Treatment of high-risk drinking, alcohol use disorder: New Canadian guideline

The guideline, published in CMAJ (Canadian Medical Association Journal), contains 15 evidence-based recommendations to reduce harms associated with high-risk drinking and to support people’s treatment and recovery from AUD.

Despite the high prevalence of AUD and high-risk drinking, these conditions frequently go untreated and unrecognized in the healthcare system. Even if recognized, AUD does not receive evidence-based interventions. It is estimated that below 2% of eligible patients receive evidence-based alcohol treatment in the form of evidence-based pharmacotherapies, likely owing to low awareness. Conversely, according to the guidelines, many Canadian patients receive medications that may be potentially harmful and ineffective.

The guideline was developed by a 36-member committee and is based on expert consensus, the latest evidence, lived and living experience, and clinical experience from across Canada. It formulated 15 recommendations for care providers about how to ask about alcohol, diagnose AUD, manage alcohol withdrawal, and create treatment plans based on the individual’s goals. These treatment plans can include medications, counselling, harm reduction or a combination.

Recommendations are as follows:

Screening

• When appropriate, clinicians should inquire about current knowledge of and offer education to adult and youth patients about Canada’s Guidance on Alcohol and Health, to facilitate conversations about alcohol use.
• All adult and youth patients should be screened routinely for alcohol use above low risk.

Diagnosis

• All adult and youth patients who screen positive for high-risk alcohol use should undergo a diagnostic interview for AUD using the DSM-5-TR criteria and further assessment to inform a treatment plan, if indicated.

Brief intervention

• All patients who screen positive for high-risk alcohol use should be offered brief intervention.

Withdrawal management

• Clinicians should use clinical parameters, such as past seizures or past delirium tremens, and PAWSS to assess the risk of severe alcohol withdrawal complications and determine an appropriate withdrawal management pathway.
• For patients at low risk of severe complications of alcohol withdrawal (e.g., PAWSS < 4), clinicians should consider offering nonbenzodiazepine medications, such as carbamazepine, gabapentin, or clonidine for withdrawal management in an outpatient setting (e.g., primary care, virtual).
• For patients at high risk of severe complications of withdrawal (e.g., PAWSS ≥ 4), clinicians should offer a short-term benzodiazepine prescription, ideally in an inpatient setting (i.e., a withdrawal management facility or hospital). However, where barriers to inpatient admission exist, benzodiazepine medications can be offered in outpatient settings if patients can be monitored closely.
• All patients who complete withdrawal management should be offered ongoing AUD care.

Treatment and ongoing care

• Adult and youth patients with mild to severe AUD should be offered information about and referrals to specialist-led psychosocial treatment interventions in the community.
• Adult patients with moderate to severe AUD should be offered naltrexone or acamprosate as a first-line pharmacotherapy to support the achievement of patient-identified treatment goals: Naltrexone is recommended for patients who have a treatment goal of either abstinence or a reduction in alcohol consumption, Acamprosate is recommended for patients who have a treatment goal of abstinence.
• Adult patients with moderate to severe AUD who do not benefit from, have contraindications to, or express a preference for an alternate to first-line medications can be offered topiramate or gabapentin.
• Adult and youth patients should not be prescribed antipsychotics or SSRI antidepressants for AUD treatment.
• Prescribing SSRI antidepressants is not recommended for adult and youth patients with AUD and a concurrent anxiety or depressive disorder.
• Benzodiazepines should not be prescribed as ongoing treatment for AUD.

Community-based supports

• Adult and youth patients with mild to severe AUD should be offered information about and referrals to peer-support groups and other recovery-oriented services in the community.

“High-risk drinking and alcohol use disorder frequently go unrecognized and untreated in our health care system, leaving individuals without access to effective treatments that can improve their health and well-being,” says Dr. Jürgen Rehm, co-chair of the guideline writing committee and senior scientist in the Institute for Mental Health Policy Research at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario.

“These guidelines give primary care providers the tools to support early detection and treatment and connect patients and families with specialized care services and recovery-oriented supports in their communities.”

Reference:

Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder. Evan Wood, Jessica Bright, Katrina Hsu, Nirupa Goel, Josey W.G. Ross, Averill Hanson, Rand Teed, Ginette Poulin, Bryany Denning, Kim Corace, Corrina Chase, Katelyn Halpape, Ronald Lim, Tim Kealey, Jürgen Rehm. CMAJ Oct 2023, 195 (40) E1364-E1379; DOI: 10.1503/cmaj.230715