Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder

Abstract

Background: In Canada, low awareness of evidence-based interventions for the clinical management of alcohol use disorder exists among health care providers and people who could benefit from care. To address this gap, the Canadian Research Initiative in Substance Misuse convened a national committee to develop a guideline for the clinical management of high-risk drinking and alcohol use disorder. Methods: Development of this guideline followed the ADAPTE process, building upon the 2019 British Columbia provincial guideline for alcohol use disorder. A national guideline committee (consisting of 36 members with diverse expertise, including academics, clinicians, people with lived and living experiences of alcohol use, and people who self-identified as Indigenous or Métis) selected priority topics, reviewed evidence and reached consensus on the recommendations. We used the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) and the Guidelines International Network’s Principles for Disclosure of Interests and Management of Conflicts to ensure the guideline met international standards for transparency, high quality and methodological rigour. We rated the final recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool; the recommendations underwent external review by 13 national and international experts and stakeholders. Recommendations: The guideline includes 15 recommendations that cover screening, diagnosis, withdrawal management and ongoing treatment, including psychosocial treatment interventions, pharmacotherapies and community-based programs. The guideline committee identified a need to emphasize both underused interventions that may be beneficial and common prescribing and other practice patterns that are not evidence based and that may potentially worsen alcohol use outcomes. Interpretation: The guideline is intended to be a resource for physicians, policymakers and other clinical and nonclinical personnel, as well as individuals, families and communities affected by alcohol use. The recommendations seek to provide a framework for addressing a large burden of unmet treatment and care needs for alcohol use disorder within Canada in an evidence-based manner.

Does This Patient Have Alcohol Use Disorder?

“…Importantly, like all diagnostic systems that depend on a standardized collection of relatively subjective criteria, there is room for scrutiny and ongoing research of the reference standard diagnosis of alcohol use disorder . For instance, when using the DSM-5 , it is critical that clinicians distinguish between mild and more severe alcohol use disorder, especially because the DSM-5 represented a marked departure from the prior biaxial model that distinguished abuse and dependence via distinct criteria . It is also important to highlight recent research implying that not all 11 DSM-5 alcohol use disorder criteria are equally informative …”

“…The review’s findings should be put into context alongside a major opportunity to improve medical care and public health given that excessive alcohol use and alcohol use disorders directly contribute to a tremendous burden of morbidity and mortality, including accounting for approximately 20% of deaths in those aged 20 to 49 years in the US . Even though there are effective psychosocial and medication-based treatments that have been proven to reduce heavy alcohol use and improve rates of abstinence, they are often underused. Recent data from a large sample of Medicare Part D claims, and that specifically examined rates of medication treatment for alcohol use disorder after alcohol-related hospitalizations, found that only 1.3% of individuals initiated medication within 30 days of discharge.…”

“…If the DSM-5 diagnostic interview is positive, she should be supported with guideline-directed interventions based on the severity of alcohol use disorder . If the DSM-5 diagnostic interview is not consistent with alcohol use disorder, the clinician should ask for more information about her drinking patterns and provide advice about the risks of alcohol use and how to decrease use …”

A public health perspective on mitigating the global burden of chronic liver disease

“…[48] Community-level programs including, but not limited to, educational campaigns and limiting availability of alcohol, training servers, and enhanced enforcement of on-premise laws and legal requirements have also been shown to reduce alcohol consumption and harm. [48] At the individual level, primary care level screening and brief interventions for hazardous and harmful alcohol use, [52] as well as therapy (both psychosocial interventions and pharmaceutical treatment) for alcohol use disorders, [53] are each associated with reductions in alcohol drinking including prolonged periods of abstinence. Their effects, however, diminish with time; thus, booster sessions are necessary for brief interventions, and among people with severe alcohol use disorders, at least 60% of those with AUD will relapse to hazardous drinking within 6 months following treatment.…”

“…Their effects, however, diminish with time; thus, booster sessions are necessary for brief interventions, and among people with severe alcohol use disorders, at least 60% of those with AUD will relapse to hazardous drinking within 6 months following treatment 54 . Peer groups and aftercare can help decrease relapse rates 53 …”