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Baclofen
Treatment of Alcohol Dependence
2
Standard Drink Measure
3
Drinking Episodes Defined (National Household Survey)
Binge Drinking as 5 or more drinks per occasion
Heavy alcohol use as 5 or more drinks for 5 or more days per month
4
Historical Trends: 1850-1997
00.5
11.5
22.5
3
1850
1916
-19
1940
1955
1975
1985
1995
Year
Gal
lon
s E
than
ol
SpiritsWineBeer
Source: Nephew et al., 1999
5
Alcohol Dependence or Alcoholism
A progressive chronic
disorder that both American
Medical Association and
American Psychiatric
Association recognize as a
disease.
It is a common disorder
posing a heavy burden on
patients, their families and
the society
What contributes to the
development of a problem
with drinking?
Neurochemical
factors,
Genetic factors, and
Emotional factors,
among others
6
Definition of Alcohol DependenceDefinition of Alcohol Dependence
Tolerance or withdrawalTolerance or withdrawal Amount/duration of use Amount/duration of use
greater than intended.greater than intended. Unsuccessful efforts to control Unsuccessful efforts to control
or reduce useor reduce use Spending much time using Spending much time using
alcohol, recovering from its alcohol, recovering from its effects, or trying to obtain it.effects, or trying to obtain it.
Reducing or abandoning Reducing or abandoning important work, social or important work, social or leisure activities because of leisure activities because of alcohol use.alcohol use.
Continued alcohol use Continued alcohol use despite knowing that it has despite knowing that it has probably caused ongoing probably caused ongoing physical or psychological physical or psychological problems.problems.
Maladaptive alcohol use causes clinically important distress or impairment, shown in a single 12-month period by three or more of the following:
7
Icon of Alcohol
+GABA
+Mu
opiates
_GLU
Alcohol
+
Cannabi
noids
In addition to enhancing GABA inhibition and reducing Glutamate excitation, alcohol also enhances euphoric effects by releasing opiates and cannabinoids
8
Overview of Treatment
Maintaining Abstinence, Preventing
Relapse
Alcohol Detoxification
Treatment of Alcoholism
STEP 1
STEP 2
9
Early Onset
Wx sxWx sx
BZDZThiamine
H2 blockersOther prn
AcamprosateAcamprosate –ve Affect
state
AcamprosateAcamprosate –ve Affect
state
Baclofen30-60 mg/d
DiathesisExternalizing
AtomoxetineBupropion
+Behavioral
Training-Cog train
-Brain train-Prob solving-Coping skills
Reverse Reverse NeuroNeuroAdaptationAdaptation
NaltrexoneOndansetron
Baclofen
Topiramate
+Unchain habits
Structure ADL
Alternative highs
Phys. Exercise
Relapse Relapse PreventionPrevention
- Relapse - Relapse TriggersTriggers
-Social support Social support -MonitoringMonitoring-Safety netSafety net
-Contingency Contingency ContractingContracting
-Regular F/URegular F/U-Single Single
therapisttherapist
Dealing with fallout
Involve sig. others
Supportive Therapy
? Directive & Prescriptive
Behav. Marital etc.
Bipolar (esp BP II) very common – ask and treat appropriately
10
Late Onset
Wx sxWx sxWx sxWx sx
BZDZThiamine
H2 blockers
AcamprosateAcamprosate –ve Affect
state
AcamprosateAcamprosate –ve Affect
state
Precursor Precursor event / event /
conditioncondition
Precursor Precursor event / event /
conditioncondition
Supportive and/
Individual Therapy prn
SSRI’s etc.
Reverse Reverse NeuroNeuroAdaptationAdaptation
Reverse Reverse NeuroNeuroAdaptationAdaptation
SSRI–Sertraline
AcamprosateTopiramate
+Unchain habitsStructure ADLAlternative highs
Yoga/ relaxation tech
Relapse Relapse PreventionPrevention
Relapse Relapse PreventionPrevention
- - Relapse Relapse TriggersTriggers
-Social support Social support -MonitoringMonitoring-Safety netSafety net
-Contingency Contingency ContractingContracting
-Regular F/URegular F/U-Single Single
therapisttherapist
Dealing with fallout
Dealing with fallout
Involve sig. others
Supportive Therapy
? Directive & Prescriptive
Behav. Marital etc.
Depression and anxiety very common – ask and treat appropriately
11
Baclofen- promising new therapy for alcohol withdrawal.
Baclofen is a GABA-B receptor agonist.
In several studies, it reduced moderate and severe symptoms in alcohol
withdrawal syndrome, and it had a more favorable side effect profile
than benzodiazepines.
Baclofen exhibits less addictive properties and may be more effective
than benzodiazepines at helping to maintain abstinence in alcoholics.
Before widespread can be recommended, larger studies comparing it
directly to benzodiazepines are needed.
12
Treating Alcohol Addiction: A Pill Instead of Abstinence?
They call it "the switch." Alcoholics who take an anticraving medication called baclofen say the drug allows them to resist the most powerful triggers of relapse: former drinking buddies, a favorite bar, the sight of alcohol or even the most potent drinking cue of all, having a single drink.
13
Baclofen - History
Dr. Olivier Ameisen, professor of
medicine at Cornell University,
reported in 2004 in the
journal Alcohol and Alcoholism that
he successfully used Baclofen to
completely suppress his own alcohol
addiction.
His therapeutic model was reproduced
by Dr. William Bucknam, (case report
in Alcohol and Alcoholism) and by
Roberta Agabio et al. (case
reportin Journal of Clinical
Psychopharmacology).
14
Mechanism of action
VTA is modulated by GABAergic inputs. GABAB receptors inhibit VTA cell bodies, i.e., when stimulated, hyperpolarize the membrane potential and
decrease firing rates of VTA neurons.
15
Mechanism of action
Different lines of experimental evidence suggest that
mesolimbic dopamine neurons are involved in the
mediation of alcohol intake and reinforcement
Interestingly, GABAB receptors are located in the
ventral tegmental area (the area where mesolimbic
dopamine neurons originate), both on the cell body of
dopamine neurons and on the terminals of
glutamatergic afferent neurons
16
Mechanism of action
Their activation by GABAB receptor agonists may exert an
inhibitory action on the dopamine neurons.
This is the possible mechanism through which baclofen
suppresses alcohol- stimulated dopamine release and, in turn,
dopamine mediated, alcohol-reinforced and -motivated behaviors.
17
Baclofen – Efficacy in alcohol dependence
18 Garbutt JC, et al. Alcohol Clin Exp Res. 2010; 34(11): 1849-57.
19
Study design
Garbutt JC, et al. Alcohol Clin Exp Res. 2010 Nov; 34(11): 1849-57.
20
Reduction in percentage of heavy drinking days
Study results
Garbutt JC, et al. Alcohol Clin Exp Res. 2010 Nov; 34(11): 1849-57
21
Increased percentage of abstinent days with baclofen treated patients
Garbutt JC, et al. Alcohol Clin Exp Res. 2010 Nov; 34(11): 1849-57.
22
Reduction in craving, anxiety, and depression with baclofen treated patients vs. placebo
Garbutt JC, et al. Alcohol Clin Exp Res. 2010 Nov; 34(11): 1849-57.
23
Increased percentage of individuals maintaining abstinence during trial by drug condition.
Garbutt JC, et al. Alcohol Clin Exp Res. 2010 Nov; 34(11): 1849-57.
24 Addolorato G,et al. Alcohol Alcohol. 2002 Sep-Oct; 37(5): 504-8.
25
Diagram on recruitment, group allocation, treatment retention and success in achieving and maintaining complete abstinence.
Study design
Addolorato G,et al. Alcohol Alcohol. 2002 Sep-ct; 37(5): 504-8.
26
Study results
A significantly higher number of patients who achieved and maintained abstinence throughout the experimental period was found in the group of patients treated with baclofen (14 out of 20, corresponding to 70.0%) compared to subjects treated with placebo (four out of 19, or 21.1%) .
Addolorato G,et al. Alcohol Alcohol. 2002 Sep-Oct; 37(5): 504-8.
27
Significant effects of treatment and time on both compulsive and obsessive drinking subscales of OCDS, with scores in the baclofen groups constantly lower than those of the placebo group throughout T1–T4.
Addolorato G,et al. Alcohol Alcohol. 2002 Sep-Oct; 37(5): 504-8.
28
The results of the present preliminary double-blind study confirm that baclofen, because of its anti-craving and anti-reward action on the one hand, and safety on the other, may have an important role in the treatment of patients with alcohol problems.
Conclusion
29
Baclofen for Alcohol Dependence in Patients with Liver Cirrhosis
Addolorato G, et al. Lancet. 2007; 370(9603): 1915–1922.
30
Background
In developed countries, alcohol is the most frequent cause
of liver cirrhosis.
Currently, few specific therapies for alcoholic liver disease
exist.
However, abstinence is single most important intervention
since continued alcohol ingestion is important risk factor
for progression of disease.
Abstinence is also important for patients who may
eventually require liver transplantation.
31
Methods
Between October 2003 to November 2006, alcohol-
dependent patients with liver cirrhosis at the Institute
of Internal Medicine of Catholic University in Rome,
Italy were assessed for the study.
Patients were referred to the institute (which has both a
liver unit and an alcohol addiction unit).
32
MethodsInclusion Criteria
Age 18-75 ETOH dependence per DSM-IV
criteria Liver cirrhosis (Diagnosed by
histological findings, PE, lab tests, imaging studies)
Alcohol intake: at least 2 heavy drinking days/week and >21 drinks/week men, >14 drinks/week women for 4 weeks prior to study.
Family member available for assistance during study
Exclusion Criteria
Severe heart or lung disease Abnormal renal function,
hepatorenal syndrome or both Malignant disease Metabolic diseases Hepatic encephalopathy Treatment with interferon or
corticosteroids in last 2 mo. Psychopathologic disease on
treatment Epilepsy Addiction to other drugs other
than nicotine
Addolorato G, et al. Lancet. 2007; 370(9603): 1915–1922
33
Methods
Addolorato G, et al. Lancet. 2007; 370(9603): 1915–1922.
34
Primary Outcome MeasuresTOTAL ABSTINENCE FROM ALCOHOL
Based on patient’s self-evaluation and family member interview. Blood, urine alcohol content also measured.
CUMULATIVE ABSTINENCE DURATIONTotal number of days abstinent from alcohol-Relapse: Daily ETOH intake of >4drinks or an overall consumption of >14 drinks per week -Lapse: Any episode of ETOH consumption not classified as relapse
Secondary Outcome Measures
DIFFERENCE IN CRAVING MEASURESEvaluated by Obsessive compulsive drinking scale at start of
study and at every visit. This scale is validated and measures obsessive and compulsive components of craving.
35
Alcohol abstinence in Baclofen group 30/42 (71%) vs. Placebo group 14/42 (29%).
Odds ratio 6.3. NNT=2.5
Cumulative abstinence duration twofold higher in Baclofen group. Mean 62.8 days versus 30.8 days.
Dropouts in Baclofen group 6/42 (14%) vs. Placebo group 13/42 (31%). p=0.12.
Significant alcohol abstinence in Baclofen group vs. Placebo.
Results
Addolorato G, et al. Lancet. 2007; 370(9603): 1915–1922.
36
Graphs to right:
1. Mean total
craving score
2. Obsessive
subscale
3. Compulsive
subscale
Baclofen significantly reduced craving scores
Addolorato G, et al. Lancet. 2007;370(9603):1915–1922.
37
Study results
Biological liver variables were also measured during 12-week study period.
Patients with baclofen had significantly reduced alanine aminotransferase, bilirubin, INR, and ϒ-glutamyl transferase from baseline and significantly increased albumin.
No difference seen for aspartate aminotransferase, mean cellular volume, and creatinine values.
38
Biological liver variables
Addolorato G, et al. Lancet. 2007 ;370(9603): 1915–1922.
39
Side effects
Baclofen=headache (4), tiredness (1), vertigo (2),
sleepiness (1).
Placebo=headache (4), tiredness (1), vertigo (1)
Treatment adherence did not differ between groups.
Placebo (79.5%) and Baclofen (82.8%).
40
Conclusion
Study suggest that give reduction in self-reported alcohol use
and with significant reductions in clinical markers, enough
evidence suggests that oral administration of baclofen is
significantly more effective than placebo in maintaining
alcohol abstinence.
41
42
Suppressing effect of baclofen on alcohol withdrawal : a comparative study versus diazepam
1 2 3 4 5 10
5
25
20
15
10
0
_
_
Baclofen
Diazepam
CIW
A_A
r sc
ore
Time (days)Addolorato G, et al. Am J Med. 2006 Mar; 119(3): 276.e13-8
43
Baclofen – Trials summary
• Baclofen administration in human alcoholics have a significant efficacy - to induce alcohol abstinence - to reduce alcohol intake - to reduce alcohol craving -in obsessive component -in compulsive component - to induce the remission of alcohol withdrawal syndrome -delirium tremens • Baclofen seems to be very manageable also showing general safety, even when administered to patients with severe liver disease
44
Baclofen Dosage used in clinical Trials
Therapy usually started with an initial low dose of about
30 mg daily and gradually titrated up in a stepwise fashion
until symptomatic relief occurs.
The usual maximum dose is 80 mg per day.
However Addolorato et al and our group have found that 50-
60 mg/day is efficacious.
45
Baclofen- side effects
Common Constipation; dizziness; drowsiness; fatigue; headache;
nausea; sleeplessness
Severe (Uncommon) Severe allergic reactions (rash; hives; itching; difficulty
breathing; tightness in the chest; swelling of the mouth,
face, lips, or tongue); agitation; chills; inability to
urinate; loss of muscle tone; seizures.
46
Withdrawal syndrome
Abrupt withdrawal can result in severe withdrawal symptoms
resembling benzodiazepine / alcohol withdrawal.
Can be stopped by recommencing baclofen
More likely if used for long periods of time (>couple of months) and can
occur from low or high doses.
Severity depends on rate of discontinuation.
To minimise withdrawal symptoms taper down slowly
47
Summary
Effective in reducing drinking and promoting
abstinence
Effectiveness started at about the 10 mg per day
Reduced craving, comorbid anxiety and depression
Combats craving by inhibiting alcohol-induced release
of dopamine in the midbrain
Adverse effects were of mild intensity
Can be administered in patients with advanced liver
disease
48
Conclusion
Bolder approaches should at least be considered where
the scientific rationale is compelling and the putative
therapeutic medication is known to be safe and
preferably approved for human use
Baclofen is safe and effective medication for treatment
of alcoholism
Baclofen’s development for treatment of alcoholism
should garner scientific interest, since few effective
medications are available for this condition
Thank You