Baclofen

"No medication works effectively for everyone, and baclofen is surely no exception... So far it seems to work in all types except for one, and that’s people who turn up once and don’t come again. But it’s not one size fits all; you have to refine it. Not to say that I’m a great doc, but every time I’m on the case I’ve yet to find a patient where it’s not a success. I’ve been playing with this medication for 10 years."

- Dr. Olivier Ameisen

Baclofen, like any medication, induces a variety of different responses in every new person that takes it. Some people report life-changing differences even at small doses, while others see no discernible changes; some people have intolerable (yet temporary) side effects, while most have none; some people don’t even notice that they’re drinking less and less and find themselves shocked at how much they’ve naturally reduced over time. Everyone’s reaction to baclofen is unique to their own biology and lifestyle.

Although baclofen has been used extensively for decades for muscle spasticity, so we have a lot of data on its potential side effects, it is now off-patent and its use for alcohol treatment is off-label, so there’s little financial incentive for pharmaceutical companies to fund studies into its effectiveness. This means that, until recently, there were very few legitimate, large-scale studies into baclofen’s efficacy as an addiction treatment. Luckily, alongside baclofen’s surge in popularity in Europe, Australia, and numerous other countries, there has been a marked increase in the amount of research being done.

Clinical trials

Conflicting Evidence

On the other hand, there are studies that found baclofen’s efficacy to be minimal. All of these have at least one obvious methodological flaw or difference of treatment, explaining the discrepancy, but they’re worth discussing nonetheless. Two other, smaller studies presented alongside the Bacloville study at the Berlin World Congress on Alcohol and Alcoholism concluded that baclofen showed little difference with placebo:

The results of baclofen treatment studies over the past few years have been remarkable, but skepticism is natural: can a simple pill really treat a problem that has plagued mankind for millenia so effectively? It’s important to recognize what baclofen is and isn’t capable of; baclofen suppresses cravings, urges, and subliminal trigger responses for alcohol in the human brain. While cravings are usually the primary symptom of AUD, baclofen has no control over the original cause: your environment. The root cause of excessive drinking almost always lies in environmental factors: maybe you learned as a teenager that alcohol can make you more confident and sociable, or you formed a habit of drinking every night to unwind from a stressful work environment. The key to highly effective baclofen treatment is to take advantage of baclofen’s suppression of subconscious urges to work on unwinding your habit loops, dealing with environmental stressors, and getting better acquainted with your brain’s habit and reward circuits.

How long does baclofen take to work?

Excessive drinking is a long-term problem, which has often been reinforced by years or even decades of habitual drinking — it can’t be solved overnight. When Dr. Olivier Ameisen first experimented with baclofen for alcohol treatment on himself, it took him 2 years to achieve his effective dose, but the effects were remarkable. Since then, more research has been done into baclofen titration, and LifeBac clients generally find their effective dose within 3 months under our personalized titration plan.

The duration of the pattern of excessive drinking, and the amount of alcohol consumed, are the most significant factors in determining how long baclofen treatment should last. The longer you’ve been regularly drinking, the stronger your neural pathways that reinforce habitual drinking have become. Just as it takes time to establish and reinforce these pathways, it will take time to reverse the damage that’s been done and return to a non-addictive relationship with alcohol.

Our experience

After reaching their effective dose, members remain there for about 3 months. During this time, our success coaches take advantage of your lack of alcohol cravings and reduced drinking to guide you through identifying the underlying causes of your excessive drinking, rewiring your neural pathways, and replacing unhealthy habits and routines with productive alternatives.

After that, you’ll begin to reduce your dose of baclofen, staying vigilant for the return of cravings and pausing your reduction if they do return. Upon finding a lower dose at which they’re still able to maintain their goals, most people choose to continue taking baclofen indefinitely.

Others find that, after participating in our habit-change program and meeting their drinking goals for many months, they can maintain healthy drinking levels without needing to continue baclofen treatment. As with every part of our program, you are in complete control; how much baclofen you take and how long your maintenance phase lasts is entirely up to you.

Clinical trials

Studies performed on high-risk drinkers undergoing baclofen treatment only — independent of any psychological treatment or habit-change guidance — can show us how baclofen use over time works in the most extreme circumstances, but in-depth studies on less severe drinkers or including additional treatment have yet to be published.

Another study conducted in 2012 looked at how successful baclofen patients reduced their baclofen dose in the years following their initial treatment. 3-4 years after the start of treatment, 38% of patients had titrated down to a small daily maintenance dose (25-50% of their maximum dose), and 16% had stopped taking baclofen entirely while maintaining their progress.

Baclofen was introduced for sale in 1974 as an antispasmodic medication to reduce muscle spasticity caused by issues in the brain or spinal cord. Its lack of severe side effects made it an excellent alternative to the most popular antispasmodic at the time, Valium. Baclofen quickly caught on and has now seen widespread use for the past 45 years in patients with spinal cord injuries, ALS, and multiple sclerosis.

Baclofen’s use in reducing alcohol consumption was discovered around the year 2000, when the French Dr. Olivier Ameisen, who was himself a severe treatment-resistant alcoholic who had been given five years to live, prescribed himself baclofen and eventually described himself as “completely and effortlessly indifferent to [alcohol].” Baclofen now has hundreds of thousands of users in France, over 10,000 prescribing physicians, and is the first-line treatment for over-drinking, but is still gaining traction in the United States. Baclofen reduces or even eliminates the cravings and withdrawal symptoms associated with reducing your drinking. It has no impact on your body’s response to alcohol, like Antabuse, and is most effective when taken in several doses targeting drinking time.

GABA and its analogs

The human brain contains GABA receptors which, when bound with a neurotransmitter called GABA, regulate feelings of fear or anxiety, among other things. Alcohol is so similar to the GABA neurotransmitter that it can actually take its place and bind with GABA receptors in the brain when we drink — that’s why alcohol can give us more confidence by reducing anxiety and fear. When drinking heavily and consistently, however, alcohol works so well as a GABA agonist that the brain slowly stops producing actual GABA, allowing alcohol to take its place. When problem-drinkers then try to cut back or quit, the brain isn’t capable of making the proper amount of GABA, which can cause anxiety and depressive symptoms as well as intense cravings for alcohol.

Baclofen is also an analog of GABA; just like alcohol, it binds to GABA receptors in the brain, but without the serious health implications and addictive nature of consistent alcohol use. By stimulating the brain’s GABA receptors, baclofen stops the brain from craving alcohol to accomplish the same job. European studies have concluded that once they’ve reached their effective dose, which generally takes between 1 and 3 months, 92% of “high-risk” drinkers report an effortless reduction in cravings. Even though it essentially replaces alcohol’s role as a GABA agonist, baclofen does not seem to be addictive, and doesn’t cause cravings, but shouldn’t be quit cold-turkey for risk of side effects.

Baclofen’s interaction with GABA is also the source of its anxiolytic (anti-anxiety) properties. Anxiety disorders are very strongly associated with excessive drinking, and the co-occurrence of anxiety and AUD is remarkably common. Not only are people with anxiety disorders much more likely to over-drink as a method of self-medication, but anxiety is one of the most prevalent symptoms of regular excessive drinking; the two conditions maintain and amplify one another in a “vicious cycle of comorbidity.” Baclofen’s effectiveness as an anxiolytic medication further suppresses cravings for alcohol and provides some of the same anxiety relief as alcohol does without all of the negative side effects.

Baclofen intervenes before cravings manifest

Alongside reducing cravings and anxiety, baclofen has also been shown to significantly slow down the brain’s subconscious reaction to visual triggers. Dr. Anna Rose Childress of the University of Pennsylvania’s Perelman School of Medicine used MRI’s to analyze the brain activity of cocaine-dependent men in response to key visual stimuli — images of drug use, paraphernalia, and preparation, as well as other aversive images. These were shown for only 33 milliseconds before switching to non-related pictures, far too quickly for the brain to consciously process the image.

Fascinatingly, even these incredibly quick flashes are subconsciously interpreted by the brain as addiction triggers, and cause a significant reaction in the reward and motivational centers of the brain. While this study focused on cocaine addiction rather than Alcohol Use Disorder, and the sample size was quite small and homogenous (20 cocaine-dependent men aged 18-55), the results are remarkable, and demonstrate a whole new factor of baclofen treatment for addiction. For split-second visual triggers, baclofen suppresses the brain’s craving response; for longer cues, baclofen gives the brain time to consciously process the trigger and make a legitimate decision, rather than instantly setting off subconscious urges for alcohol.

How the body reacts

Because baclofen is processed and absorbed by the human body very quickly, it usually needs to be taken three times throughout the day to remain effective. Fortunately, this absorption takes place in the kidneys, not the liver like most other drugs, rendering baclofen the only major AUD treatment drug that can still be taken by people with liver damage or cirrhosis.

Baclofen must be titrated up and down when starting and stopping to minimize the risk of side effects. Side effects at all are infrequent, but the most common ones are fatigue, insomnia, dizziness, and nausea. They usually only happen on dose increases, and pass within a day or two. Recurrent side effects can be mitigated by slowing down your titration. Baclofen has no known permanent or long-term side effects.

Common reasons for treatment failure

While the results discussed above are certainly remarkable, there are still a minority of baclofen users who either fail to significantly reduce their drinking, or choose to prematurely stop treatment. Let’s go over some of the most common reasons baclofen doesn’t work.

The most common reason for stopping baclofen treatment prematurely is side effect management. Baclofen’s most common side effects are nausea, dizziness, tiredness, and insomnia, although more severe effects like paresthesia (tingling), tinnitus, hallucinations, and mania have been reported in very rare cases. For the vast majority of people, side effects are very mild and only occur on dose increases; slowing down titration will usually mitigate side effects.

Unfortunately, because baclofen treatment in the U.S. is often done independently, and over-drinkers are very likely to also suffer anxiety, mild side effects at low doses are much more likely to scare people off, but adjusting your titration can end their experience of unwanted side effects. Here at LifeBac, we pay close attention to side effects, especially in the early stages of treatment, and can almost always solve the issue of unwanted side effects with slight titration schedule adjustments.

Medication management

Another surprisingly widespread cause of failed baclofen treatment is people just not taking their baclofen. With Alcohol Use Disorder especially, it’s quite common for people to be “forced” into treatment by an ultimatum from their partner or family, usually with the traditional expectation of total lifelong abstinence as the goal. In these cases, the user is not internally motivated to continue treatment, and might actually have the opposite motivation; this is just another reason that self-empowerment, goal-setting, and personal control over treatment are core principles of the LifeBac program. People who aren’t genuinely motivated to improve themselves might purposely fail their treatment — whether consciously or subconsciously — so that they can rationalize returning to excessive drinking.

It’s also quite common for people who aren’t used to taking regular medication, take a wide range of medications, or are frequently intoxicated, to simply forget to take their baclofen or accidentally dose themselves incorrectly. Other people may have a psychological issue with having to take medication at all. At LifeBac, we make your comprehensive titration plan readily available to you through the app and web portal, as well as encouraging you to track your medication doses taken in the app’s Agenda View and regularly checking in with your personal Success Coach. You are in control, you decide your goals and the speed at which you would like to achieve them, we help with physicians, medication and coaching ensure you achieve long-term change.

Finding support

The other major cause of baclofen treatment failure is when AUD is heavily enforced by environmental factors — even more so than internal urges or cravings. If alcohol is an important part of your culture, family, or social and professional lives, it can seem impossible to cut down even with baclofen suppressing your cravings. Baclofen can only affect you; it has no power over your family, home life, or external pressures to drink. This is what LifeBac’s success coaching program is all about; our success coaches are trained to help you use the increased autonomy and mental clarity that baclofen’s suppression of cravings provides in order to properly deal with the external stressors that led to your excessive drinking in the first place.

For the most part, the cause of failed baclofen treatment is either unrealistically high expectations of the medication — baclofen takes time, it won’t cure you overnight, and it can’t change your environment aside from making you more capable of doing so yourself — or a lack of motivation on behalf of the user.