The End of My Addiction

280 mg). For those patients currently receiving >80 mg (n = 10), the mean dose of baclofen was 141 mg (SD, 50.7), and for those who had ever taken >80 mg (n = 15), the mean dose was 137 mg (SD, 60.2). Table 2 gives the distribution of baclofen dosage for the entire sample.

    TABLE 2. Distribution of baclofen dosage
    Of the eight patients who had discontinued baclofen, none were taking more than 60 mg (<80 mg, 100%; mean, 27.5 mg; SD, 18.3 mg; range, 5 to 60 mg). The most common reasons for stopping baclofen (table 3) were lack of benefit as observed by the patient or physician (n = 4) and weakness (n = 3). One patient discontinued treatment because of urinary incontinence and one because of nausea. No reason was recorded for another patient. Two patients had two reasons for discontinuing baclofen. Only two patients sought advice from their physician before stopping the drug.
    Of the 24 patients who had ever reduced their dosage from their maximum recorded levels (table 3), the most common reason was weakness (n = 15). For eight of these, dosage reduction was suggested by their physician. Two additional patients reduced the dose because of drowsiness, one each because of nausea, urinary incontinence, and lack of additional benefit, and three for unstated reasons. In one patient, the dose was reduced by the physician because of an episode of possible confusion reported by the family.

    TABLE 3. Reasons for discontinuing or ever reducing baclofen dose
    Relationships between baclofen use and patient characteristics were examined. Compared with women, there was a nonsignificant trend for men to be more likely to have received baclofen (men = 78.9%; women = 59.5%; p = 0.064). Otherwise, there were no sex differences. Patients who had received baclofen were significantly older (48.5 years versus 38.7 years; p > 0.001) and had MS longer (14.9 years versus 9.2 years; p > 0.01) than those who had never taken baclofen, probably because spasticity is more likely to appear or to get worse as the disease progresses. However, there was no relationship between age or duration of illness and either the highest dose recorded or the current dose.
    Discussion
    Baclofen is an effective drug for the treatment of spasticity of spinal origin. 3 Adverse effects are generally mild and transient. 4 Unfortunately, physicians tend to underutilize baclofen because the recommended maximum is 80 mg/d. 5,6 As patients may suffer serious complications because of inadequate spasticity relief, 1 it is important to alleviate at least some of the more serious manifestations of severe spasticity, such as lower limb flexor spasms. Although high-dose baclofen has never been studied prospectively, our experience suggests that MS patients can readily tolerate relatively large doses.
    There are several references to long-term, high-dose baclofen treatment for spasticity. Jones and Lance 7 summarized their experience with 113 patients with spasticity treated with baclofen for up to 6 years. Baclofen dosage ranged from 30 to 200 mg daily with the mean varying from 60 to 110 mg depending on the cause of spasticity. Treatment was abandoned in only four patients because of intolerable side effects, and another 20% required a reduction in dosage. Pedersen et al. 8 treated patients with up to 100 mg of baclofen daily for more than 3 years. Adverse effects were transient but more frequent at higher doses. Pinto et al. 9 identified patients who had taken up to 225 mg daily for up to 30 months and emphasized that many patients need more than 100 mg daily and that side effects are only infrequently a persisting problem.
    The present study did not attempt to collect objective evidence indicating that doses of baclofen in excess of 80 mg/d are safe or result in increased benefit. However, the results of this retrospective study do suggest that doses in excess of 80 mg/d are used rather frequently in clinical practice and should be considered when more aggressive management of spasticity is indicated. Our study also suggests that adverse effects may only rarely be important as obstacles in determining the best dose.
    Recently, considerable interest has been generated by reports of the efficacy of intrathecal baclofen. 10 While a welcome addition to the management of refractory spasticity, this treatment is expensive, invasive, and prone to complications. We hope that patients being considered for intrathecal baclofen will first be given an adequate trial with oral baclofen