The End of My Addiction

reported a completely satisfactory response. He felt that drinking was now “an alien world” to him. On occasion, when stressed, he increased his dosage to 140 mg/day. He experienced only mild relaxation, not sedation, as a side-effect. This benefit did not abate, as had been his experience with naltrexone, and he continued to report baclofen as “my miracle drug.” If he chose to drink his consumption was never more than 12 per week, or 3 per occasion, and his sense of euphoria from that was dulled. With the guidance of his other psychiatrist he discontinued the paroxetine, experienced return of depression and anxiety, had a brief unsuccessful trial on Effexor XR 75 mg, and returned to paroxetine.
    Discussion
    Having worked with chemically dependent individuals struggling for recovery for over 20 years, I am a supporter of AA and Narcotics Anonymous (NA) and believe connection with those organizations to be the most likely route toward quality recovery. With or without such a connection, however, I have repeatedly been faced with the patient who, despite his or her apparent best efforts, has not been successful at resisting the impulse to relapse, even when I believe I have successfully treated psychiatric comorbidity. I have experienced such patients benefiting from either oral naltrexone, acamprosate, or the combination of both. I make disulfiram available to patients whom I believe it will help, but do not rely upon it to reduce the phenomenon of craving. I have yet to treat anyone with injectable naltrexone.
    Mr. A is an individual whom I believe represents a very large number of patients who do not experience a satisfactory anti-craving response to either the current FDA-approved medications for alcohol dependence or to topiramate. My report is that he has experienced a satisfactory response to high-dose baclofen that has been sustained over ten months without significant side-effect. Tolerance has not developed, whereas it had with oral naltrexone. Tolerance to baclofen has uncommonly been reported only after years of intrathecal use for severe spasticity (Nielsen et al ., 2002). In contrast with Dr. Ameisen’s experience, use of a selective serotonin reuptake inhibitor (SSRI; paroxetine) did appear to be necessary as baclofen by itself did not satisfactorily reduce Mr. A’s anxiety or depression.
    Being a case study, this report is obviously limited. Placebo response is a possibility. If that is the case, however, there is no apparent explanation for why it did not appear in trials of either naltrexone or acamprosate, alone or in combination, or with topiramate. Given the nearly four decades of use of high-dose baclofen for the long-term comfort care of patients with muscular spasticity from various neurological conditions (spinal injuries, multiple sclerosis), and the absence of report of serious or irreversible adverse effect, baclofen may be a safe, effective and well-tolerated adjunct to our treatment efforts with this population. Hypotension, changes in glucose control in diabetics, sedation and changes in seizure control are potential side-effects. Randomized trials of high-dose baclofen should be conducted to test elimination of alcohol craving and its potential consequences.
    Acknowledgement
    I am grateful to Dr. Ameisen for his support and the sharing of his experience.
    References
    Addolorato, G., Caputo, F., Capristo, E. et al. (2002a) Baclofen efficacy in reducing alcohol craving and intake: a preliminary double-blind randomized controlled study. Alcohol and Alcoholism 37 , 504–508.
    Addolorato, G., Caputo, F., Capristo, E. et al . (2002b) Rapid suppression of alcohol withdrawal syndrome by baclofen. American Journal of Medicine 112 , 226–229.
    Addolorato, G., Leggio, L., Abenavoli, L. et al . (2006) Baclofen in the treatment of alcohol withdrawal syndrome: a comparative study vs diazepam. American Journal of Medicine 119 , 276.e13–276.e18.
    Ameisen, O. (2005a) Naltrexone treatment for alcohol dependency. Journal of the American Medical Association 294 , 899–900; author reply 900.
    Ameisen, O. (2005b) Complete and prolonged suppression of symptoms and consequences of alcohol-dependence using high-dose baclofen: a self-case report of a physician. Alcohol and Alcoholism 40 , 147–150.
    Balldin, J., Berglund, M., Borg, S. et al . (2003) A 6-month controlled naltrexone study: combined effect with cognitive behavioral therapy in outpatient treatment of alcohol dependence. Alcohol and