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

Results

Eight of the 21 patients were lost to clinic follow up. Five of these patients transferred to their General Practitioner or a residential rehabilitation service for follow up, while a further three patients offered clinic follow up did not attend appointments.

Thirteen patients attended for comprehensive outpatient care (Table 1), with a mean age of 49 years (range 41–62 years). Ten patients were male and three female. The mean duration of alcohol dependence was 15 years (range 2–32 years). Baseline daily alcohol consumption ranged from 110 to 400 g daily. Thirteen patients had a depressive disorder and eight of those also had a co-existing anxiety disorder (including Post-traumatic Stress Disorder, Generalized Anxiety Disorder, Social Anxiety Disorder, Panic Disorder). Nine patients reported significant suicidal ideation prior to treatment. Patients were on a range of psychotropic medications, as outlined in Table 1.

Follow-up periods ranged from 4 days to 27 months, with two patients relapsing immediately after discharge, both non-compliant with baclofen. Alcohol consumption during follow up is outlined for each patient in Table 1, indicating total number of drinking days for the follow-up period, as well as amounts of alcohol consumed during those drinking days. The term 'relapse' is used to indicate a return to drinking at pre-treatment levels.

Baclofen doses prescribed by the clinic ranged from 30 to 275 mg daily, administered in three divided doses. Of note, patient 5's General Practitioner independently reduced the baclofen dose to 10 mg daily, adding naltrexone 50 mg daily.

Side effects ranged from mild and transient at lower doses to more problematic at higher doses. The most common side effects were tiredness and sedation. Several patients reported a gradual reduction in anxiety as a positive side effect. One patient developed severe back pain at doses of 120 mg and above, despite no evident spinal pathology. The pain resolved completely with cessation of the drug, and was only mild in nature when baclofen was reinstated. The other patient noted increased tiredness and somnolence, with occasional bedwetting and dizziness at 275 mg of baclofen, and at times he felt close to fainting. These symptoms settled on doses of 200–250 mg, with limited return of cravings. This patient is described in detail below.

Two patients experienced an overdose of other central nervous system (CNS) depressants in combination with baclofen in the first week of treatment, both requiring emergency review, with full recovery. One of these cases is described in detail later.

Case 1

Mr A (Patient 2, Table 1), a 44-year-old single man, had a 16 year history of alcohol dependence, drinking 150–300 g of alcohol daily. A previous 6-months period of abstinence was associated with severe alcohol cravings. Acamprosate had been ineffective. Psychiatric history included depression with chronic suicidality, and panic attacks with agoraphobia. Mr A could not attend AA due to disabling panic attacks when he left the house. While Mr A reported a reduction in cravings and alcohol consumption on baclofen 175 mg daily, drinking continued at 150 g daily. Baclofen dose was gradually titrated to 275 mg daily with weekly reviews, at which point all cravings for alcohol were suppressed, despite exposure to previous drinking cues. At this dose, Mr A experienced increased tiredness, somnolence with occasional bedwetting and dizziness, which led him to feel he might faint. He was able to maintain abstinence on lower doses of baclofen, but found that cue-related cravings were more evident with baclofen doses below 200 mg daily. Ongoing major depression and severe panic attacks required treatment with mianserin and alprazolam as well as cognitive therapy. Mr A has been abstinent from alcohol for 16 months.

Case 2

Mr B (Patient 12, Table 1), a 47-year-old male beneficiary, presented with a 7-year history of alcohol dependence, drinking 240 g of alcohol daily at presentation. Mr B had multiple previous detoxification and rehabilitation admissions, as well as unsuccessful treatment with acamprosate. Mr B had a history of chronic opioid dependence successfully managed with methadone then buprenorphine, and was Hepatitis C positive. At presentation, he was injecting methamphetamine fortnightly and was abstinent from illicit opioids for many years. Psychiatric history included borderline and antisocial personality disorder, and he was on venlafaxine XR 225 mg daily. Chronic suicidal ideation had resulted in multiple suicide attempts, but none recently. Mr B was stabilized on baclofen 10 mg tds. He reported acute anxiolytic effects at this dose, rapidly escalating the dose in the first week of treatment, without consultation. After taking 80 mg of baclofen over 90 min in combination with prescribed buprenorphine and venlafaxine, as well as diazepam he had at home (dose unknown), he became sweaty, dizzy, ataxic and disoriented. He collapsed briefly and required emergency department admission overnight, with full recovery. Mr B denied this was a deliberate overdose, denied alcohol use and said he escalated the dose for its anxiolytic effects. Daily doses of baclofen were arranged through a pharmacy. He reported no alcohol use when on baclofen, because of the reduction in his anxiety. Mr B disengaged from treatment after further requests to increase the dose were refused, obtaining baclofen from a different doctor and pharmacy. Within a month he was hospitalized for alcohol withdrawal.

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....