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.

Figure 1:

Summary of clinical pathway for alcohol use disorder. DSM-5-TR = Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision.

Figure 2:

Alcohol use disorder (AUD) care pathway. Note: AUDIT = Alcohol Use Disorders Identification Test, AUDIT-C = AUDIT–Consumption, DSM-5-TR = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, SASQ = Single Alcohol Screening Question. *See Appendix 1, Section A2.2. †See Appendix 1, Box 10. ‡See Appendix 1, Box 11. §Brief advice consists of clinician-led feedback on the effects of alcohol, benefits to reducing, and strategies to reduce drinking. ¶See Appendix 1, Box 5. **Previously labelled as “alcohol abuse” in DSM-IV. ††Based on patient’s goals and preferences. ‡‡First-line pharmacotherapies are naltrexone and acamprosate.

Figure 3:

Withdrawal management pathway for alcohol use disorder. Note: AUD = alcohol use disorder, BID = twice daily, CIWA-Ar = Clinical Institute Withdrawal Assessment for Alcohol–Revised, DTs = delirium tremens, PAWSS = Prediction of Alcohol Withdrawal Severity Scale, QID = 4 times daily, SAWS = Short Alcohol Withdrawal Scale. *See Appendix 1, Box 16. †See Appendix 1, Box 7. ‡Offer oral thiamine (200 mg daily) before and during withdrawal management. In inpatient settings, offer parenteral thiamine (200–300 mg daily) for patients with suspected Wernicke encephalopathy, decompensated liver disease, or at risk of malnourishment, for 5 days minimum, followed by oral thiamine. §See Appendix 1, Box 14. ¶See Appendix 1, Box 15. **Example prescription for severe withdrawal: diazepam 10 mg BID-QID (days 1–3), 5 mg BID-QID (days 4–5), then reassess for days 6–7. Adjust daily based on symptoms and consider daily dispensing or blister packaging.