BC Guidelines

High-Risk Drinking and Alcohol Use Disorder

Screening for alcohol use and alcohol use disorder (AUD) is important, given its impact on acute and chronic conditions, relationships, and other aspects of well-being. Evidence supports routine screening in primary care practice. This guideline aims to support clinicians in identifying and managing high-risk drinking (HRD) and AUD in adults and youth. This guideline adapts the British Columbia Centre on Substance Use’s (BCCSU) Provincial Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder (2019) and the Canadian Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder (2023). 

Key Recommendations

Practitioners should examine their preconceptions or biases regarding alcohol use, who uses it, and how it is used. Differentiate between high-risk alcohol use and alcohol use disorders. Consider how to investigate and communicate alcohol related diagnoses, being mindful of potential stigmatization and bias in care. See associated documents for examples. 

Screening and Brief Intervention 

1. Screen all patients routinely for alcohol use above low-risk limits. [Certainty of Evidence: Low, Strength of Recommendation: Strong.] 
2. Screen youth patients for alcohol use with the Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) instrument (see associated documents) or the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) Screening Tool. [Certainty of Evidence: Moderate, Strength of Recommendation: Strong.]
3. To facilitate discussions about alcohol use, when appropriate, ask patients about current knowledge of and offer education about Canada’s Guidance on Alcohol and Health. [Certainty of Evidence: Low, Strength of Recommendation: Strong.] 
4. Assess patients who screen positive for high-risk alcohol use or for AUD (See  DSM-5-TR Diagnostic Criteria for Alcohol Use Disorder ). [Certainty of Evidence: Low, Strength of Recommendation: Strong.] 
5. Use brief intervention for all patients who screen positive for alcohol use at moderate or high-risk limits but who do not meet the criteria for AUD. [Certainty of Evidence: Moderate, Strength of Recommendation: Strong.] 
6. Consider using a motivational interviewing-based approach to support achieving treatment goals. [Certainty of Evidence: Moderate, Strength of Recommendation: Strong.

Withdrawal Management

1. Use Prediction of Alcohol Withdrawal Severity Scale (PAWSS) to identify the most appropriate withdrawal management pathway. PAWSS is a validated tool for assessing the risk of severe complications of alcohol withdrawal. See associated documents for criteria. [Certainty of Evidence: Moderate, Strength of Recommendation: Strong.] 
2. For patients at low risk of severe complications of alcohol withdrawal (ie., PAWSS < 4), consider prescribing alternatives to benzodiazepines, e.g., gabapentin, carbamazepine and/or adjuvants such as clonidine for withdrawal management in an outpatient setting. [Certainty of Evidence: Moderate (gabapentin) Low (carbamazepine, clonidine), Strength of Recommendation: Strong.] 
3. For patients at high risk of severe withdrawal complications (ie., PAWSS ≥ 4), offer a short-term benzodiazepine prescription. This is ideally completed in an inpatient setting (i.e., a withdrawal management facility or hospital). Where inpatient admission is not available, benzodiazepine medications can be offered to patients in outpatient settings if they can be closely monitored and supported. [Certainty of Evidence: High, Strength of Recommendation: Strong.] 
4. Do not prescribe benzodiazepines as ongoing treatment for AUD. [Certainty of Evidence: High, Strength of Recommendation: Strong] 
5. When possible, patients who complete withdrawal management should be offered continuing care. Withdrawal management is a short-term intervention that does not resolve the underlying medical, psychological, or social issues of AUD and should be considered a bridge to continuing care. [Certainty of Evidence: Low, Strength of Recommendation: Strong.] 
6. Patients should not be prescribed antipsychotics or selective serotonin reuptake inhibitors (SSRI) antidepressants if the primary reason is for the treatment of AUD. If SSRI antidepressants are prescribed for individuals with co-occurring mood disorders, clinicians and patients should be alert to the risk of increased alcohol cravings and use with SSRI therapy and discontinue as appropriate. [Certainty of Evidence: Strong, Strength of Recommendation: Moderate.] 

Continuing Care

1. Consider offering naltrexone or acamprosate to adult patients with moderate to severe AUD. These are first-line pharmacotherapy agents that may support patient-identified treatment goals. 
   1. Naltrexone is recommended for patients who have a treatment goal of either abstinence or a reduction in alcohol consumption. [Certainty of Evidence: High, Strength of Recommendation: Strong.] 
   2. Acamprosate is recommended for patients who have a treatment goal of abstinence. [Certainty of Evidence: High, Strength of Recommendation: Strong.] 
2. Consider offering topiramate to adult patients with moderate to severe AUD who do not benefit from or have contraindications to first-line medications. Some patients may express a preference for topiramate or gabapentin. 
   1. Topiramate. [Certainty of Evidence: Moderate, Strength of Recommendation: Strong.] 
   2. Gabapentin. [Certainty of Evidence: Low, Strength of Recommendation: Conditional.] 
3. Consider providing information about and referrals to specialist-led psychosocial treatment interventions to all patients with AUD. See the resource section for referral and specialist information. [Certainty of Evidence: Moderate, Strength of Recommendation: Strong.] 
4. Consider providing all patients with AUD information about and referrals to peer-support services, harm reduction interventions and/or other recovery-oriented services in the community. [Certainty of Evidence: Moderate, Strength of Recommendation: Strong

Extended Learning Document: Primary Care Approaches to Addressing the Impacts of Trauma and Adverse Childhood Experiences (ACEs)

All individuals experience trauma throughout their lives. These traumatic experiences may be previous events, or they may be current. The health care community’s understanding of trauma’s impacts on our health continues to evolve, particularly in the context of the In Plain Sight Report  highlighting the experiences of Indigenous peoples in Canada, the ongoing toxic drug crisis, and mass traumatic events, such as natural disasters, warfare and genocide. Primary care providers are encouraged to learn how trauma affects an individual's and community’s health, as well as their utilization of the health care services, and health care experiences.

This extended learning document seeks to introduce primary care providers to the concept of trauma-informed practice (TIP). It provides information about tools including, but not limited to, the Adverse Childhood Experiences (ACEs) questionnaire. This document also provides additional resources for ongoing learning and professional/ personal development. 

This is not a clinical practice guideline as research in this area is still evolving, especially the evidence for the use of the ACEs questionnaire in clinical practice. The focus of the document is on adults. While some resources are referenced for the pediatric population, history taking and management of adverse childhood experiences in children and adolescents are outside the scope of this guideline.

Key Learnings

• Build a strong, ongoing, consistent, and trusting relationship with patients. This is important to successfully address difficult topics in a culturally safe way and to support an individual’s ability to make positive changes over time. This enables primary care practitioners providing longitudinal care to better support their patients to improve their well-being, address past experiences, and give hope. While an ongoing relationship is important, there will be episodic encounters where practicing in a trauma-informed way will be imperative, to ensure patients return to seek care (e.g., walk-in or emergency department setting).

• Recognize and respect the prevalence of historical, intergenerational and current trauma, as well as the many ways that trauma can be experienced. See Indian Hospitals in Canada to learn more.

• Be sensitive to trauma-informed principles in patient interactions.

• Practice a reflective, continuous commitment to ongoing education, which is an important aspect of trauma-informed practice (TIP).

• Practice trauma-informed care, including considerations for staff and clinicians who have experienced trauma in their own lives. This trauma may come from personal experiences, or it could be secondary trauma experienced during exposure to another individual's traumatic experiences.

• It is important that healthcare providers build an informal system of peer support that they can draw on or contribute to. Skills, such as “The Four Cs,” can support care providers’ well-being while delivering TIP. The Physician Health Program (PHP) offers a confidential 24-hour intake and crisis support line (1-800-663-6729).

• It is not enough to have cultural awareness and cultural sensitivity to improve access and quality of health care services.  It is imperative that all these concepts are applied in practice as practitioners continue their cultural safety and humility journey and learning.

Minor revisions to the Direct Oral Anticoagulants (DOACs) (2023) guideline to reflect new PharmaCare coverage for Apixaban and FRAIL-AF randomized control trial results.

Venous Thromboembolism – Diagnosis and Management (2024) provides recommendations for the diagnosis and management of venous thromboembolism (VTE) in adults aged ≥ 19 years with hemodynamic stability. It includes lower limb deep vein thrombosis (DVT) and pulmonary embolism (PE) diagnosis in the outpatient setting and management of acute VTE.

Superficial thrombophlebitis and thrombosis in unusual sites (e.g., cerebral venous thrombosis, splanchnic vein thrombosis, upper extremity thrombosis) are outside the scope of this guideline. For information refer to the Thrombosis Canada Guidelines.

Key Recommendations include:

When DVT/PE is suspected, first calculate the Wells Score to determine the likelihood of DVT/PE as “likely” or “unlikely” before ordering any testing.

• For outpatients with suspected DVT/PE:

  • Do not order D-dimer if DVT/PE is deemed “likely” per Wells Score. Proceed directly to imaging.

  • Order D-dimer when deemed ‘unlikely’ per Wells Score because a negative test indicates imaging is not necessary and DVT/PE is excluded.

• For inpatients, proceed directly to imaging because risk stratification using D-dimer has not been validated.

• While awaiting objective imaging to diagnose VTE, start empiric anticoagulant therapy in Patients with higher likelihood (“likely”) of DVT/PE.

• Most patients with hemodynamically stable VTE can be treated on an outpatient basis.

• Direct Oral Anticoagulants (DOACs) are considered as first line therapies for most outpatients. They are contraindicated in pregnancy, breastfeeding, liver failure (Child-Pugh class C), dialysis, or triple-positive antiphospholipid syndrome (i.e., has lupus anticoagulant, anticardiolipin and antibeta-2-glycoprotein-1 antibodies).

• Ensure appropriate anticoagulant dosage is used for the specific treatment phase (initial therapy, primary treatment, secondary prevention).

• Minimum duration of anticoagulation is 3-6 months for all patients with an acute DVT/PE.

• Referral to a thrombosis specialist is recommended to help determine optimal duration of anticoagulation. Continue anticoagulation therapy while awaiting referral.

• Avoid elective surgeries during the first 3-6 months of treatment.

• Hereditary thrombophilia testing and occult cancer screening are not indicated in most patients with thrombosis because results rarely influence management.

Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management in Primary Care (2024) provides recommendations for adults with chronic obstructive pulmonary disease (COPD) in primary care.

Key Recommendations include:

Diagnosis

• Confirm all presumptive, symptom-based diagnoses of COPD one time with spirometry postbronchodilator ratio of FEV1/FVC < 0.7.
• Understand asthma and COPD are distinct diagnoses and may exist in the same patient. [NEW, 2024]
• CT is not needed to diagnose COPD but may be useful for screening lung cancer. [NEW, 2024]

Management

• Encourage all patients who smoke to quit or decrease use as treatment for COPD.
• Manage COPD early in order to slow disease progression. [NEW, 2024]
• Investigate and manage possible comorbidities to optimize outcomes.
• Refer patients, especially those with moderate to severe COPD, to a respiratory therapist for education and/or pulmonary rehabilitation.
• Provide appropriate immunizations to reduce the risk of exacerbation and mortality. [NEW, 2024]
• Consider checking baseline blood eosinophil count prior to commencing inhaled corticosteroid (ICS). [NEW, 2024]

Environmental Impact and Climate Change

• Consider medication options with lower environmental impact. Metered-dose inhalers (MDIs) contribute disproportionately to climate change, which in turn can affect COPD. [NEW, 2024]
• Prepare for climate events such as wildfire and extreme heat, which can exacerbate COPD symptoms. [NEW, 2024]

Education

• Prescribe appropriate controller and rescue medications along with a COPD action plan.
• Evaluate the patient's inhaler adherence and technique regularly.