The simple answer is “as long as it’s needed”. There’s no upper or lower limit on the length of treatment. I generally suggest starting with 12 months of treatment and reviewing from there.
Baclofen has been used in patients for over 40 years so we know that it’s safe over the long term. Baclofen’s original use was to relax muscle spasms in patients with conditions like paraplegia, multiple sclerosis and cerebral palsy. These patients would usually take baclofen for the rest of their lives and this could be many decades. So we know there are no harmful side effects from prolonged baclofen treatment.
The length of baclofen treatment needed in alcoholism is not yet well defined. We know that repeated compulsive drinking reinforces the brain’s addiction pathways for alcohol. It becomes both “normal” and important for the brain to seek alcohol. The longer the alcoholic has been drinking, the more brain connections form to reinforce the addictive behaviour and after many years they form a well developed network.
Once the person is no longer drinking in an addictive fashion ie no alcohol or only drinking occasionally, the addictive brain connections progressively wither away because they are no longer being used. It’s like a muscle wasting when it’s not being used. When this process of unpicking the addictive pathway is complete, the brain should react to alcohol in a more “normal”, non-addictive way.
This is a pretty basic explanation but there is neurobiological research to support this reasoning.
However simplistic, it is useful way of looking at how the brain slowly changes when the addiction is no longer being “fed”. It helps patients to understand that the addictive pattern in the brain will not suddenly disappear when they stop drinking. It takes time to undo the changes in their brain and the baclofen supports them while this happens. Patients then have a more realistic idea of the required length of baclofen treatment – it is likely to measure years rather than weeks or months, especially if the alcohol addiction has endured for many years.
The de Beaurepaire study of 100 chronic alcoholics treated with baclofen and followed for 2 years is helpful.
Started with 100 patients
The study started with 100 heavy, daily drinkers. After 6 months of baclofen treatment, all but one of the low risk drinkers was still taking baclofen. By 12 months, a few more were able to stop baclofen and still remain at low risk drinking – that means abstinent or at low levels. By the end of 2 years, half of the original 100 patients were still drinking at low risk levels. Most of them, 40 patients, were still taking baclofen but 10 had stopped their baclofen treatment without relapsing into unsafe levels of drinking. So some patients can stop pretty quickly but most chose to stay on treatment.
So what happens to the dose of baclofen needed by the patient over the years? Does it follow the same pattern as alcohol and benzodiazepines and tend to creep up over time? No, it does the opposite.
In France, we can track this because baclofen has been used to treat alcohol addiction there since 2008. They have shown that the average dose of baclofen drops with time. In a group of patients successfully treated and surveyed in 2012:
The average daily dose of baclofen fell over this 4 year period from 2008 to 2012. Patients who had been taking baclofen for less than 12 months were taking an average dose of 121mg/day. Patients who had started baclofen treatment 3-4 years previously were now down to an average of 77mg per day. Within that group averaging 77mg/day there are 16% who were no longer taking any baclofen and 38% who are taking a small doses of 30-60mg/day. 33% of patients were still at medium doses of 60-150mg per day with only 12% on high doses of 150mg/day or more.
Some patients are keen to get off baclofen when it’s possible but others are in no hurry. They are delighted to have a life without alcohol and they don’t see why they would risk this by reducing or stopping baclofen treatment. Others feel better on baclofen because it helps their anxiety, irrespective of the issue of alcohol cravings.
For patients who do want to come off baclofen, it is worth looking at a range of factors in advising them. The first is the duration of the compulsive drinking pattern. This will affect how long it will take to unpick the brain’s alcohol addiction pathways. The second is looking what lay underneath the alcohol addiction – severe anxiety or traumatic experiences for which the anxiolytic effects of baclofen are valuable. The patient’s current situation is also very important, looking at how much the patient’s life has changed since achieving control over drinking. This includes their overall stability, support networks, social networks and work or other meaningful activities. Also important is whether the patient has strengthened their resilience in the face of adversity eg by successful treatment for anxiety or trauma via medical and non-medical therapies.
Patients who want to reduce their baclofen dose to see if they still need it should do so really slowly. They can start by reducing the daily dose by 10mg over a week. Here’s an example.
This patient taking 100mg per day as four 25mg doses over the day might drop down to 25/20/25/20mg over a week. The reduction can continue at this slow rate if the first dose reduction passed without problems. If at any dose reduction, the cravings for alcohol return, the patient has reached their lower dose limit. Increase the dose back up little until the cravings disappear again and kept steady for another 6-12 months.