The End of My Addiction

The authors point out that such effects (that were not assessed beyond the 12-week duration of the trial) may be obtained only with moderately dependent alcoholics. The severity of my dependence and anxiety might explain why I did not benefit from topiramate.
    A recent multicentre trial showed the advantage of monthly intramuscular naltrexone depot over oral naltrexone in improving the total abstinence rate because of compliance issues with oral naltrexone (Kranzler et al ., 2004). Naltrexone—as disulfiram, acamprosate and topimarate—does not claim efficacy in reducing symptoms of anxiety. In contrast, baclofen, by its additional effect on anxiety, encourages compliance and represented an effective monotherapy for me.
    Deep relaxation
    During cravings, it had always been extremely difficult for me to apply CBT techniques because the efforts required induced anxiety in such a context. In contrast, in the first 37 days during which cravings were present (escalating baclofen doses), when deep relaxation occurred after an additional baclofen dose, it was much easier for me to use CBT and AA techniques to combat cravings and avoid drinking than before. Deep relaxation reliably occurred within the hour after an additional 20–40 mg of baclofen.
    Tolerance
    Tolerance, though uncommon, has been reported in spasticity after years of intrathecal baclofen therapy, requiring minor adjustments in dosage (Nielsen et al ., 2002). Should tolerance develop, there is ample room for me to safely increase the dosage until other medications demonstrate efficacy.
    Possible mechanisms of action of baclofen
    Medications that facilitate GABA neurotransmission (baclofen, topiramate) show promise in treatment of alcohol and cocaine dependence (Addolorato et al ., 2000, 2002a,b; Johnson et al ., 2003, 2004; Shoptaw et al ., 2003; Kampman et al ., 2004). GABA neurotransmission is an important common denominator in the pathophysiology of anxiety and mood disorders (Brambilla et al ., 2003; Nemeroff, 2003). GABA modulation is a highly probable mechanism by which the clinical expression of alcohol dependence is blocked by baclofen. However, at high doses, recruitment of additional mechanism(s) by baclofen cannot be excluded. Behaviours that resemble human diagnostic criteria for addiction have been recently described in rats (Deroche-Gamonet et al ., 2004). This new animal model should allow further research on the mechanisms by which baclofen reverses dependence.
    Chronic treatment
    Currently, I use baclofen primarily to control anxiety. It is impossible for me to know whether symptoms of dependence would reoccur, and at which lower dosage, since I have not contemplated weaning myself off baclofen. Would conscious cognition that I have remained indifferent to alcohol for several months modify my behavioural response if symptoms were to reoccur? I believe that the new situation created by baclofen-mediated suppression of symptoms of alcohol dependence offers a window of opportunity to explore the effects of other approaches, such as CBT, in helping reduce or suppress requirement for life-long baclofen treatment. Moreover, the necessity for life-long baclofen treatment could be studied in the newly described addiction model in rats (Deroche-Gamonet et al ., 2004).
    The major limitation of this report is that it is a self-case report, not a study. But it suggests a new concept of treatment: the blockade of the expression of substance dependence symptoms with simultaneous intervention on anxiety. This case could result from a placebo effect, but I believe this to be unlikely since there has been no report of such complete and prolonged effects in clinical trials. The efficacy of high-dose baclofen should be tested for reproducibility in randomized trials under strict medical surveillance to confirm the validity of the concept of dose-dependent suppression of symptoms of alcohol dependence.
    Acknowledgements
    A physician’s signed corroboration of the author’s self-report has been provided by Dr Jean-Paul Descombey, former chief of psychiatry at Hôpital Sainte-Anne, Paris, and a member of the Administrative Council of the French Society of Alcohology. He has known the author for the last 5 years. The author states that he has no financial or other connections with any company marketing baclofen, or other conflict of interest.
    References
    Addolorato, G., Caputo, F., Capristo, E. et al . (2000) Ability of baclofen in reducing alcohol craving