The End of My Addiction

(Ameisen, 2005b). Thus it appears, upon review of the literature, that baclofen is the only agent capable of completely suppressing cravings, while alleviating comorbid anxiety.
    The data presented thus far was previously reported in a letter to the editor of Journal of the American Medical Association (Ameisen, 2005a) and in a case study authored by Olivier Ameisen, MD, who used himself as the subject of study (Ameisen, 2005b). Dr. Ameisen had previously tried recommended dosages of disulfiram, oral naltrexone, acamprosate, and topiramate and had had extended periods of abstinence utilizing CBT and extensive involvement in alcoholics anonymous (AA). He nevertheless persisted to have alcohol cravings and anxiety symptoms, which had predated his alcohol dependence, despite trials of buspirone, selective serotonin reuptake inhibitors, valproate and carbamazepine. Hypothesizing that the dose-dependent suppression of alcohol consumption (3 mg/kg body wt) in animals could be transposed in humans, he subjected himself to a trial. He self-prescribed baclofen up to 270 mg/day (3.6 mg/kg body wt) during the first 37 days and experienced, for the first time in his alcoholic life, the absence of craving for alcohol. Indeed, he reported a state of complete and persistent indifference to alcohol, along with substantial reduction of anxiety, for a duration of 9 months at the time of his report. For reasons of somnolence, he subsequently reduced his dosage to 120 mg/day and used extra 40 mg p.r.n. stressful situations. The somnolence abated and he never experienced muscle weakness or other side effects. Blood tests remained within normal limits.
    Patient and Methods
    Mr. A is a 59-year-old married successful businessman who frequently presides over national conventions and speaks before hundreds of people. He enjoys a stable home life, does not smoke, has no other chronic medical illnesses, and exercises regularly. He sought my services as an addiction psychiatrist in May 2005 despite having a beneficial ongoing relationship with both a psychologist and a psychiatrist for the management of depression and anxiety. He had been given a diagnosis of major depressive disorder. His symptoms had responded to paroxetine over the previous 2–3 years. Prior to taking paroxetine he had had trials of fluoxetine, citalopram, and sertraline which he considered to have been tainted by his heavier alcohol consumption at the time. He spontaneously identified himself as an alcoholic and presented a strong family history of the same. He presented with a strong distaste for AA meetings, which he had tried, and refused to consider returning. He was not interested in a recommendation for outpatient chemical dependency programming. In counseling sessions he was advised to pursue abstinence from alcohol.
    His ardent desire, however, was to be able to control his drinking so as to not have it continue, in its unpredictable fashion, to embarrass and/or episodically incapacitate him in his professional endeavors. Toward that end, he had already completed the Drinkwise program offered through the University of Michigan. This program utilizes CBT techniques to assist those with an alcohol abuse diagnosis to be able to drink in a controlled fashion, if they so choose. It did not work for him, which appropriately led him to his own conclusion that he had alcohol dependence rather than alcohol abuse.
    Through his other psychiatrist he had already taken oral naltrexone. A dosage of 100 mg/day had initially been necessary before he noticed any attenuation of his alcohol cravings. This was short-lived, however, and by the time he presented to me he was taking 150 mg/day with no apparent benefit. He was still consuming an average of 35 drinks distributed over a week and up to 12 drinks per occasion. He remained concerned about the potential damage such drinking might do to his health, professional and home life. I recommended he continue naltrexone at 150 mg/day and added acamprosate 2 g/day. After 1 month, that did not reduce his craving or drinking so I offered a trial of topiramate in its place. Topiramate, similarly, offered no benefit and was associated with word-finding difficulties, a side-effect he could not abide.
    At this juncture, September 2005, a trial of baclofen was agreed upon. Scales to evaluate craving and laboratory parameters were not used. Over the first month he gradually increased his dosage to 100 mg/day, taken on a t.i.d. schedule, and