A Pill Instead of Abstinence?

By Maia Szalavitz

Jul. 29, 2009

They call it "the switch." Alcoholics who take an anticraving medication called baclofen say the drug allows them to resist the most powerful triggers of relapse: former drinking buddies, a favorite bar, the sight of alcohol or even the most potent drinking cue of all, having a single drink.

Bob, 62, a business owner in the Midwest, who asked not to be identified by his real name, experienced his switch at a dinner party two years ago. Bob had battled alcohol dependency for several decades, regularly drinking at least 35 beers a week. Normally he would have downed several glasses of wine before dinner, he says, but that night, after taking baclofen for two weeks, he found himself sipping soda water instead, engrossed in conversation. "I realized I wasn't having that nagging feeling in my head, 'I should really get a drink,'" says Bob. "It never appeared during the dinner either so that was the eureka moment." He continues to take baclofen and now drinks about two or three times per week, no more than a beer or two at a time.
(Read about the many faces of addiction.)

A similar experience prompted French cardiologist Dr. Olivier Amiesen to write the highly publicized memoir The End of My Addiction (Farrar, Straus and Giroux, 2009). A longtime alcoholic, Amiesen had checked into various rehabilitation centers at least eight times and attended nearly 5,000 Alcoholics Anonymous (AA) meetings, without being able to maintain sobriety. More than five years ago, he began taking baclofen, and since then, he says, he has consistently been able to abstain from drinking altogether or drink moderately in social situations, without having cravings or other addiction-related problems.

"I never understood how people could leave liquor in a glass," says Amiesen, "Now you could give me a sip of champagne and I could leave it. That was impossible in my wildest dreams. And it's effortless. Complete suppression, not reduction of cravings. I'm indifferent to it."

Despite such anecdotal successes, so far there is little scientific data in humans to support them. Past studies in animals suggest that baclofen does have a powerful anticraving effect, however, and two large, randomized controlled trials of high doses of baclofen are under way. Meanwhile, more and more American doctors are prescribing baclofen for their alcoholic patients, based on experiences like Amiesen's. And yet even if the apparent anti-addiction benefits of the drug which is currently approved by the government to treat muscle spasms are borne out in human trials, it might do little to persuade most American addiction-treatment providers to use it.
(Read "Can Amphetamines Help Cure Cocaine Addiction?")

At issue is the definition of treatment. In the U.S., successful treatment of addiction has traditionally been an all-or-nothing undertaking, involving complete abstinence as promulgated by supporters of 12-step programs like AA rather than a regimen of moderation. For many, that definition includes abstinence even from drugs that would help fight cravings. Indeed, for decades, experts have debated whether drug addicts who cannot or will not quit should even be offered ongoing treatments that would reduce harm related to their drug abuse. Although many providers have recently become more open to new options, the majority of American addiction treatment continues to use the 12-step abstinence model.

But in many other countries harm reduction is a widely accepted treatment model. In Europe and Canada, government-funded antiaddiction programs routinely help alcoholic patients reduce drinking, even if they won't quit; in Sweden, health officials suggest that cigarette smokers switch to snus (smokeless tobacco), which, unlike smoking, is not associated with lung cancer or cardiovascular disease. American proponents of moderation also argue that by demanding complete sobriety, it is possible that we are missing the chance to improve the health of smokers or problem drinkers who cannot or are not ready to stop entirely.

What's more, the abstinence-only model is far from foolproof: 90% of alcoholics do not get sober on their first attempt, and most rehab programs report a more than 50% relapse rate in their patients within months. First attempts to quit smoking cold turkey fail just as often. So, helping drinkers and smokers cut down, even if they can't quit immediately, may have significant value, says Teri Franklin, a professor of neuroscience at the University of Pennsylvania. "If you can prevent people from inhaling the 4,000 chemicals in just one cigarette, over 400 of which are carcinogenic, you can get a health benefit," she says, noting that she was only able to quit smoking by first cutting down.

Franklin is now studying the effect of baclofen on nicotine cravings. In one nine-week controlled trial involving 60 smokers, she found that those who worked up to a daily 80 mg dose of baclofen were able to reduce their smoking from 20.5 cigarettes a day to eight, a significant improvement over the placebo group, which was able to cut down to 12. And there was a distinct point at which the effect appeared to turn on just like the switch discussed by alcoholics.

That switch may apply to a variety of cravings, such as binge eating or even using heroin or cocaine, say researchers. Why? Because baclofen appears to intercept them at their roots: addiction is driven by the same brain system that motivates people to seek natural pleasures like food and sex. These rewarding experiences trigger the release of the neurotransmitter dopamine the brain's "do it again" signal. Over time, addicts' brains become narrowly focused on drug-related pleasures and hypersensitive to cues associated with them, such as seeing an old drinking pal. Hanging out with that friend would prompt a rise in dopamine levels in the brain's reward system. Researchers think that's where baclofen cuts in: by binding to the GABA-B receptor in the brain, it modulates this system and prevents the release of dopamine in response to cues. That appears to short-circuit cravings.

Still, not all research has been conclusive. While it was baclofen's effect in a crack-addicted patient that first got Penn scientists interested (the patient, a paraplegic named Edward Coleman who was taking baclofen for muscle spasms, reported that it also cut his cravings for crack), a recently published multisite trial of the drug in cocaine addicts did not produce significant results. "We think one of the reasons is the dose," says Franklin, noting that most alcoholics who have reported the switch tend not to experience it at less than 80 mg per day; the cocaine trial used 60 mg.

At high doses, however, baclofen can cause drowsiness and muscle spasms, although preliminary studies including Franklin's suggest that these side effects can be prevented with gradual exposure. Patients must also be weaned off the medication slowly to avoid muscle problems and anxiety. And for the treatment of addiction, it appears that baclofen must be taken indefinitely, since cravings return once the drug is stopped.

Whether or not baclofen proves to be the next big quit drug there are at least four other prescription drugs currently available to help people stop smoking or drinking, including naltrexone, buproprion, acomprosate and Chantix, which have shown varying degrees of benefit most addiction researchers would continue to encourage abstinence. "There are always some patients who can [cut down] to drink small amounts, but they are the exception," says Dr. Nora Volkow, director of the National Institute on Drug Abuse, which is funding several ongoing trials of baclofen. Although Volkow thinks baclofen shows promise in helping patients quit drinking altogether, she says the idea of controlled drinking is unwise: "My advice to patients is, don't risk it."

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