Baclofen

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GroverPsychMD said:
The patient I have is on baclofen (from pcp) and I have her on naltrexone and antabuse.
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one med with no useful evidence it works, one med with poor evidence it works, and one med that may provide a small amount of benefit above placebo. I'm not criticizing here and realize that there probably isn't a lot of harm with this kitchen sink approach, but just reading this reinforces how little useful pharm there is for addiction(other than ORT....won't even go there).....
 
Please tell me about how antabuse has only a small amount of benefit over placebo. Patient is in AA, with sponsor. Husband watches her take antabuse every day. We decided not to use campral due to compliance with dosing and after looking over the evidence. I can't work harder than the patient. What do you recommend vistaril?
 
vistaril said:
one med with no useful evidence it works, one med with poor evidence it works, and one med that may provide a small amount of benefit above placebo.
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You really haven't read much of the research on naltrexone, have you?
 
Whats the proposed mechanism for baclocen in this context? Is it actually related to its GABA-B effects or does it just have some GABA-A cross reactivity such that its essentially being used as a weak benzo?

(Or more likely something even more complicated that I haven't even considered)
 
notdeadyet said:
You really haven't read much of the research on naltrexone, have you?
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small benefit over placebo isn't a bad/negative thing. And yes I've read the pertinent naltrexone research regarding it and alcohol dependence.
 
GroverPsychMD said:
Please tell me about how antabuse has only a small amount of benefit over placebo. Patient is in AA, with sponsor. Husband watches her take antabuse every day. We decided not to use campral due to compliance with dosing and after looking over the evidence. I can't work harder than the patient. What do you recommend vistaril?
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I don't have anything to recommend. I certainly don't see how you could be doing anything else to help this patient pharmacologically. My initial comment was just sort of a statement on how poor our 'anti-addiction drugs' work.
 
Instead of typing in the big box at the bottom, look on the post you want to quote and look to the right side of the screen. There should be #xx for the post number, then links for Like or Reply. Click on Reply and it quotes that post in your reply...
 
notdeadyet said:
Instead of typing in the big box at the bottom, look on the post you want to quote and look to the right side of the screen. There should be #xx for the post number, then links for Like or Reply. Click on Reply and it quotes that post in your reply...
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Cool!
 
GroverPsychMD said:
Any other recs to help alcohol patients with the resources we have currently?
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I am using a fair amount of Gabapentin now. Certainly not a risk free therapy, but we see some pretty awful and life threatening alcohol dependence at the VA I work at. Recent RCT in JAMA internal medicine shows benefit at 900 and 1800mg doses, more so at 1800. Can pubmed the name below if you want to read it.

Gabapentin Treatment for Alcohol Dependence A Randomized Clinical Trial
 
I've heard about this, but still haven't been able to figure out why you'd choose gabapentin over a benzo for this purpose...
 
notdeadyet said:
You can prescribe it for anxiety. Folks going sober tend to be anxious…
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Or there anxiety drove the drinking in the first place, and treating the anxiety is going to be a really important part of sobriety. Neurontin isn't the safest medicine to use in these populations, but the efficacy/safety ratio is much more favorable than a benzo.
 
billypilgrim37 said:
Or there anxiety drove the drinking in the first place, and treating the anxiety is going to be a really important part of sobriety.
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Exactly, that's why the above study doesn't really blow me away. I would prefer to see a good study showing the effects of Neurontin versus SSRI versus placebo.
 
billypilgrim37 said:
Or there anxiety drove the drinking in the first place, and treating the anxiety is going to be a really important part of sobriety. Neurontin isn't the safest medicine to use in these populations, but the efficacy/safety ratio is much more favorable than a benzo.
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That's the nice part. You can avoid some to much (depending on who you ask) of the problems with benzodiazapines while providing relatively fast relief for patients without all the wind-up time of SSRIs. There is some initial sedation which can also help with sleep (subjectively a huge concern for people I see coming off heavy alcohol dependency).

I also don't see any reason why this has to be used independently from an SSRI and hopefully further work will elucidate if both Gabapentin and a SSRI is superior to either alone.

GroverPsychMD said:
The evidence from that study is allowed for off label va use? Really?
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Yup, just cleared it with the head psychopharmacologist who oversees our prescribing today in fact. Starting on the inpatient unit to observe for side-effects/tolerance and then to be followed up by the psychiatrists in ATP or residential domiciliary.
 
The study doesn't have that many people 150 people only. And the people are not heavy drinkers (so they are not regular outpatients, at least not the ones I see) and 1800 mg of Gabapentin is going to be a hefty side effect profile (9 out of 150 left the study and I don't know what dose they are on, maybe not even close to 1800). Wait a minute, what is heavy drinking defined as? And what manual based system did they use? I don't have access to the whole article so I would appreciate more information.
 
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notdeadyet said:
Exactly, that's why the above study doesn't really blow me away. I would prefer to see a good study showing the effects of Neurontin versus SSRI versus placebo.
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A more reliable study might be "how mean are my dual inpatients to me when I prescribe them a) Prozac alone, b) Remeron alone, or c) Prozac + Remeron + rapid titration of neurontin and all the vistaril they can use without getting a bowel obstruction." The BP meanness scale is a very reliable psychometric assessment tool.
 
GroverPsychMD said:
BP meanness scale? I cannot find this.
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