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The Review Course in Family Medicine
Nov 252 min read

GUIDELINE ALERT: Alcohol Use Disorder Management and Prescriptions That Family Docs Should Know

New Canadian and BC Guidelines BONUS: Free CME course from UBC CPD on this topic! Available here (Disclosure: The Review Course faculty were consulted by UBC CPD on the creation of this course)

A man holding up a glass of whisky

Recommendations


Screening:

  • Inquire about all patients existing knowledge of alcohol consumption and offer education 

  • All adult and youth patients should be screened for alcohol consumption above level of low risk

    • Using Single Alcohol Screening Question (SASQ)

    • then, use Alcohol Use Disorders Identification Test (AUDIT) or AUDIT-Consumption (AUDIT-C)

    • For youth, use National Institute on Alcohol Abuse and Alcoholism (NIAAA) screener


Diagnosis:

  • Any adult and youth patient that screens positive for high-risk alcohol use should undergo diagnostic interview for AUD using DSM-5 TR criteria, and assessment for a treatment plan 


Brief Intervention:

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

    • Motivational interviewing to discuss patient’s health concerns, set goals

    • Develop a treatment plan tailored to goals and preferences


Withdrawal Management:

  • Use clinical parameters (seizure, delirium tremens) and the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) to assess risk and tailor management 

    • High Risk (PAWSS > or = to 4, past seizure)

      • Inpatient care (recommended): short course of benzodiazepines, CIWA 

      • Outpatient (only if inpatient not available or not preferred): short course of benzodiazepines (tapered), CIWA, monitor for withdrawal 

    • Low Risk (PAWSS <4)

      • Outpatient (recommended): prescribe gabapentin/carbamazepine and/or clonidine, use CIWA, monitor for severe withdrawal

      • Inpatient: if contraindications to outpatient (e.g. homelessness)


Treatment and ongoing care

  • Community: supportive recovery programs, peer groups, harm reduction 

  • Psychosocial: CBT, family-based therapy 

  • Pharmacotherapy: 

    • 1st line = Naltrexone or acamprosate - can also also use these for youth for moderate-severe AUD (Case-by-case)

    • Off-label (for moderate-severe AUD with contraindications to 1st line): gabapentin, topiramate: CAUTION - warn patients as this can lead to acute glaucoma!

    • AVOID: antipsychotics or SSRIs (including for concurrent anxiety/depression with AUD)

      • Monitor closely or refer to specialist for a history of mental health disorder that has shown response to psychiatric medications

    • DO NOT prescribe Benzodiazepines for ongoing treatment of AUD


Bottom line:

  • Screen any and all patients for high risk alcohol use using a single question (SASQ)

  • Diagnose patients with AUD and begin some interventions

  • Manage acute withdrawals based on risk stratification

  • Use a multi-level approach to long-term management and supplement with acamprosate or naltrexone, or consider gabapentin, topiramate. and AVOID antipsychotics and SSRIs!


References 

CMAJ October 16, 2023 195 (40) E1364-E1379; DOI: https://doi.org/10.1503/cmaj.230715


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