduce craving for cocaine and methamphetamine, and there are plans to test it on alcohol dependence. Studies of vigabatrin in the treatment of epilepsy have reported that it is associated with a high rate of ocular toxicity and that 30 to 60 percent of the patients treated with it develop visual field constriction that is irreversible.
    Given the documented ocular toxicity risk of vigabatrin and its yet unproven benefits, I would never have taken it during my alcoholism, even if there were no alternative. As a physician, I would not want to expose a patient to such a danger when there is an effective alternative in baclofen that has been shown safe over forty years of use.
    Recent history has shown that once a medication is introduced on the market, the first patients to use it sometimes run a serious risk. The case of the anti-inflammatory Vioxx illustrates this. The drug came on the market in 1999 and was widely prescribed. But an FDA study found that 27,785 deaths and cardiac problems could have been caused by Vioxx between 1999 and 2004, and it was subsequently withdrawn from the market.
    Two recently introduced drugs for smoking cessation, rimonabant (marketed as Acomplia) and varenicline (Chantix) also were reported to have serious potential side effects after they were put on the market. Rimonabant has been reported to greatly increase depression, and early in 2008 the FDA warned that varenicline may double suicidality.
    We need to reassess what constitutes remission in addiction. The DSM-IV defines full remission from addiction as more than twelve months of abstinence, regardless of the presence of addictive craving and obsessive thoughts about the addictive substance. In other words, the patient still has crippling primary symptoms, and in no other disease would this qualify as full remission. When the World Health Organization (WHO) announced the preamble to its constitution in 1948, it defined health as not only the absence of impairment or disability, but the presence of well-being.
    Even in the best scenario, anticraving agents such as naltrexone, acamprosate, and topiramate leave patients in an active disease state, in which they still must struggle, sometimes hour after hour, against addictive craving and obsessive thoughts of the addictive substance or behavior, symptoms that carry the risk of relapse and death. Moreover, these medications do not relieve the underlying dysphoria, such as preexisting anxiety or depression, that makes so many people vulnerable to addiction. In terms of the WHO’s definition of health, they reduce, but do not eliminate, the impairment and disability of addiction, and they do not promote well-being by relieving chronic dysphoria.
    Among addiction medicines, baclofen is unique to date in showing the ability to suppress, as opposed to reduce, motivation to consume alcohol, cocaine, heroin, nicotine, and amphetamine in animal studies. It is also unique among addiction medicines in its beneficial effect on dysphoria in human patients.
    As I have already described, I postulated in 2003 that baclofen’s dose-dependent ability to suppress animals’ motivation to consume addictive substances could be transposed to human beings, and that baclofen would additionally promote well-being because of its effect on my underlying anxiety. I tested the postulate