Abstinence or Social Drinking on Baclofen?

The traditional view is that alcoholics will always be alcoholics and will never be able to drink in a normal or safe way. This is certainly the view of AA with its dogma of strict life long abstinence. There is logic to this because most alcoholics using AA’s method will be fighting against strong cravings to stay sober and if they drink any amount of alcohol, will rapidly fall back into heavy drinking. It therefore makes sense to have a clear message of strict sobriety.

However it’s long been known that after a period of sobriety, some alcohol addicted patients can maintain a long term pattern of social drinking. However the majority cannot do this. If they start drinking alcohol again, they will return to uncontrolled drinking, either immediately or gradually over weeks to months. Some exhibit control over their intake initially but the old habits and addiction pathways in the brain are rapidly resurrected.

The current anti-craving medications, acamprosate and naltrexone, have weak or no anti-craving effects for most patients trying them. Prior to starting them, patients need to be abstinent from alcohol for 5-10 days. Even then, the improvement in abstinence rates seen between these medications and placebo is only 10%.  With only this weak effect, it’s unlikely that naltrexone or Acamprosate would allow alcohol addicted patients to drink normally.

So is it different with baclofen?

Yes, it can be. Baclofen is the only anti-craving treatment which is started while patients are still drinking at their usual levels and is able to bring the majority of patients to abstinence. So patients chose not to drink, even when alcohol is allowed.

Olivier Ameisen, who discovered baclofen for this use, described having the occasional alcoholic drink and not wanting to consume more alcohol on that occasion or after. This pattern is commonly described by patients on baclofen in France. About half of French patients aim for occasional drinking rather than abstinence because drinking is very much woven into the fabric of family and social life in France.

This diagram from the French baclofen users forum Aubes shows the final drinking pattern of 415 patients who consider themselves be successfully treated with baclofen (link). Just over half the patients drink occasionally while a quarter are abstinent. That leaves 16% who are still drinking daily.


So what should be the aim of baclofen treated patients?

The reality is that it’s pretty much impossible to predict in advance where any individual will end up – needing to stay sober or able to drink occasionally. It’s more complex than simply deciding what the outcome should be.

It’s a matter of taking the journey and seeing where it ends.

Amongst my patients, some start with the aim of drinking occasionally because they cannot imagine how their social or professional life would function in the complete absence of alcohol. However many find that they prefer to be sober when they are able to freely decide. They now find drinking alcohol is much less pleasurable than before and that having a social life without alcohol is not actually hard.

Many patients try drinking early in their treatment, when their brains’ addiction pathways are still strong, and it usually escalates into uncontrolled drinking, particularly if they drink alone or as a reaction to stress. That’s not social drinking, it’s falling back into the old pattern.

My opinion is that it IS feasible to drink occasionally or at safe levels on baclofen. However this is not a place half way between heavy drinking and normal drinking. It has to be truly normal drinking ie freely chosen and in social situations – not driven by cravings, compulsion or using alcohol as a quick fix for pain or stress.

It generally takes time to get to this situation, months or years. From a neurobiological perspective, the addiction pathways need to be well controlled by baclofen and their strength diminished by a period without compulsive drinking. It also requires patients to work on their drinking triggers such as anxiety and relationship issues. They need to have good self awareness and a stable social and work situation.

My advice to patients who want to try social drinking for the first time is to select an occasion when there are friends or family around and talk honestly about the experience with someone trusted afterwards. The patient needs to be honest – if drinking alcohol is reigniting old desires then they are not ready for social drinking.