Why does baclofen fail in some patients?

SECTION 1: INTRODUCTION

Why does baclofen fail in some patients?

Baclofen is very effective in significantly reducing cravings for alcohol in the majority of patient. This is my experience and that of the more experienced French prescribers who describe reduced craving over 90% of their patients. However this does not always translate into the patient being either abstinent or at low, safe levels of alcohol intake.

These are three major reasons why baclofen treatment fails:

  1. Bad side effects
  2. Drinking continues despite no cravings
  3. Stops taking the baclofen or doesn’t take it regularly

SECTION 2: Bad side effects:

Baclofen potentially has a lot of side effects and these range from common, such as nausea, dizziness, tiredness and sleep disturbance to rare, unusual problems such as hallucinations, paraesthesia (tingling) of the limbs, tinnitus, confusion and mania.

The common side effects from baclofen like nausea and tiredness generally appear when the treatment is started or the dose is increased. They last a couple of days then disappear despite continuing the treatment. The faster the dose is increased, the greater the risk of side effects. This is why a slow initial titration is strongly advised.

Other side effects like tinnitus or confusion tend to appear when higher baclofen doses are reached, usually over 100-150mg per day.

As this patient group often has underlying anxiety, they can get really spooked by side effects although the anxiolytic effect of baclofen can mitigate this.

The important information for the patient is that there are potentially lots of side effects from baclofen but that they will go away and leave no lasting effect. In most cases it’s enough to leave the baclofen at the same dose, provide symptomatic treatment or reassurance and wait for the side effect to go.

However for more distressing side effects like hallucinations or parasthesias, the baclofen dose needs to be reduced straight back down to the previous dose so that it disappears. When the side effect has gone and another 5-10 days has passed, the dose can be very slowly increased again and the side effect will generally not reappear. In most cases, it is simply a matter of going slowly enough to allow the brain to adapt to the increased dose without precipitating unpleasant effects.

Other patients will want to stop baclofen treatment because of side effects which they are embarrassed to discuss such as sexual dysfunction or continence problems.  It is worth asking about these directly when the reason for wanting to stop the baclofen is not clear.

However a small group of patients have genuinely intolerable side effects and therefore cannot get to a dose of baclofen sufficient to suppress their cravings. Examples are severe diarrhoea and urinary incontinence.

Other side effects may be very disturbing to the patient although benign in nature, but the patient is frightened by them and does not wish to continue baclofen treatment.

More experienced prescribers will tend to do better with these cases, being more familiar with the range of side effects and are able to provide reassurance and ways to deal with them to avoid treatment cessation.

SECTION 3: Drinking continues despite no cravings:

Some patients continue to drink alcohol despite baclofen having an excellent effect on suppressing their cravings. There are two main reasons for this.

  1. The role and rituals around alcohol in their life.
  2. The refuge from life which alcohol provides.

The role and rituals around alcohol in their life.

The first concerns the role of alcohol in the fabric of their life. This may be the rituals around social and professional life. An example is where drinking alcohol is an expected and valued part of gatherings with friends or family. Drinking may be part of their work culture – for example working in the hospitality industry or in a job requiring “wining and dining” of clients. The patient may also get great enjoyment out of alcohol and, while aware of it’s harmful effects, cannot envisage a life of sobriety.

While most alcohol addicted patients have come to detest alcohol and wish to be sober, others reject this vision and see treatment for their alcoholism as leading them to a life which is simply not worth living.

Once this problem is uncovered, the discussion can turn towards reduction rather than cessation of alcohol, about getting back control of their drinking. Most will understand that they are drinking too much for their health. Baclofen is often used in France to reduce alcohol intake to safe levels, usually occasional drinking, rather than abstinence. Baclofen has a powerful enough anti-craving effect that some alcohol addicted patients can drink in a normal pattern for their peer group.

Some patients start baclofen with the intention of aiming for controlled drinking but realise that they actually don’t like alcohol anymore and that not drinking is not as socially or professionally troublesome as they expected. These patients often end up abstinent by choice.

The refuge from life which alcohol provides.

For many patients, alcohol helps them to deal with an unpleasant past and/or present and a frightening future. It calms anxiety and numbs negative emotions such as sadness, regret, guilt, shame and fear and makes it easier to live day to day. Alcohol also occupies a lot of time when life is lonely, scary or without purpose.

For such patients, life without alcohol is a frightening place. Not only do they have to face the day to day stresses of life but also the full brunt of their anxiety, their painful experiences of the past and the realisation of how impoverished their life has become because of their alcoholism. This loss is not only financial.  More important is the loss of connection with others – friends, family, professional.

Such patients find baclofen treatment yields a very mixed result – they appreciate the anxiolytic effect of baclofen but don’t like life without the refuge of alcohol. When on baclofen, they often relapse into drinking in the face of stressful events. The key is persistence in getting them back on track quickly when they relapse, treating underlying anxiety with medication and psychological techniques simultaneously and, most importantly, helping them to get reconnected socially – this might be volunteering, AA meetings, study, retraining or work  – to put positive experiences, friendship and hope back into their lives.

Baclofen is certainly not a miracle cure for such patients but it’s combined anti-craving and anxiolytic properties can kickstart the process of rebuilding a life.

It’s easier to help patients early in their path of alcohol addiction, before too much of their life is destroyed.

SECTION 4: the patient stops taking the baclofen or doesn’t take it regularly.

Baclofen treatment only works if it’s taken regularly. It’s a very short acting medication so needs to be taken multiple times a day. Some patients simply don’t take the baclofen regularly enough to give it a chance to really work. There are a number of reasons to look out for:

Chaotic/disorganised/busy:

They mean to take it but often forget. In the tech savvy patient, reminder messages can be programmed onto their phone. Other strategies are a dosette box or Webster pack, especially if the patient takes other medications.

Resistant:

They don’t really like being reliant on medication or having to take pills. Discussing this may help.

Pushed into treatment:

They are doing this for someone else and not motivated themselves. Sometimes there is a passive aggressive element where forgetting baclofen is the weapon of choice.

Prefer other treatments:

They simply prefer alcohol or benzodiazepines so want the baclofen therapy to fail so they can justify going back to them.

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