Primary care management of alcohol use disorder and at-risk drinking

Counsel

Offer all patients with at-risk drinking a brief counseling session and follow-up. Physicians should review the LRDG with their patients and express concern about the amount or frequency of their patients’ alcohol consumption. They should link it to possible short- and long-term consequences and then determine the patients’ goals and readiness to change. Practical advice from physicians on reducing alcohol consumption helps patients achieve their goals (Box 1). The patient LRDG handout from the Canadian Centre on Substance Abuse summarizes this information.¹⁷ Patients should be offered a follow-up appointment to review their alcohol use. An important determinant of success in counseling is the strength of the relationship between the patient and the therapist.¹⁵ Strong relationships are characterized by trust, compassion, empathic listening, and encouragement of self-efficacy.

Offer all patients with AUD counseling sessions and ongoing (frequent and regular) follow-up. The counseling approach for patients with AUD is similar to patients with at-risk drinking. Physicians should express concerns about patients’ drinking and link it to consequences in patients’ lives.

Explore the patient’s goals. For those with milder AUD and few life consequences, reduced drinking is a reasonable goal. Pregnant women and those with health conditions that are worsened by alcohol use (eg, liver dysfunction, mood disorders, seizure disorders) should be encouraged to target abstinence. As well, patients with severe AUD typically find reduced drinking difficult to achieve. However, in all cases, to maintain engagement the physician should continue to support the patient if his or her goal is reduced drinking, while providing encouragement and practical advice that might help the patient obtain and sustain abstinence (Box 2). Physicians might want to negotiate with patients to have a short trial (1 to 2 months) of reduced drinking, and if that is not successful, target abstinence instead.

Determine if the patient is ready to make a change. For those who do not want to make a change, physicians should express concern but remain supportive. If the patient is considering a change but remains ambivalent, an exploration of the pros and cons of drinking can be helpful.

Once patients are ready to make a change, they need practical advice and solution-focused counseling for reduced drinking or abstinence (Boxes 1 and 2). Physicians should explore the barriers and conduits to change. The physician should work with the patient on plans to avoid triggers and encourage the patient to develop a supportive social network and healthy lifestyle. The physician should provide methods to cope with cravings (Box 3).¹⁸ Behavioural interventions incorporating these techniques have positive outcomes.¹¹ The physician should encourage frequent visits (weekly or every 2 weeks initially) and provide ongoing support.

Relapse is common in recovery; patients often go through many cycles of relapse and remission before achieving long-term remission. Patients typically feel shame and guilt about relapse, so physicians should address and normalize this possibility early on. Physicians and patients should work together to identify what led to the relapse and come up with a plan to minimize further relapses.

Prescribe

Family physicians should prescribe medications early in treatment. They should be familiar with the 3 Health Canada–approved medications used to treat AUD: disulfiram, naltrexone, and acamprosate (Table 1).^19,20 They should also be aware of the indications for the use of selective serotonin reuptake inhibitors. Typically these medications are prescribed for 6 months but they can be prescribed for longer. These medications are effective¹⁴ with a number needed to treat of 12 for both acamprosate and for naltrexone.¹⁹ Naltrexone and acamprosate also reduce health care utilization and costs.^21,22 Disulfiram is effective when taken under supervision.²⁰

Most private drug plans provide coverage for these medications. Quebec and the Yukon have naltrexone on the general formulary. Several provinces, such as Ontario, provide access to naltrexone and acamprosate through a special request process. Some provinces, such as Alberta, have no coverage. For patients who do not have drug plans, naltrexone and acamprosate are expensive. Disulfiram is no longer produced in Canada; however, it is inexpensive and patients can purchase it at compounding pharmacies or online.

Several other medications have shown promise in controlled trials, such as topiramate, ondansetron, and baclofen. However, use of these medications for AUD is off label; they should only be used if a patient has not responded to other medications. It is unclear if combining medications improves outcomes.²³

Naltrexone: Naltrexone is the first-line agent. It blocks the opioid receptor and diminishes the euphoric effects associated with alcohol. Studies have found it reduces the number of heavy drinking days and the amount consumed in single drinking episodes.²⁴ It also helps patients maintain abstinence.¹⁹ It can be prescribed while patients are still drinking. Naltrexone is contraindicated in patients who use opioids because, as an opioid antagonist, it can precipitate acute, severe withdrawal. Naltrexone has been associated with reversible elevations in liver transaminases at excessive doses (doses well above 50 mg/d). For this reason, it is contraindicated in patients with liver failure (ascites, encephalopathy, portal hypertension, etc) and should be used with caution in patients with any type of liver dysfunction or disease. Physicians should check liver transaminase levels before initiation and should not prescribe naltrexone if levels are greater than 3 times the upper limit of normal. They should also monitor levels regularly during therapy and discontinue naltrexone if transaminase levels rise to 3 times greater than baseline. To keep this in perspective, controlled trials have demonstrated that patients taking naltrexone have lower liver transaminases than patients taking placebo,²⁵ suggesting that naltrexone is safer for the liver than alcohol is. Patients must be instructed to tell other health care providers that they are taking naltrexone if they need opioids for acute pain; they will initially require higher doses of opioid pain relievers until the naltrexone wears off. To minimize gastrointestinal upset, the initial dose is 25 mg of naltrexone daily for 3 days, then 50 mg daily. The patient should experience reduced drinking and reduced cravings within a few days. If 50 mg has minimal effects on cravings, the dose can be increased to 100 mg or 150 mg (Table 1).^19,20

Disulfiram: Disulfiram blocks the conversion of acetaldehyde to acetic acid. The buildup of acetaldehyde causes flushing, tachycardia, sweating, and gastrointestinal upset. Studies have found disulfiram to be effective when it is dispensed under supervision.²⁰ The best candidates for this medication are highly motivated patients who have a partner, pharmacist, or Alcoholics Anonymous sponsor who is willing to supervise their use of the medication. Side effects include hepatitis, psychosis, neuropathy, and depression. Disulfiram is contraindicated in patients with liver dysfunction, cardiac disease, psychosis, or cognitive dysfunction, and in patients who are pregnant or trying to get pregnant. Patients must be abstinent before initiation for several days and cannot drink while taking the medication (Table 1).^19,20

Acamprosate: Acamprosate antagonizes glutamate, an excitatory neurotransmitter affected by alcohol. It increases the time to relapse but does not reduce heavy drinking.^19,26 Acamprosate is only effective for patients who have been abstinent for at least several days, so physicians should wait until a patient is abstinent for at least 4 days before starting the medication. However, if patients do relapse and drink, it does not cause a reaction. Contraindications include severe renal dysfunction. The dosage is 666 mg 3 times daily. Moderate renal dysfunction and low body weight require a dose adjustment (Table 1).^19,20

Selective serotonin reuptake inhibitors: Selective serotonin reuptake inhibitors should be prescribed for patients with a primary (underlying) mood or anxiety disorder. A primary disorder should be suspected if the mood or anxiety predates the AUD and persists during periods of abstinence.

Connect

Additional addiction and mental health services can improve outcomes for patients with AUD. However, patients with addictions have high no-show rates (often 50% or more) for services outside of their primary care clinics.²⁷ The reasons are multifactorial, but include ambivalence around treatment, lack of a therapeutic alliance with the provider, concurrent mental health problems, and costs associated with the visit (transportation, child care, etc).^28,29 Therefore, physicians need to be persistent and continually encourage patients to follow up with appointments and seek out other services.

Counselors: Counselors can play a key role in addiction recovery. Counselors should have specific addiction-counseling training such as relapse-prevention therapy, behavioural counseling, motivational therapy, and cognitive-behavioural therapy for addictions.³⁰

Support groups: Mutual support groups, like Alcoholics Anonymous and the Secular Organizations for Sobriety, might reduce risk of relapse for patients who attend regularly and engage in treatment.³¹ Patients should try several support groups before selecting one to find a good fit. Support groups have several advantages over formal treatment programs. In larger cities, meetings are held daily at multiple locations. Patients do not have to endure waiting lists or assessments. Members provide informal social support, which can be crucial for patients who have nonsupportive or negative social networks.

Day and residential treatment programs: These programs typically provide structured relapse prevention therapy in a group setting. Most residential programs last a few weeks, with ongoing follow-up (“after care”) of up to 2 years. Dropout rates for residential and day treatment programs are high,³² but for patients who complete a program, a third are abstinent at 1 year, and most of the remaining two-thirds show reductions in alcohol use.³³

Concurrent treatment: There is strong evidence that patients with concurrent mental health disorders (anxiety, depression, personality disorders, bipolar disorder, and other mental health problems) do best when they receive concurrent and integrated treatment (ie, treatment of both conditions at the same time with the same providers).³⁴ If these services are not available, primary care physicians can refer such patients to mental health services for assistance in providing concurrent (nonintegrated) treatment. Some patients might not need a referral; family physicians might feel comfortable providing concurrent treatment for noncomplex patients with mood disorders.

Trauma services: Patients with posttraumatic stress disorder benefit from concurrent services. They do best with validated trauma-specific integrated and concurrent services such as Seeking Safety.³⁵

Addiction medicine: Primary care physicians should consult an addiction medicine physician for more complex patients or if patients are not improving with primary care management.