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

Patients and Methods

All patients described in this case series required admission to a 15-bed inpatient withdrawal ('detoxification') unit, which provides a Statewide service for patients with a comprehensive range of substance use disorders.

In 2008, pharmacotherapy options for alcohol dependence prescribed after withdrawal included acamprosate, naltrexone and disulfiram. Patients were discharged on one or more of these medications as part of a comprehensive aftercare programme, including counselling, rehabilitation, medical review and recovery groups.

In 2009, baclofen was introduced as an alternative pharmacotherapy for patients reluctant to use or unable to afford disulfiram (not subsidized in Australia), and with limited response or contraindications to the use of other pharmacotherapies. Pregnant patients and those with a history of epilepsy were excluded from baclofen treatment. Precautions taken to limit the risks of intoxication, suicide attempts and/or adverse side effects included provision of limited medication supplies at discharge (weekly pharmacy dispensing), initiating treatment with low doses, gradually titrating the dose upwards and regular outpatient monitoring.

Baclofen was initiated once the patient had undergone alcohol withdrawal, usually 3 or more days after the last drink. The dose prescribed was 5 mg tds for 3 days, then 10 mg tds as the usual maintenance dose. The final stabilization dose of baclofen prescribed was at the discretion of the treating clinician, based on clinical response including side effects. Adverse reactions to baclofen were recorded, including reasons for discontinuation of treatment. All patients were offered a comprehensive treatment programme after withdrawal, including individual counselling and medical review. Patients were also encouraged to attend Alcoholics Anonymous (AA) and rehabilitation.

Of the 541 admissions to the unit in 2009, 288 were for patients with alcohol dependence (Fig. 1). Of these 288 admissions, 126 patients had one or more non-psychotic comorbid mental health disorders, in the form of depressive disorder, anxiety disorder/s and bipolar disorder.

Figure 1.

Diagram on selection of alcohol-dependent patients for baclofen treatment.

Of these 126 patients, (a) 57 had no previous treatment with alcohol pharmacotherapy, and selected acamprosate, naltrexone, disulfiram or no treatment, with General Practitioner review after discharge; (b) 18 patients had had prior pharmacotherapy and selected one of these options with General Practitioner review; (c) 30 patients were inaccessible for follow up (lived outside the local catchment area, were transferred to rehabilitation centres or refused follow up); (d) 21 patients had prior unsuccessful treatment with and/or contraindications to standard alcohol pharmacotherapy, had received a range of other alcohol treatment modalities, were on concurrent psychotropic medication, were available for clinic follow up and provided informed consent for treatment with baclofen. These patients were provided with detailed information about baclofen, including the risks and benefits, and recent studies of baclofen in alcohol dependence. Four of these patients had other coexisting substance use disorder/s, including two on opioid substitution treatment.

The following demographic and clinic data were collected: age, gender, severity and duration of alcohol dependence, baseline alcohol use, previous treatments, alcohol-related problems, comorbid medical and psychiatric conditions, other substance use disorders, psychotropic medication, psychosocial and forensic history, duration of follow up and alcohol consumption at follow up.

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