SECTION 1: Introduction
This section discusses additional treatments which can help alcohol addicted patients on baclofen treatment. Alcohol addiction is complex and while baclofen is very helpful, other treatments are often needed to address other aspects of the problem. The best combination of treatments varies between patients but here are some of the common ones:
- Help to get good quality, restorative sleep.
- Long acting anti-anxiety treatments.
- Social support and connection with others.
- Addiction Services counselling.
- Psychological therapy.
- Getting back into meaningful activities.
SECTION 2: Help to get good quality, restorative sleep:
Patients with alcohol addiction usually have very poor quality sleep. They often use alcohol to get to sleep but typically wake several hours later and then struggle to stay asleep. They either drink again to get back to sleep or toss and turn for many hours, finally falling asleep again around dawn.
My practice is to actively manage sleep with medication in the first phase of baclofen treatment. This can be for a brief time, 1-2 weeks until the natural sleep pattern is restored, or for longer, until the patient’s alcohol intake has stopped and life has become more stable. Sleep is a vital respite from the challenges of the day and gives the patient resilience in the face of stress and anxiety.
In some patients, the evening or bedtime dose of baclofen relaxes the patient enough to sleep easily, especially if the alcohol intake is reduced or has stopped. For others, this is either insufficient or baclofen disturbs rather than aids sleep when taken late in the evening.
My commonest choice for night sedation is mirtazapine, 30mg at bedtime (range 15-60mg). Its sedative effect provides reliable, pleasant sleep without onerous morning drowsiness. It also has anxiolytic effects which are useful in the anxious alcohol addicted patient and has antidepressant effects which can assist with low mood. Mirtazepine doesn’t have serotonergic effects so can be combined with SSRIs and SNRIs if these are required for additional anxiolytic or antidepressant effect.
The commonest side effect of mirtazapine is increased appetite. This is useful for some patients and is initially hard to distinguish from the normal return to good eating as the alcohol intake decreases. However some patients develop an unstoppable desire to eat, especially during the night, and this necessitates ceasing the mirtazepine.
An alternative with somewhat less effect on appetite is mianserin, 30mg at bedtime (range 15-60mg). Mianserin can also be used in combination with SSRIs or SNRIs without causing serotonergic syndrome.
Another option is melatonin, the natural hormone of sleep. It helps to reset normal sleeping patterns when taken at a dose of 5-10mg at bedtime. It’s an expensive option as it needs to be made at a compounding chemist at a cost of $50-$90 for 100 capsules. The PBS subsidised preparation of melatonin is only 2mg and this seems to be insufficient for effect.
Amitriptyline is an alternative for patients who overeat on mirtazapine and mianserin. It’s reliably sedative at 10-25mg at bedtime but has unpleasant side effects of morning drowsiness, daytime fatigue, dry mouth and constipation. These effects will lessen with continuing use. However amitriptyline cannot be used with SSRI/SNRIs because the combination can precipitate serotonergic syndrome with disagreeable symptoms of agitation, anxiety and tremor.
I avoid using benzodiazepines or anti-psychotic medications for night sedation. Both have significant issues which make them less than ideal, especially for long term treatment.
SECTION 3: Long acting anti-anxiety treatment:
Baclofen has substantial anxiolytic effects but it is a short acting medication, lasting 4-6 hours only. Many anxious alcohol addicted patients need smoother control of anxiety than baclofen alone will give. My first choice is using mirtazapine because it also helps sleep. However mirtazepine is not always sufficient to stabilise anxiety or cannot be used because of side effects. The addition of an SSRI or SNRI may be indicated although it will take around 6 weeks for the full anxiolytic effect to occur.
My commonest choice is escitalopram but if another SSRI has been effective for anxiety for the patient, I continue or restart that one. The effectiveness of any one SSRI/SNRI is highly variable between patients so it can take trying a few to find a suitable one. I generally avoid fluoxetine because of its long washout period which makes switching antidepressant a lengthy process. The SNRIs like duloxetine, venlafaxine and desvenlafaxine can either improve or worsen anxiety but are very anxiolytic in some patients.
For some highly anxious patients who either cannot tolerate or don’t respond to these treatments, I try other anxiolytic agents on top of the baclofen. Options are topiramate, pregababin or gabapentin. I tend to add these in first to get control of the anxiety, then titrate down the less effective or less desirable medications like benzodiazepines, antipsychotics or antidepressants to leave the minimum effective number and dose of medications.
SECTION 4: Social support and connection with others:
The social situations of alcohol addicted patients encompasses the whole range. For some there is excellent support but for others the support available is toxic, unhelpful or punitive. There can be disengaged social networks or support reduced to only one person. The worst off are isolated patients whose social ties disintegrated many years previously.
The families and friends of alcohol addicted patients take a severe battering over the years from the effects of the patient’s alcoholism. By the time the patient agrees to help the family are often exhausted, distrustful and desperate. They need support themselves and assistance to understand how to best help. The balance between support and control can be hard to achieve. Some families try to take control over the patient’s life to keep them safe and get them treated but this can be counterproductive as the patient rebels against this by drinking.
Some patients need a new environment to rebuild their life –through a rehab program, living in supported accommodation or actively participating in a treatment program through addiction services, AA or church. This can take pressure off the entourage trying to help the patient and restore more normal relationships.
Patients with little social support can be very difficult to help but here again, regular attendance at AA meetings, church groups, counselling groups and getting back into some type of activity such as voluntary or paid work are ways to meet and be with others. A companion animal can also help.
The importance of social connection cannot be overemphasised. It is a basic, vital need of all human beings. Finding social connection and meaningful activity in life are key to the long term success of addiction treatment.
SECTION 5: Addiction Services counselling:
These are outpatient programs with group and/or individual counselling. The counsellors are generally recovered addicts who are well aware of the issues which face their clients on their road to recovery.
Addiction services often also have groups to teach alternative ways to alcohol in dealing with stressful situations or cravings. These techniques include relaxation and breathing exercises, Mindfulness and meditation to improve resilience in the face of stress.
Addiction services are also a place where patients can find social contact with other patients who share the same problems.
SECTION 6: Psychological Therapy:
This can be to learn specific techniques such as Cognitive or Dialectical Behavioural Therapies (CBT or DBT) which aim at changing the way a person thinks and behaves from unhealthy and unhelpful patterns to more adaptive ones.
The other indication for psychological therapy is when there are specific issues underlying the anxiety or alcohol addiction which the patient wants to deal with. It can be something obvious from the patient’s life story such as childhood or later traumas. There are specific treatments for PTSD such as EMDR therapy. Or sometimes the problem is longstanding, unhelpful patterns of behaviour in relationships with others, personal or professional.
It can take time for the patient to realise that this type of help is needed and patients shouldn’t be pushed or rushed into it. This can be traumatic and counterproductive. The underlying issues may be uncovered by analysing the events around relapses and reflecting on how the pattern of response is problematic or unhelpful. Essential to the success of such therapies is that the patient wants to change something and feels comfortable and safe with the psychologist.
This area is further discussed in the section “Tips for sucess in the Tough Cases”.
SECTION 7: Getting back into meaningful activities:
This encompasses both personal and professional activities. Reconnecting with family and friends is of primordial importance to the recovering alcohol addicted patient.
Supporting the patient to retain or return to a professional activity brings many benefits: giving back structure in the day, social contact, a sense of worth and wages.
For others, a slow or graded return to work is needed. This may be via voluntary work, part time work or work below their level of previous competence until life becomes more stable.
Some patients are unlikely or unable to get back into any form of work but finding activities which are meaningful and provide social contact make a life without alcohol worth living.