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

A new Canadian guideline for treating high-risk drinking and alcohol use disorder (AUD) with 15 evidence-based recommendations to reduce harms associated with high-risk drinking and to support people's treatment and recovery from AUD is published in CMAJ (Canadian Medical Association Journal).

High-risk drinking, AUD and alcohol-related harms are common in Canada. Nearly 18% of people aged 15 years or older in Canada will meet the clinical criteria for an AUD in their lifetime, and over 50% of people in Canada aged 15 years or older currently drink more than the amount recommended in Canada's Guidance on Alcohol and Health.

Despite the high prevalence of high-risk drinking and AUD, these conditions frequently go unrecognized and untreated in the health care system. Even if recognized, AUD does not receive evidence-based interventions. It's estimated that less than 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 guideline, many Canadian patients receive medications that may be ineffective and potentially harmful.

Guideline developed in partnership with Canadian research initiative on substance misuse

To address this health issue, the Canadian Research Initiative on Substance Misuse (CRISM) and the BC Center on Substance Use (BCCSU) developed the "Canadian Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder." The guideline provides recommendations for the clinical management of high-risk drinking and AUD to support primary health care providers to implement evidence-based screening and treatment interventions.

The guideline, developed by a 36-member committee, is based on the latest evidence, expert consensus, and lived and living experience, as well as clinical experience from across Canada. It makes 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, counseling, harm reduction or a combination.

"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 Center 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."

The website Helpwithdrinking.ca will be available to raise awareness of resources and treatments available to people in Canada based on the new guidelines.

Practice article highlights potential harms of prescribing medications not recommended in guideline

A related practice article highlights the complexity of providing treatment to patients with AUD and the possible negative effects of selective serotonin reuptake inhibitor (SSRI) therapy, which can worsen the disease in some people.

"Although the initiation of an SSRI appeared to be a likely explanation for the escalation in this patient's alcohol use, other factors may also have played an important role," writes Dr. Nikki Bozinoff, associate scientist at CAMH, with co-authors. "This case illustrates that although it may be common practice to prescribe SSRIs for people with AUD, SSRIs may not be effective for depressive symptoms in people with concurrent active AUD, and may worsen alcohol use in some."

The guideline recommends against SSRI antidepressants in patients with AUD, or AUD and concurrent anxiety or depression.

"Despite the burden of illness, there remains a tremendous gap between what we know is effective treatment and the care Canadians are actually receiving," says Dr. Evan Wood, co-chair of the guideline writing committee and an addiction medicine specialist.

"Unfortunately, in the absence of effective care, people are being routinely prescribed potentially harmful medications that can, unknown to most prescribers, actually increase alcohol use in some patients. These guidelines seek to close that gap and ensure Canadians are accessing the safest and most effective treatments that meet their needs."