Tips for success in the tough cases

SECTION 1: The Empty Life:

These are the saddest but also the toughest. Many longstanding alcoholics have literally lost everything and alcohol is their only companion. In the most extreme cases, they are street homeless, living from social security payments with poor physical and mental health. More common are the alcoholics living alone in precarious or social housing, impoverished both financially and socially by their alcoholism. They no longer have friends or family for support and they cannot see a way out of their lonely life. The alcohol serves to pass the time, dull the pain of past and present problems and stop them thinking about the future. Removing alcohol is often a very mixed blessing.

As one of my patients told me “ I don’t want to get up in the morning. The thought fills me with horror. How am I going to fill up all that time before I can go back to bed if I’m not drinking. If I get up late in the morning, there’s only the afternoon and the early evening to get through and then it’s bedtime again”.

Baclofen cannot fill this void. It creates the void if the treatment is successful. The void has to be filled with connection to others. Connection is an innate need of all human beings and people do not flourish without it. Finding opportunities for connection for very isolated people is challenging but not impossible if the person is willing. AA can be very valuable, especially attending meetings with a regular group and getting an AA sponsor. Another options are Addiction services outpatient programs or community support workers.

Doing volunteer work can be very helpful, particularly when it involves helping other vulnerable people and gives back a sense of self worth. For other patients it can be about identifying a long desired life goal, unfulfilled because of the alcoholism. Unlocking this and working towards it can bring the patient back to life. It can be rediscovering creative or artistic talents or a professional goal like nursing or community work. Here the patient’s lived experience of alcoholism is an asset rather than a negative.

It doesn’t always work. Even with an excellent response to baclofen treatment and community support, some patients don’t move from drinking and isolation. Sometimes it just takes one person who connects with the patient to help them to make the transition back to normal life. Sometimes with even short periods of sobriety, the patient sees a better life as possible and finds the strength to reach out to society again. It is near impossible if their anxiety and cravings are not well controlled.

It is a tragedy of our society that we waste so much human potential. Many people slip through the cracks in critical times of life because the support or treatment is not available when they need it.

SECTION 2: There’s a major trauma behind the alcoholism:

This is also common: there’s a loss which the patient cannot come to terms with and they drink to avoid the pain. Sometimes the patient identifies it readily, often as the trigger for their transition from controlled to uncontrolled drinking. Sometimes it only emerges with time and trust.

Common examples are the loss of parents especially in childhood, loss of partners, siblings, special friends and especially children. Others are traumatic times or events which have destroyed life’s normality: childhood abuse in all it’s forms, physical or sexual assault, abusive relationships, military service, witnessing or being part of traumatic events such as natural disasters. These traumas make the person hypervigilant, anxious and frightened. Alcohol provides rapid and effective relief. It numbs out painful memories and emotions and makes life easier to bear. But it also numbs life’s positive emotions and therefore moving towards recovery.

These patients often get stuck. They are too scared to face the trauma without something to numb their fears but then are too numb to participate in therapy.

It’s frustrating to others around them. The solution seems easy: just do the therapy, sort things out and all will be better.

In reality the prospect of going over the traumatic events can be terrifying because it will bring up painful memories and emotions which the person cannot face. These patients either won’t attend therapy or will turn up intoxicated. If previous therapy attempts have tackled the painful issues too rapidly or have left the patient emotionally traumatised, they will refuse these treatments again.

There is no simple answer – my approach is to first assist in dealing with the anxiety and cravings with baclofen +/- SSRI/SNRI and ensure a good sleep pattern via good sleep hygiene, sobriety and generally medication initially – mirtazapine or melatonin. Getting these right increases the patient’s resilience and lessens their need to self medicate anxiety with alcohol.

The next step for the patient is often learning ways of dealing with painful emotions and anxiety without alcohol – mindfulness, CBT, breathing exercises, meditation. Often patients have learnt these techniques already but found they were not effective when they became acutely stressed/distressed. Baclofen treatment gives them distance between the strong emotions and the impulse to drink so that psychological techniques can be used.

Once they have better control over their anxiety, they can decide whether to broach the painful area. Sometimes this happens naturally through dreams, or gradually letting themselves think about it. Sometimes the issues fade into the background: the patient comes to accept that events have happened but are no longer defining them and they chose to move on. Others patients want to work on these issues because they are still troubling and impacting their life.

Many rehabilitation programs, such as AA, insist that patients must be off all medication to participate, with the idea that the patient must face their fears and issues without the support of medication so they can get to the bottom of them. I think this is too narrow a view. Medication can help patients to feel safe and supported enough to tackle difficult issues.

SECTION 3: The Chaotic Patient:

These patients don’t always take their baclofen regularly nor turn up to appointments every time. It’s hard to keep a track on what is really happening with them so it’s hard to progress the treatment in a steady fashion. They may only come to appointments when they run out of medication. When they come to appointments, it can be difficult to decide whether to increase their dose or not, whether they need a higher dose and whether they would be safe on higher doses. And they don’t respond to goal setting or being told off.

It’s often simply been the way they’ve always lived- maybe the result of an unstable or traumatic upbringing.

There are no easy answers except to keep supporting them with what’s reasonable and celebrate the breakthroughs and the good stuff. Some will slip out of view forever but others will slowly start to see better times and make great gains. I’ve seen both.

SECTION 4: The Boom or Bust Patient:

When they are good, there isn’t a problem in the world but it doesn’t take much to send them back to the bottom. Life is black or white with nothing in between. Their carefree attitude and confidence can make it look like they are going fine but it’s a “house of cards”. These patients lack resilience in the face of any adversity.

It often takes a few tumbles back into drinking to get them to realise this and accept that there is a problem to deal with, not just when they are in the black zone. Seeing a psychologist is the most helpful to work through this, learning to understand why they react to adversity like they do and how to deal with it differently.

They feel intense shame at each relapse and are often reluctant to present early in the relapse, when it’s easiest to deal with. They often don’t want to discuss why it happened. However going through events in detail is important. It’s important that they learn to see each tumble as an “opportunity for growth” because it really is. The information gained from these relapses is very useful for identifying their triggers. This is the only way to learn how to avoid the same pitfalls next time and stop the cycle of relapse.

These patients can be frustrating to start with but persistence often pays off.

SECTION 5: The frail alcoholic:

The cognitively impaired and physically frail alcoholics are the ones you really want to help because they are clearly on a downward spiral from their alcoholism and are on a fast track to death. But they are very hard to help without proper support and this is where it can come unstuck.

Cognitive impairment may be obvious or quite subtle. It often accumulates from a multitude of brain insults – alcohol itself, trauma from falls, nutritional defiencies eg Wernicke/Korsakoff and increasing age. In these patients it is hard to measure compliance and titrate the treatment safely because of a lack of accurate information from the patient.

To have a good chance of success, there needs to be a support person or a supervised environment to ensure the treatment is taken correctly and to observe the effect on drinking. This is often the stumbling block for these patients.

Physical frailty also presents risks for baclofen treatment, especially if the baclofen is titrated up as the alcohol intake comes down. The combined effects of alcohol and baclofen in this titration phase can cause drowsiness and falls. These patients are better of with an inpatient withdrawal on baclofen and then slow titration of the baclofen while sober.

SECTION 6: The patient experiences unpleasant side effects from baclofen:

This group combines patients who have side effects which spook the patient but are manageable and others which don’t go away despite the usual measures of slower and more widely spaced dose increases.

It’s important to point out that most patients will tolerate unpleasant baclofen side effects because they can feel beneficial effects on their anxiety and cravings and are motivated to get off alcohol.

It really helps if patients are well informed about potential side effects, know that they are short lived and have ways of dealing with them using symptomatic treatments like anti-emetics or by reducing the dose back down.

Side effects can be a problem in the initial titration when the increases in dose are relatively large eg doubling the dose from 5mg to 10mg. As the dose rises the increases are proportionally smaller eg from 50mg to 60mg, so there is less of a problem with dose increases.

The other time side effects commonly appear is when the baclofen dose gets into the higher ranges. These side effects tend to be the odd, uncommon ones. It is worth reminding the patient of this if their dose goes over 100mg. If they get a new side effect, they can either

– push on at the same dose and it will generally fade with time or

– drop back to the previous dose and stay there for 5-10 days more before attempting to increase the dose again but more slowly.

Patients need to be aware that they should not stop their baclofen treatment abruptly. They can go back down to their previous dose quickly and this will get rid of the unpleasant side effect within 6-8 hours. If they want to stop the baclofen altogether, they need to take the dose down over 1-2 weeks eg by 10mg per day, depending on the dose. If they drop the baclofen dose too fast or stop it abruptly, they risk having a nasty withdrawal syndrome if they have been on baclofen for more than 2-3 months.