Problem Drinking

Effective Date: April 1, 2011
Revised Date: April 1, 2013

Problem Drinking Part 1 - Screening and Assessment (HTML) - PDF version (PDF, 573KB) Problem Drinking Part 2 - Brief Intervention (HTML) - PDF version PDF, 377KB Problem Drinking Part 3 - Office Based Management of Alcohol Withdrawal and Prescribing Medications for Alcohol Dependence (HTML) - PDF version PDF, 370KB

Problem Drinking Part 1 - Screening and Assessment

Recommendations and Topics

Scope

This guideline provides practitioners with practical information on how to conduct screening for problem drinking in adults aged ≥ 19 years.* Approximately 350,000 British Columbians are problem drinkers.¹ This means that in a typical family practice of 1,500 patients, 120-200 patients are at risk for alcohol abuse or dependence. Problem drinking affects the medical management of every chronic medical and mental health condition. Research has shown that many screened patients cut down on their drinking simply because they were asked about their alcohol use, and effective screening for problem drinking can be completed in as little as 5 minutes.² Although this document does not deal specifically with teenagers, screening for this age group is also recommended.

* Significant portions of this guideline were adapted from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), "Helping Patients Who Drink Too Much", A Clinicians' Guide, Updated 2005 Edition, and should be fully acknowledged for developing this useful clinical tool. A full copy of their guideline and reference materials can be found on NIAAA's website at http://pubs.niaaa.nih.gov

The following steps are outlined in this guideline:

• Screening - asking about alcohol use
• Assessment for at-risk drinking, alcohol abuse or dependence

Diagnostic Code:

303: Alcohol dependence syndrome 305: Non dependent use of drugs

Screening and Assessment

Screening identifies patients who need further assessment or treatment by determining their level of risk based on reported alcohol use and other relevant clinical information. Consider the following two screening questions during any patient interaction, when clinical triggers/red flags are observed (see Table 1) and/or when a patient fails to respond to appropriate management (see Screening - Asking About Alcohol Use [PDF, 154KB]).

Q1.	Do you sometimes drink beer, wine or other alcoholic beverages?
Q2.	How many times in the past year have you had - 5 or more drinks in one day (men)? 4 or more drinks in one day (women)?

Practitioners may wish to use the Alcohol Screening Note (PDF, 154KB) provided with this guideline.

Interventions should be selected based on the assessment completed during the screening. Although alcohol misuse is a spectrum disorder, positive screens will fall into one of three categories:

1. At-risk drinking:	Men - 5 or more drinks on one or more days in the last year. Women - 4 or more drinks on one or more days in the last year.
2. Alcohol abuse:	Patient meets 1 or more Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria for abuse in the last 12 months.
3. Alcohol dependence:	Patient meets 3 or more DSM IV criteria for dependence in the last 12 months.

Table 1: Clinical Triggers / Red Flags

Medical	Mental	Psychosocial
MCV > 96 Elevated GGT, AST, ALT (esp. ↑ GGT or AST:ALT > 2:1) GERD, hypertension, diabetes, pancreatitis Chronic non-cancer pain Alcohol on breath	Cognitive impairment or decline Mood, anxiety or sleep disorder Significant behavioural or academic change	Unexplained time off work/loss of employment Frequent no show for appointments Poor medication compliance Significant life event (e.g., divorce, loss of spouse, parent) Recent or recurrent trauma or domestic violence High-risk behaviours (e.g., problem gambling, DUI, STIs)

Note: Laboratory evaluation, including liver function tests, are not necessary unless clinically indicated and are not sensitive enough to be used alone as screening tests.

Abbreviations: MCV, Mean cell volume; GGT, Gamma-glutamyl transpeptidase; AST, Aspartate aminotransferase; ALT, Alanine transaminase; GERD, Gastroesophageal reflux disease; DUI, Driving under the influence; STI, Sexually transmitted infection

AUDIT, CAGE and CRAFFT Tests

• AUDIT: The Alcohol Use Disorders Identification Test (AUDIT), a 10 item questionnaire, can identify at-risk or problem drinking as well as dependence.³ The test can be used as a re-assessment tool by repeating it at a later time.
• CAGE: The CAGE questionnaire is a less sensitive tool at detecting alcohol abuse. This test can be used in addition to the screening provided in this guideline. However for primary screening it is recommended physicians use the two-question screen first.
• CRAFFT: The CRAFFT screen is specifically designed for use in adolescents.

Screening - Asking About Alcohol Use

Assessment For Alcohol Abuse or Dependence

Assessment

• The following tables provide the DSM IV criteria and sample questions for determining alcohol abuse or dependence.
• Questions correspond with alcohol screening note criteria for abuse or dependence.
• First assess for alcohol abuse, then, if indicated, assess for dependence.

General questions

One of the following introductory questions can be used before asking about abuse or dependence:

Q. Has your life ever been affected by alcohol?
Q. Has your spouse or anyone said anything about your drinking?
Q. How long have you been drinking like this?

Questions and Criteria for Assessing Abuse

In the past 12 months, has the patient's drinking caused or contributed to -	Sample Questions	No	Yes
A1. Role failure	Q. Have you missed work or class because of your drinking?
A2. Risk of bodily harm	Q. Do you sometimes drink and drive?
A3. Run-ins with the law / legal issues	Q. Have you been charged with a DUI or been given a road side suspension?
A4. Relationship trouble	Q. Has your spouse or family complained about your drinking?

Conclusion -

Yes ≥ 1 --- your patient has alcohol abuse. Proceed to the questions below. No --- proceed to Part 2 - Brief Intervention for At-Risk Drinking.

Questions and Criteria for Assessing Dependence

In the past 12 months, the patient has -	Sample Questions	No	Yes
D1. Increased tolerance	Q. Do you need to drink more to get the same affect?
D2. Experienced withdrawal	Q. When you stop drinking, have you ever experienced physical or emotional withdrawal? Have you had any of the following symptoms: irritability, anxiety, shakes, sweats, nausea, or vomiting?
D3. Failed to stick to drinking limits	Q. Do you often drink more than you plan to?
D4. Failed attempts to cut down or stop drinking	Q. Have you ever tried to cut down or stop drinking? How long did that last?
D5. Spent a lot of time on drinking related activities	Q. Do you spend more time thinking about or recovering from alcohol than you used to? Have you ever thought of ways to avoid getting caught?
D6. Spent less time on other matters	Q. Have you reduced family or recreational events because of alcohol use in the past year?
D7. Kept drinking despite psychological or physicalproblems	Q. Do you think that drinking is causing problems for you? What keeps you drinking?

Conclusion -

Yes ≥ 3 --- your patient has alcohol dependence. Proceed to Part 2 - Brief Intervention for Alcohol Dependence. No --- your patient still has alcohol abuse. Proceed to Part 2 - Brief Intervention for Alcohol Abuse.

Rationale

Every health care practitioner will encounter patients with alcohol problems in their practice. It is therefore important that all adolescent and adult patients be screened for problem drinking at some time. In BC as many as one in 10 visits to Vancouver General Hospital Emergency Room was for substance abuse.⁴ As well, the number of patients staying at Vancouver General and University of British Columbia Hospitals due to substance abuse increased by 44% between 2005 and 2008 (from 1,317 to 1,896).⁵ Screening and brief intervention are effective ways to reduce alcohol use as well as reduce acute care utilization. Research shows:

• Screening, Brief Intervention and Referral to Treatment (SBIRT) can cut hospitalization costs by $1,000 per person screened and save $4 for every $1 invested in trauma center and emergency department screening.^6,7,8
• Comparing the results of those who received brief counseling with those who did not, researchers found that counseling resulted in a 40 to 50% decrease in alcohol consumption, a 42% drop in emergency room visits, a 55% decline in motor vehicle crashes, and a 100% reduction in arrests for alcohol or other substance violations.²

Research has also shown that many screened patients cut down on their drinking simply because they were asked about their alcohol use; likewise, brief interventions have been shown to effectively reduce alcohol and other drug use.⁹

References

1. BC Ministry of Health. Every door is the right door: A British Columbia planning framework to address problematic substance use and addiction. May 2004.
2. Grossberg, PM, Brown, DD, Fleming MF. Brief physician advice for high-risk drinking young adults. Ann of Fam Med. 2004; 2: 474-480.
3. Babor TF, De La Fuente, JR, Saunders, et al. (1992). AUDIT: The Alcohol Use Disorder Identification Test. Guidelines for use in primary health care. Geneva, Switzerland: World Health Organization.
4. Brubacher JR, Mabie A, Ngo M, et al. Substance-related problems in patients visiting an urban Canadian emergency department. Can J Emerg Med. 2008;10:198-204.
5. Vancouver Coastal Health Authority. Acute inpatients for Vancouver General Hospital and University of BC Hospital data for fiscal years 2005/2006, 2006/2007, and 2007/2008, mental and behavioural disorders due to psychoactive substance use (F10-F16, F18-F19) diagnosis types: most responsible diagnosis (type M) and pre-admit comorbidity diagnosis (type1).
6. Richard Brown, M.D., associate professor at the University of Wisconsin School of Medicine and Public Health. "Taking Burden Off Physicians Key to SBI Growth" Join Together Project, Boston School of Publiuc Health.
7. Gentilello LM, Ebel BE, Wickizer TM, et al. Alcohol interventions for trauma patients treated in emergency departments and hospitals. A cost benefit analysis. Ann Surg. 2005 April;241(4):541-550.
8. Longnecker M, MacMahon B. Associations between alcoholic beverage consumption and hospitalization, 1983 National Health Interview Survey. Am J of Public Health. 1988 Feb;78(2):153-6.
9. Anderson P, Aromaa S, Rosenbloom D, et al. Screening and brief intervention: Making a public health difference. Published 2008 by Join Together with support from the Robert Wood Johnson Foundation.

Resources

BC Health Authority Websites - search under mental health and substance use
Fraser Health Authority:	www.fraserhealth.ca
Interior Health Authority:	www.interiorhealth.ca
Northern Health Authority:	www.northernhealth.ca
Provincial Health Services Authority:	www.phsa.ca
Vancouver Coastal Health Authority:	vch.eduhealth.ca www.vch.ca
Vancouver Island Health Authority:	www.viha.ca

British Columbia Resources
Centre for Addictions Research of BC: www.carbc.ca
Centre for Applied Research in Mental Health and Addiction: www.carmha.ca.

Canadian Centre on Substance Abuse: www.ccsa.ca

Centre for Addiction and Mental Health: www.camh.net

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar): www.chce.research.va.gov

CRAFFT: www.projectcork.org

Here to Help: www.heretohelp.ca

National Institute on Alcohol Abuse and Alcoholism (NIAAA)
For examples on conducting screening and interventions, please visit:
https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/screen-and-assess-use-quick-effective-methods

Physicians are strongly recommended to complete the NIAAA case examples (and CME credits) as it will assist them in using the guideline.

Materials on the website also include:

• Physician education and video case examples
• Sample forms for your office
• Medication information
• Patient education
• Online CME/CE Credits

Appendices and Associated Documents

Appendix A - Standard Drink Size Illustration (PDF, 195KB)

Alcohol Screening Note (HLTH 2824) (PDF, 154KB)

Problem Drinking Part 2 - Brief Intervention

Recommendations and Topics

Scope

This guideline provides practitioners with practical information on how to conduct brief intervention for problem drinking in adults aged ≥ 19 years and can be used after a positive screen occurs when using the BC Guideline "Screening for Problem Drinking".* Once screening is complete and a patient is deemed at-risk, physicians may perform a brief intervention. Problem drinking is a behaviour that can be changed through intervention, and physicians in primary and hospital based care are in a key position to make a difference.^1-5 A study of two minute brief intervention screenings concluded that "self reported patient status at 6 months indicated significant improvements over baseline for illicit drug use and heavy alcohol use."⁶

Brief interventions motivate patients to lower their risk for alcohol related problems and are often successful in addressing other medical issues including medication adherence, weight loss, smoking cessation and dietary habits. If your patient is seeing you for another problem, it may be necessary for screening to be done at the first appointment and intervention done at a follow up appointment.

* Significant portions of this guideline were adapted from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), "Helping Patients Who Drink Too Much", A Clinicians' Guide, Updated 2005 Edition, and should be fully acknowledged for developing this useful clinical tool. A full copy of their guideline and reference materials can be found on NIAAA's website at http://pubs.niaaa.nih.gov

The following steps are outlined in this guideline:

• Brief intervention
• Follow-up and support

Diagnostic Code:

303: Alcohol dependence syndrome 305: Non dependent use of drugs

Selected interventions should be based on the assessment completed during the screening (See Problem Drinking Part 1 - Screening and Assessment). Although alcohol misuse is a spectrum disorder, positive screens will fall into one of three categories.

1. At-risk drinking:	Men - 5 or more drinks on one or more days in the last year. Women - 4 or more drinks on one or more days in the last year.
2. Alcohol abuse:	Patient meets 1 or more Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria for abuse in the last 12 months.
3. Alcohol dependence:	Patient meets 3 or more DSM IV criteria for dependence in the last 12 months.

Practitioners may wish to use the Brief Intervention Follow-up Note (PDF, 147KB) provided with this guideline.

Brief Intervention For At-Risk Drinking (no abuse or dependence)

Intervention for Alcohol Abuse

Intervention for Alcohol Dependence

Follow-up and Support

Rationale

Every health care practitioner will encounter patients with alcohol problems in their practice. It is therefore important that all adolescent and adult patients be screened for problem drinking at some time. In BC as many as one in 10 visits to Vancouver General Hospital Emergency Room was for substance abuse.⁷ As well, the number of patients staying at Vancouver General and University of British Columbia Hospitals due to substance abuse increased by 44% between 2005 and 2008 (from 1,317 to 1,896).⁸ Screening and brief intervention are effective ways to reduce alcohol use as well as reduce acute care utilization. Research shows:

• Screening, Brief Intervention and Referral to Treatment (SBIRT) can cut hospitalization costs by $1,000 per person screened and save $4 for every $1 invested in trauma center and emergency department screening.^9-11
• Comparing the results of those who received brief counseling with those who did not, researchers found that counseling resulted in a 40 to 50% decrease in alcohol consumption, a 42% drop in emergency room visits, a 55% decline in motor vehicle crashes, and a 100% reduction in arrests for alcohol or other substance violations.¹²

Research has also shown that many screened patients cut down on their drinking simply because they were asked about their alcohol use; likewise, brief interventions have been shown to effectively reduce alcohol and other drug use.¹³

References

1. Fleming MF, Manwell LB, Barry KL, et al. Brief physician advise for alcohol problems in older adults: a randomized community-based trial. J Fam Pract. 1999 May;48(5):378-84.
2. Wood MD, Fairlie AM, Fernandez AC, et al. Brief motivational and parent interventions for college students: a randomized factorial study. J Consult Clin Psychol. 2010 June;78(3):349-61.
3. Hermansson U, Helander A, Brandt L, et al. Screening and brief intervention for risky alcohol consumption in the workplace: results of a 1-year randomized controlled study. Alcohol Alcohol. 2010 May-June;45(3):252-7.
4. Kaner EF, Dickinson HO, Beyer FR, et al. Effectiveness of brief alcohol interventions in primary care populations (Review). The Cochrane Collaboration 2009, Issue 3.
5. Henry-Edwards S, Humeniuk R, Ali R, et al. Brief intervention for substance use: A manual for use in primary care. (Draft version 1.1 for field testing). Geneva, World Health Organization, 2003.
6. Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009 Jan 1;99(1-3):280-95. Epub 2008 Oct 16.
7. Brubacher JR, Mabie A, Ngo M, et al. Substance-related problems in patients visiting an urban Canadian emergency department. Can J Emerg Med. 2008;10:198-204.
8. Vancouver Coastal Health Authority. Acute inpatients for Vancouver General Hospital and University of BC Hospital data for fiscal years 2005/2006, 2006/2007, and 2007/2008, mental and behavioural disorders due to psychoactive substance use (F10-F16, F18-F19) diagnosis types: most responsible diagnosis (type M) and pre-admit comorbidity diagnosis (type1).
9. Richard Brown, M.D., associate professor at the University of Wisconsin School of Medicine and Public Health. "Taking Burden Off Physicians Key to SBI Growth" Join Together Project, Boston School of Publiuc Health.
10. Gentilello LM, Ebel BE, Wickizer TM, et al. Alcohol interventions for trauma patients treated in emergency departments and hospitals. A cost benefit analysis. Ann Surg. 2005 April; 241(4):541-550.
11. Longnecker M, MacMahon B. Associations between alcoholic beverage consumption and hospitalization, 1983 National Health Interview Survey. Am J Public Health. 1988 Feb;78(2);153-6.
12. Grossberg PM, Brown DD, Fleming MF. Brief physician advice for high-risk drinking young adults. Ann Fam Med. 2004; 2:474-480.
13. Anderson P, Aromaa S, Rosenbloom D, et al. Screening and Brief Intervention: Making a Public Health Difference. Published 2008 by Join Together with support from the Robert Wood Johnson Foundation.
14. Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician. 2004 Mar 15;69(6):1443-1450.

 

Associated Documents

Brief Intervention Follow-up Note (HLTH 2825) (PDF, 147KB)

Problem Drinking Part 3 - Office Based Management of Alcohol Withdrawal and Prescribing Medications for Alcohol Dependence

Recommendations and Topics

Scope

This guideline provides practitioners with practical information on how to conduct office based management of withdrawal and medication management for adults aged ≥ 19 years with alcohol dependence.

* Significant portions of this guideline were adapted from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), "Helping Patients Who Drink Too Much", A Clinicians' Guide, Updated 2005 Edition, and should be fully acknowledged for developing this useful clinical tool. A full copy of their guideline and reference materials can be found on NIAAA's website at http://pubs.niaaa.nih.gov

The following are outlined in this guideline:

• Office based management of alcohol withdrawal
• Prescribing medications for alcohol dependence

Diagnostic Code:

303: Alcohol dependence syndrome 305: Non dependent use of drugs

Family physicians with a supportive, nonjudgmental, yet assertive attitude can be a great asset in confronting and treating patients with alcohol and other substance abuse problems. With the right attitude and the right tools, primary care physicians can manage most patients through the withdrawal phase of their illness and be a powerful influence in their ongoing struggle for recovery.¹

Section 1 - Office Based Management of Alcohol Withdrawal

Contraindications to outpatient alcohol withdrawal management: History of withdrawal seizure or withdrawal delirium. Multiple failed attempts at outpatient withdrawal. Unstable associated medical conditions: Coronary Artery Disease (CAD), Insulin-Dependent Diabetes Mellitus (IDDM). Unstable psychiatric disorders: psychosis, suicidal ideation, cognitive deficits, delusions or hallucinations. Additional sedative dependence syndromes (e.g., benzodiazepines, gamma-hydroxy butyric acid, barbituates and opiates). Signs of liver compromise (e.g., jaundice, ascites). Failure to respond to medications after 24-48 hours. Pregnancy. Advanced withdrawal state (e.g., delerium, hallucinations, temperature > 38.5 ° ). Lack of a safe, stable, substance-free setting and care giver to dispense medications.

Benzodiazepines are considered the treatment of choice for the management of alcohol withdrawal symptoms. Benzodiazepines reduce the signs and symptoms of alcohol withdrawal, incidence of delirium, and seizures. Based on indirect comparisons there is currently no strong evidence that particular benzodiazepines are more effective than others and selection should be made on an individual basis.^2,3 Alprazolam and triazolam are not recommended.

Diazepam (Valium®) is recommended because of  its efficacy profile, wide therapeutic window and "self tapering" effect due to its long half life. Other benzodiazepines can be considered such as: clonazepam, lorazepam and oxazepam. In the case of intolerance to benzodiazepines, physicians may wish to consider using a different class of medications (e.g., anticonvulsants). It is recommended that physicians with less experience with diazepam follow the rigid schedule. Physicians with experience using diazepam for alcohol withdrawal can consider front loading. Three medication protocols are provided (see Table 1).

When conducting outpatient withdrawal, do the following: Start on a Monday or Tuesday unless weekend coverage is available. See the patient daily for the first three to four days and be available for phone contact. Have the patient brought to the office by a reliable family member or caregiver. Prescribe thiamine (Vitamin B1) 100 mg daily for five days. Encourage fluids with electrolytes, mild foods and minimal exercise. Avoid natural remedies, caffeine or any activity that increases sweating (e.g., hot baths, showers and saunas/sweat lodges). Assess vital signs, withdrawal symptoms, hydration, emotional status, orientation, general physical condition and sleep at each visit. Encourage patient to call local (including health authority/municipal) Alcohol and Drug or Employee Assistance Programs and attend Alcoholics Anonymous (AA) meeting on day 3. Monitor for relapse, explore cause, and correct if possible. If unable to address cause, refer to inpatient detox.

Table 1: Treating Alcohol Withdrawal With Diazepam (Valium) ^1,2

Schedule	Day 1	Day 2	Day 3	Day 4
Rigid	10 mg four times daily	10 mg three times daily	10 mg twice daily	10 mg at bedtime
Flexible	10 mg every 4 to 6 hours as needed based on symptoms*	10 mg every 6 to 8 hours as needed	10 mg every 12 hours as needed	10 mg at bedtime as needed
Front loading**	20 mg every 2 to 4 hours until sedation is achieved; then 10 mg every 4 to 6 hours as needed. Max 60 mg/day	10 mg every 4 to 6 hours as needed. Max 40 mg/day	10 mg every 4 to 6 hours as needed. Max 40 mg/day	None

* Pulse rate >100 per minute, diastolic BP > 90 mm Hg or signs of withdrawal.
** Frequently, very little additional medication is necessary after initial loading.
Note: Benzodiazepines should be discontinued after withdrawal symptoms resolved (5-7 days).

Section 2 - Prescribing Medications for Alcohol Dependence

Three medications are currently available:   Naltrexone: Blocks euphoria associated with alcohol use. CONTRAINDICATED in patients taking opiates. Acamprosate: Reduces chronic withdrawal symptoms. Disulfiram: Adversive agent, causes nausea, vomiting, dysphoria with alcohol use and requires abstinence and counseling before initiation. Disulfiram should be used with caution.

Why should medications be considered for treating an alcohol use disorder?

Consider pharmacotherapy for all patients with alcohol dependency. Patients who fail to respond to psychosocial approaches and/or addiction counselling are particularly strong candidates. The above medications can be used immediately following withdrawal or any time thereafter; however, these medications should be used in conjunction with addiction counselling and other psychosocial supports.

Must patients agree to abstain?

No matter which alcohol dependence medication is used, patients who have a goal of abstinence, or who can abstain even for a few days prior to starting the medication, are likely to have better outcomes. Still, it is best to determine individual goals with each patient. Some patients may not be willing to endorse abstinence as a goal, especially at first. However, abstinence remains the optimal outcome.

A patient's willingness to abstain has important implications for the choice of medication. For example, a study of oral naltrexone demonstrated a modest reduction in the risk of heavy drinking in people with mild dependence who chose to cut down rather than abstain.⁴ Acamprosate is approved for use in patients who are abstinent at the start of treatment. Total abstinence is needed with disulfiram. Disulfiram is contraindicated in patients who continue to drink, because a disulfiram-alcohol reaction occurs with any alcohol intake.

Which of the medications should be prescribed? (see Appendix A: Prescription Medication Table for Alcohol Dependence (PDF, 142KB))

Which medication to use will depend on clinical judgment and patient preference. Each has a different mechanism of action. Some patients may respond better to one type of medication than another.

NALTREXONE:

Naltrexone works by blocking the euphoria associated with alcohol use. Its use is CONTRAINDICATED in patients taking opiates. Oral naltrexone is associated with lower percentage drinking days, fewer drinks per drinking day, and longer times to relapse.^5,6 It is most effective in patients with strong cravings. Efficacy beyond 12 weeks has not been established. Although it is especially helpful for curbing consumption in patients who have drinking "slips" it may also be considered in patients who are motivated, have intense cravings and are not using or going to be using opioids. It appears to be less effective in maintenance of abstinence as meta-analyses have shown variable results. Monitoring of liver enzymes may be required.

ACAMPROSATE:

Acamprosate works by reducing chronic withdrawal symptoms. Acamprosate increases the proportion of dependent drinkers who maintain abstinence for several weeks to months, a result demonstrated in multiple European studies and confirmed by a meta-analysis of 17 clinical trials.⁷ However, this has not been demonstrated in patients who have NOT undergone detoxification and NOT achieved alcohol abstinence prior to beginning treatment. Acamprosate should be initiated as soon as possible after detoxification and the recommended duration of treatment is one year. There is currently insufficient evidence to suggest that acamprosate has a therapeutic advantage over naltrexone.

DISULFIRAM:

Disulfiram is an adversive agent that causes nausea, vomiting, and dysphoria with alcohol use. Abstinence and counselling are required before initiation of treatment with disulfiram. Data on the effectiveness of disulfiram in alcohol use disorders is mixed. Disulfiram has been shown to have modest effects on maintaining abstinence from alcohol, particularly if it is administered under supervision. It is most effective when given in a monitored fashion, such as in a clinic or by a spouse. Thus the utility and effectiveness of disulfiram may be considered limited because compliance is generally poor when patients are given it to take at their own discretion.^8,9 Disulfiram may be considered for those patients that can achieve initial abstinence, are committed to maintaining abstinence, can understand the consequences of drinking alcohol while on disulfiram, and can receive adequate ongoing supervision. It may also be used episodically for high-risk situations, such as social occasions where alcohol is present. Daily uninterrupted disulfiram therapy should be continued until full patient recovery, which may require months to years.

How long should medications be maintained?

The risk for relapse to alcohol dependence is very high in the first 6 to 12 months after initiating abstinence and gradually diminishes over several years. Therefore, a minimum initial period of 6 months of pharmacotherapy is recommended.  Although an optimal treatment duration has not been established, treatment can continue for one to two years if the patient responds to medication during this time when the risk of relapse is highest. After patients discontinue medications, they may need to be followed more closely and have pharmacotherapy reinstated if relapse occurs.

If one medication does not work, should another be prescribed?

If there is no response to the first medication selected, you may wish to consider a second. This sequential approach appears to be common clinical practice, but currently there are no published studies examining its effectiveness. There is not enough evidence to recommend a specific ordering of medications.

Is there any benefit to combining medications?

There is no evidence that combining any of the medications to treat alcohol dependence improves outcomes over using any one medication alone.

Should patients receiving medications also receive specialized alcohol counselling or a referral to mutual help groups?

Offering the full range of effective treatments will maximize patient choice and outcomes, since no single approach is universally successful or appealing to patients. Medications for alcohol dependence, professional counselling, and mutual support groups are part of a comprehensive approach. These approaches share the same goal while addressing different aspects of alcohol dependence: neurobiological, psychological, and social. The medications are not prone to abuse, so they do not pose a conflict with other support strategies that emphasize abstinence. Using medications to treat patients does not interfere with counselling or other abstinence based programs such as AA.

Almost all studies of medications for alcohol dependence have included some type of counselling, and it is recommended that all patients taking these medications receive at least brief medical counselling. In a recent large trial, the combination of oral naltrexone and brief medical counselling sessions delivered by a nurse or physician was effective without additional behavioral treatment by a specialist.¹⁰ Patients were also encouraged to attend mutual support groups to increase social encouragement for abstinence.

Rationale

Outpatient alcohol withdrawal is safe and cost effective for the vast majority of problem drinkers.^11-14 Only about 20 per cent of problem drinkers require a hospital based or inpatient setting for alcohol detoxification.¹ Patients are treated earlier in the course of their disease in an office based setting which prevents further complications, and reduces the need for hospitalization. Withdrawal as an outpatient is more effective in reaching certain populations that may not use inpatient detox, such as women, children, youth, older adults, psychiatric populations, human immunodeficiency virus (HIV) affected, and people with other disabilities.

References

1. Bayard M, Mcintyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician. 2004 Mar 15;69(6):1443-1450.
2. Myrick H,  Anton RF. Treatment of alcohol withdrawal. Alcohol Health and Res World. 1998;22(1):38-43.
3. Amato L, Ninozzi S, Vecchi S, et al. Benzodiazepines for alcohol withdrawal. Cochrane Database of Systematic Reviews. 2010, Issue 3.
4. Kranzler HR, Armeli S, Tennen H, et al. Targeted naltrexone for early problem drinkers. J Clin Psychopharmacol. 2003;23(3):294-304.
5. Bouza C, Angeles M, Munoz A, et al. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: A systematic review. Addiction. 2004;99(7):811-828.
6. Srisurapanont M, Jarusuraisin N. Naltrexone for the treatment of alcoholism: A meta-analysis of randomized controlled trials. Int J Neuropsychopharmacol. 2005;8(2):267-280.
7. Mann K, Lehert P, Morgan MY. The efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals: Results of a metaanalysis. Alcohol Clin Exp Res. 2004;28(1):51-63.
8. Fuller RK, Gordis E. Does disulfiram have a role in alcoholism treatment today? Addiction. 2004;99(1):21-24.
9. Allen JP, Litten RZ. Techniques to enhance compliance with disulfiram. Alcohol Clin Exp Res. 1992;16(6):1035-1041.
10. Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioural interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. JAMA. 2006;295(17):2003-17.
11. Prater CD, Miller KE, Zylstra RG. Outpatient detoxification of the addicted or alcoholic patient. Am Fam Physician. 1999;60:1175-83.
12. Hayashida M, Alterman Al, McLellan AT, et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. N Engl J Med. 1989;320:358-65.
13. Hayashida M, Alterman A, McLellan T, et al. Is inpatient medical alcohol detoxification justified: results of randomized, controlled study. NIDA Res Monogr. 1988;81:19-25.
14. Stockwell T, Bolt L, Milner I, et al. Home detoxification from alcohol: its safety and efficacy in comparison with inpatient care. Alcohol Alcohol. 1991;26:645-50.
15. Kranzler HR, Gage A. Acamprosate efficacy in alcohol-dependent patients: Summary of results from three pivotal trials. Am J Addict. 2008 Jan-Feb;17(1):70-6.
16. Sass H, Soyka M, Mann K, et al. Relapse prevention by acamprosate: Results from a placebo-controlled study on alcohol dependence. Arch Gen Psychiatry. 1996 Aug;53(8):673-80.
17. U.S. Department of Health & Human Services, National Institutes of Health, National Institute of Alcohol Abuse and Alcoholism. Helping patients who drink too much: A clinician’s guide. 2005.

 

Appendices

Appendix A: Prescription Medication Table for Alcohol Dependence (PDF, 195KB)

This guideline is based on scientific evidence as of the Effective Date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association, and adopted by the Medical Services Commission.

The principles of the Guidelines and Protocols Advisory Committee are to: encourage appropriate responses to common medical situations recommend actions that are sufficient and efficient, neither excessive nor deficient permit exceptions when justified by clinical circumstances. Contact Information Guidelines and Protocols Advisory Committee PO Box 9642 STN PROV GOVT Victoria BC V8W 9P1 E-mail: hlth.guidelines@gov.bc.ca Web site: Clinical Practice Guidelines

 

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.