ABSTRACT: Alcohol use disorder is highly prevalent and has a significant impact on individuals and society. Research suggests that physicians underutilize medications for relapse prevention even though there is good evidence to support pharmacotherapy for this. Moreover, in outpatient settings, benzodiazepines for alcohol withdrawal are sometimes prescribed in ways that may not be safe. The Quick Guide to Outpatient Treatment of Alcohol Use Disorder was created as part of a UBC Family Practice Resident Scholar Project. The guide was developed with feedback from physicians who have experience in addiction medicine, and was subsequently reviewed and approved by the British Columbia Centre on Substance Use to ensure it was consistent with the centre’s newly released clinical guidelines. The guide focuses on safe management of alcohol withdrawal in an outpatient setting and on relapse prevention. Physicians can use this supplementary resource along with practice guidelines and clinical judgment.
An easy-to-use guide produced as part of a UBC Family Practice Resident Scholar Project supports physicians prescribing medications to treat alcohol withdrawal symptoms and prevent relapse.
Alcohol is the most frequently used intoxicating substance in the world and is responsible for substantial morbidity and mortality. Numerous resources have been committed to managing health issues related to marijuana and opioid use, but in Canada, alcohol use continues to have a much greater societal and economic impact than all illegal drugs combined. Alcohol is legal, highly available, and more socially accepted than other intoxicating substances.
Alcohol use disorder
Alcohol use disorder (AUD) is defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress. It is a common primary care issue affecting approximately 2% to 9% of family practice patients. The 12-month prevalence of AUD in North America is 8.5%. In Canada, at least half of all alcohol consumed is in excess of Canada’s Low-Risk Alcohol Drinking Guidelines.
The costs of AUD to individuals and society are immense and include accidents, violence, and suicide, as well as negative impacts on driving, school, work, interpersonal relationships, and physical health.
Treatment of alcohol use disorder
Several studies have shown that treatments for AUD and alcohol withdrawal are underutilized.[5-14] Less than 33% of patients with AUD receive any treatment, and less than 5% receive medications as a part of treatment. Some of the common barriers for physicians include a lack of knowledge about AUD and alcohol withdrawal, a lack of formal training in treating AUD, and a lack of familiarity with different treatment options and the benefits and risks of each option.[5,7-11,13,16,17] There are no clear data on which of these barriers is the most significant in terms of preventing more physicians from treating AUD and alcohol withdrawal in an outpatient setting.
Treatment of AUD includes widely known and well-accepted behavioral intervention programs. However, there is increasing evidence that medications can be used as well for both alcohol withdrawal syndrome and relapse prevention.[6,8,12,14,17-29] The number needed to treat (NNT) to either reduce heavy drinking or increase abstinence from alcohol for the two most commonly used medications (naltrexone and acamprosate) is 10 to 12, which is substantially better than the NNT for medications used for many other medical disorders. However, evidence suggests that these medications are underutilized by prescribers.[5-13,18,19,31]
Traditionally, alcohol withdrawal has been treated with benzodiazepines (BZDs), but there is increasing awareness of problems associated with their use.[8,9,28,29] This has motivated researchers to find safer but still effective alternatives to use in outpatient settings. Evidence for gabapentin in treating mild to moderate alcohol withdrawal symptoms is increasing.[8,14,19-21,23,25,26,32] Head-to-head trials that have compared gabapentin and BZDs have shown gabapentin is as effective as lorazepam or chlordiazepoxide in treating mild to moderate alcohol withdrawal symptoms.[28,29] Naltrexone, an opioid antagonist, is considered first-line therapy for relapse prevention; it works by reducing the pleasurable and reinforcing effect of alcohol. Acamprosate, a GABA agonist/glutamate antagonist, is also commonly used for relapse prevention; it works by rebalancing neuronal brain changes that occur from chronic alcohol use.
Prior to the 2019 release of the British Columbia Centre on Substance Use (BCCSU) Provincial Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder, there was little readily available information on outpatient management of alcohol withdrawal. The previous BC guidelines outlined an approach for identifying and managing alcohol withdrawal in an outpatient setting, but this approach focused on using benzodiazepines in a home setting. The pharmacological treatment listed in the previous BC guidelines involves using diazepam for acute withdrawal symptoms and then naltrexone, acamprosate, or disulfiram for long-term relapse prevention. UpToDate has information on treating mild alcohol withdrawal with either BZD or gabapentin in an outpatient setting, and provides options for relapse prevention. Other position papers provide information only on BZD use; they have not been updated to include gabapentin or other treatments.
Guide to treating AUD
To address knowledge gaps regarding the treatment of AUD, we created a clinical resource for family physicians to use when considering treatment for a patient with suspected AUD. The Quick Guide to Outpatient Treatment of Alcohol Use Disorder [Figures 1A and 1B] was developed as part of a UBC Family Practice Resident Scholar Project. The guide focuses on the assessment, treatment, and monitoring of AUD, and relies on the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) scoring system [Figure 2] for assessing the risk of alcohol withdrawal syndrome. A 2018 study by St. Paul’s Hospital in Vancouver examined the usefulness of various predictive alcohol withdrawal severity scales and found the PAWSS score to be the most useful.
The guide emphasizes the importance of behavioral interventions and provides details on medications that can be used to manage alcohol withdrawal safely in an outpatient setting and how to prevent relapse. Information on using BZDs in withdrawal management and cautions that should be exercised are also provided. Instructions for accessing PharmaCare coverage are included.
The guide is based on previous guidelines, research, and expert opinion from local addiction medicine physicians, and was reviewed and approved by the BCCSU to ensure it was consistent with the 2019 provincial guideline. Development of the guide was inspired by a similar quick reference guide to buprenorphine/naloxone.
The guide was designed for easy use and distribution so that a wide range of primary care providers can become familiar with prescribing certain medications to treat AUD. This will make AUD treatment more accessible and affordable for patients and will improve treatment outcomes. AUD treatment should not have to be limited to specialized care. However, the guide was not designed to be a comprehensive resource, and its users are encouraged to seek support for challenging cases. There may be other treatment options that were excluded from the guide for the sake of simplicity.
While we were unable to critically assess the impact of the guide on prescribing practices during the Resident Scholar Project, we hope that we or another resident group will be able to do so in the future.
Alcohol is the most frequently used intoxicating substance in the world, and alcohol use disorder is a common primary care issue. Our guide was created to support family physicians in safely treating AUD and managing mild to moderate alcohol withdrawal. The guide focuses on pharmacotherapy and emphasizes the importance of using concurrent behavioral interventions. It can be used as a supplementary resource in an office setting, along with current practice guidelines and clinical judgment.
We would like to thank Dr Roger Walmsley, our residency project preceptor and ER physician with a focus on addiction medicine, as well as Dr Hector Baillie and Dr Heather Yule, academic site leads, for their input and guidance throughout the residency project. We would also like to thank Dr Theodore Jankowski, Dr Ramm Hering, and Dr Christy Sutherland, addiction medicine physicians who kindly provided input on the handout, as well as Ms Emily Wagner and Ms Amanda Giesler from the BC Centre on Substance Use for their generous help in reviewing and editing the handout.
This article has been peer reviewed.
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33. Government of British Columbia. BC guidelines. Problem drinking, 2013. Accessed 10 December 2018. www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/problem-drinking.
34. British Columbia Centre on Substance Use. Provincial guideline for the clinical management of high-risk drinking and alcohol use disorder. 2019. Accessed 19 August 2020. www.bccsu.ca/wp-content/uploads/2020/03/AUD-Guideline.pdf.
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Dr Molavi completed a family medicine residency at UBC’s Nanaimo site and enhanced skills training in addiction medicine through UBC, and is now a family physician and a staff addiction medicine physician at Nanaimo Regional General Hospital. Dr Guruge also completed a family medicine residency at UBC’s Nanaimo site and is currently practising as a family physician in White Rock. Dr Kelly completed a family medicine residency at UBC’s Strathcona site and is currently practising as a family physician in Comox.
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