Clinical Experience With Baclofen in the Management of Alcohol-dependent Patients With Psychiatric Comorbidity

A Selected Case Series

G.M. Dore; K. Lo; L. Juckes; S. Bezyan; N. Latt

Disclosures

Alcohol Alcohol. 2011;46(6):714-720. 

In This Article

Abstract and Introduction

Abstract

Aims: To illustrate the potential indications for, and adverse effects of, baclofen pharmacotherapy for alcohol dependence in patients with co-existing psychiatric illness.
Methods: Audit of the files of alcohol-dependent patients treated for comorbid non-psychotic psychiatric illness in a specialist detoxification unit with integrated outpatient treatment. Files were selected of patients who had been offered treatment with baclofen because other alcohol pharmacotherapies had previously been unsuccessful in preventing relapse or were contraindicated.
Results: Of the 21 selected patients, 13 attended for outpatient treatment, with follow-up periods ranging from 4 days to 27 months, and the outcomes could be rated. Prescribed baclofen doses ranged from 30 to 275 mg daily. Common side effects at lower doses included tiredness and sedation; one patient on 120 mg/day developed reversible severe back pain, and a patient taking up to 275 mg/day developed somnolence, dizziness and incontinence. Seven patients maintained significant periods of abstinence, and one patient reduced daily consumption to non-problematic levels. Two patients consumed an overdose of other central nervous system (CNS) depressants, while taking baclofen in the first week of treatment, were briefly unwell, were given emergency monitoring, but made a full recovery.
Conclusion: While more than half the patients reported significant reduction in alcohol use, it is not possible to draw definite conclusions about the effectiveness of baclofen, given that it was combined with other psychiatric and alcohol treatments, and because there was no control or comparison group. We recommend caution when offering baclofen to patients with a history of recurrent overdosing or a history of other substance misuse. When prescribing in conjunction with other medications with CNS depressant action, close monitoring is recommended at initiation and during dose escalation.

Introduction

The gamma-aminobutyric acid (GABA)-B receptor agonist, baclofen, is a muscle relaxant introduced in the 1960s for the treatment of muscle spasticity due to spinal cord injury, multiple sclerosis and cerebral injuries resulting in spasticity (Dario and Tomei, 2004; Leo and Baer, 2005). Recent randomized controlled trials (RCT's) have also found baclofen to be effective in treating patients with alcohol dependence (Addolorato et al., 2002, 2007, 2011). The anti-craving and anti-reward effects of baclofen appear to relate to its agonist effect on GABA-B receptors in the ventral tegmental area, which are reported to control the activity of mesolimbic dopamine neurons, one of the major pathways in the regulation of the reinforcing properties of drugs of addiction (Addolorato et al., 2002; Colombo et al., 2004).

The Addolorato studies found doses of 10 mg three times daily (tds) to be effective and well-tolerated, even in patients with significant liver disease. Addolorato et al. (2011) also found provisional evidence of a dose–response effect, with the effect of baclofen 20 mg tds being greater than baclofen 10 mg tds. Individual case reports (Ameisen, 2005; Bucknam, 2007) have documented reduction and suppression of cravings for alcohol with much higher doses of baclofen, up to 270 mg daily, but such high doses have not been systematically studied.

A meta-analysis by Bouza et al. (2004) outlines the effectiveness of naltrexone and acamprosate as adjuvant treatments for alcohol dependence in adults, with a moderate effect size. Both drugs are safe and reasonably well-tolerated, although high levels of non-compliance with treatment are common. However, most studies select medically stable patients with no other comorbidities or dependencies. At the same time, the literature indicates that comorbid psychiatric disorders are common with alcohol dependence (Regier et al., 1990; Kessler et al., 1994) and these disorders often predict a poorer prognosis and a shorter time to relapse into drinking (Rounsaville et al., 1987; O'Sullivan et al., 1988; Murphy et al., 1992; Cornelius et al., 2003).

No studies have yet investigated the potential effectiveness and safety of baclofen in improving drinking outcomes in patients with comorbid psychiatric disorders. Preliminary reports have indicated its potential usefulness in improving psychiatric symptoms, with reports of baclofen improving panic symptoms, Post-traumatic stress disorder and state anxiety (Breslow et al., 1989; Krupitsky et al., 1993; Addolorato et al., 2002; Drake et al., 2003; Ameisen, 2005). Agabio et al. (2007) reported almost complete suppression of alcohol use in an alcohol-dependent patient with schizophrenia, on 75 mg of baclofen daily.

In this paper, the authors summarize their clinical experience with the use of baclofen in a selected group of patients with alcohol dependence and comorbid non-psychotic mental illness, through retrospective file audit. Tolerability and safety of this medication in a group of complex patients on other psychotropic medication were of particular interest.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....