What is the role of baclofen in maintaining abstinence in a patient with a history of ethanol (alcohol) abuse and psychotic symptoms?

Baclofen for Alcohol Abstinence in Patients with Psychotic Symptoms

Baclofen is an appropriate choice for maintaining alcohol abstinence in patients with alcoholic liver disease, but requires careful monitoring when psychotic symptoms are present, as haloperidol (not baclofen) should be used to manage acute psychotic symptoms during withdrawal. 1

Role of Baclofen in Alcohol Abstinence

Baclofen (30-80 mg/day) is specifically recommended for maintaining abstinence in patients with alcoholic liver disease and cirrhosis, where it has demonstrated both safety and efficacy. 1, 2, 3

Evidence for Efficacy

• Baclofen likely reduces the risk of relapse to any drinking (RR 0.87,95% CI 0.77-0.99) and increases percentage of days abstinent by approximately 9% compared to placebo, with this effect being most robust in detoxified patients 4
• The medication works as a GABAB receptor agonist that reduces alcohol craving and maintains abstinence over 12-week treatment periods 1, 3
• Baclofen does not increase adverse events, treatment dropouts, or dropouts due to adverse events compared to placebo 4

Specific Advantages in Liver Disease

Unlike naltrexone (which can cause hepatocellular injury), baclofen is considered safe in patients with alcoholic liver disease and cirrhosis, making it the preferred pharmacological option in this population. 3

• Randomized trials specifically in cirrhotic patients have demonstrated both safety and efficacy for promoting abstinence 3
• Biochemical markers of liver injury (GGT, ALT, bilirubin) show significant improvement after 12 months of baclofen treatment in patients with alcohol-related liver disease 5

Dosing Strategy

Start baclofen at 30 mg/day (divided doses) and titrate gradually up to 80 mg/day based on tolerability and response. 3

• The standard dosing range is 30-80 mg/day, with 80 mg/day being the maximum recommended dose with marketing authorization 3
• For patients with severe liver disease, use more gradual dose titration 3
• Higher doses (above 100 mg/day) have been reported but require close medical supervision and are not routinely recommended 4, 6
• Never discontinue baclofen abruptly due to potential withdrawal symptoms 3

Critical Considerations for Psychotic Symptoms

Baclofen does not treat psychotic symptoms—haloperidol (0.5-5 mg PO every 8-12 hours or 2-5 mg IM) should be used as adjunctive therapy for agitation or psychotic symptoms such as hallucinations that are not controlled by benzodiazepines during acute withdrawal. 1

Management Algorithm for Patients with Psychotic Symptoms:

1. Acute withdrawal phase with psychosis: Use benzodiazepines as first-line for withdrawal symptoms, add haloperidol specifically for psychotic symptoms (hallucinations, agitation) 1

2. Post-detoxification maintenance: Initiate baclofen for abstinence maintenance once withdrawal symptoms have resolved 1, 3

3. Ongoing psychiatric management: Psychiatric consultation is mandatory for evaluation, treatment, and long-term planning of alcohol abstinence in patients with comorbid psychiatric illness 1, 2

Important Safety Caveats

Exercise extreme caution when prescribing baclofen to patients with a history of recurrent overdosing or other substance misuse, as baclofen combined with other CNS depressants can cause severe sedation. 7

• Common side effects include fatigue, dizziness, somnolence/sedation, dry mouth, paresthesia, and muscle spasms 4
• Two patients in one case series consumed overdoses of other CNS depressants while taking baclofen during the first week of treatment, requiring emergency monitoring 7
• Close monitoring is essential at initiation and during dose escalation, particularly when combined with other medications having CNS depressant action 7

Comprehensive Treatment Approach

Baclofen must be combined with psychosocial interventions including individual psychotherapy, psychoeducation, group therapy, and cognitive behavioral therapy. 2, 3

• All patients with alcohol use disorder require thiamine supplementation (100-300 mg/day for 4-12 weeks) to prevent Wernicke encephalopathy 1, 2
• Treatment duration should be at least 12 weeks, with many patients requiring longer-term therapy 4
• Adherence to baclofen is generally good, with 53-55% of patients maintaining complete abstinence at 12 months in observational studies 5