Here is the revised article on AUD by Dr. Harries, which more prominently emphasizes the stepwise approach in the BC AUD guidelines.
We appreciate the patience of our readership and special thanks to Dr. Harries for his passion and commitment to treating AUD. We would also like to thank Dr. Keith Ahamad (co-chair of the BC AUD guidelines) and Dr. Paxton Bach (addictions specialist) for their helpful review of this article.
By Dr. Jeff Harries (biography and disclosures)
Disclosures: Member of the BC Centre on Substance Use’s AUD Guideline Development Committee in 2018–2019. Currently involved in presenting the new BCCSU AUD Guidelines to GP/FP/NP’s and MH&SU clinicians across BC.
What I did before
Alcohol Use Disorder (AUD) is an illness that can strike anyone, anywhere; from fishing boats on BC’s Coast to ranches, orchards, or vineyards in BC’s Interior. It can stalk the elderly in Victoria, a family in Vanderhoof, and the young in Shaughnessy or Creston. It can impact people of any racial background or upbringing. Since anyone, anywhere, can develop AUD, it is crucial to address it whenever it is recognized. The option to send every person with AUD to a specialized treatment program is a significant hardship on the patient and their family and is often unnecessary. In most cases, someone with AUD is best cared for locally.
Approximately 350,000 British Columbians are problem drinkers. 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. Apr 1, 2011 Problem Drinking — Province of British Columbia (gov.bc.ca).
Previously, those with an alcohol use disorder were usually just told to stop drinking and to attend AA to reduce their chance of restarting. I sometimes prescribed disulfiram (Antabuse), but this never seemed to help. I found it hard to be hopeful because AUD was a very challenging condition, and continued suffering was often the norm for the patient, their family, and their community.
What changed my practice
I learned that there are a number of medications with a strong evidence base supporting their efficacy in treating someone with an alcohol use disorder, and the medications can be started while the patient is still drinking. Seeing how effective the right medication could be for a patient made it easy for me to impart hope to the patient, their family, and their community that attaining their goals — whether that is abstinence, or reduced heavy drinking — is possible.
I learned that AUD was like many other disorders we help our patients with. There are several possible pharmacotherapies that may work, and we just needed to be thoughtful and methodical about trying each option before we can arrive at the best one for our patient.
I learned that the most sensitive measure is that of the patient describing how they feel under different conditions or therapies. Like so many other conditions we treat, the patient’s history and response to treatment can guide the choice of therapeutic options.
What I do now
I listen carefully to the patient’s history and I help them to understand that they have a brain disorder caused by a combination of genetics, environment, and chronic heavy alcohol use. I help them understand they mustn’t feel shame and that they are not a bad person. I tell them the alcohol has injured their brain and caused changes that make it very difficult for them to go without alcohol. I tell them that we now know there are medications that can be started, along with counselling and other supports, even while they are still drinking, and that they can be effective at helping reduce cravings and supporting them in reducing or stopping drinking. I tell them about the BCCSU’s new AUD guidelines that identify 4 medications that have been shown to help them reduce or stop their drinking.
Those medications are:
- Naltrexone is a first-line therapy, an opiate receptor antagonist that makes alcohol less rewarding over time. It can be effective both at helping to reduce heavy drinking, as well as promoting abstinence from alcohol. The starting dose is 12.5mg BID x 3 days, with subsequent increases towards 50mg as needed and/or tolerated. Do not use naltrexone if a patient is taking an opiate or may need to take an opiate.
- Acamprosate is an alternative first-line therapy that is useful for patients to reduce their chance of going back to drinking once they have stopped. However, if the patient is still drinking or resumes drinking, acamprosate is less likely to be effective. The dose is 2 x 333mg TID, except if renally impaired.
- Topiramate is a second-line therapy that is also well-evidenced to help people both reduce or stop drinking. Start at a dose of 25mg once daily and titrate up by 25-50mg once daily each week, to a target dose of 200-300mg daily as tolerated. Note that side effects of topiramate such as parasthesias, dysgeusia, and cognitive fogging are common, and may limit its effectiveness in some patients.
- Gabapentin is an alternative second-line therapy that has been shown to help people reduce or stop drinking. Start at a dose of 100-300mg TID titrate up to maximum of 1800mg daily as tolerated. Gabapentin has some additional safety considerations including physiologic dependence, potential for non-medical use, and increased overdose risk.
More details on using these medications can be found on https://www.bccsu.ca.
The most important thing to remember is that one of these meds is likely to help your patient with AUD and you must commit to helping them find which of the meds will help them reduce or stop their alcohol use. Don’t stop looking until you are successful. If none of the first or second-line therapies described in the BCCSU AUD Guidelines work for your patient contact an Addictions Specialist (in BC call the RACE line at 1-877-696-2131) who may suggest a trial of other pharmacotherapies that early research shows may work for particular sub-groups of patients.
It is also important to understand and communicate with the patient that they will not necessarily need to be on these medications forever. A trial of a minimum of 3 months is usually recommended, depending on the circumstances, with the option to continue for as long as the patient feels as if the medications are helpful. When stopping, a preplanned option of resuming the medications if needed is suggested (i.e. they resume or feel like they will resume drinking).
I do not recommend people put themselves into acute withdrawal unless that is the only way they can be at a location where they can be physically safe. A gradual reduction in use over many weeks using one of these AUD medications is preferred to abruptly stopping alcohol intake. Importantly, however, if someone is in acute withdrawal you may use the PAWSS (Predicative Acute Withdrawal Severity Scale) to determine if they need to be hospitalized or if their withdrawal can be safely managed in the community. Benzodiazepines remain the primary treatment for acute alcohol withdrawal for admitted patients.
When I did not have much to offer patients with AUD, I did not look very hard in my practice for people with the disorder. Now, screening for people with AUD is extremely rewarding. It has been shown that risky drinking (more than 3 drinks/day or 15 drinks/week for men and 2 drinks/day or 10 drinks/week for women) can be reduced just by helping your patient understand the potential complications of risky drinking such as a higher risk of developing AUD, various cancers, injuries, etc.
The other essential thing I now know is to develop the goals with the patient, and not impose them on the patient. Helping patients to have hope and understand what is possible and to help them manage this disorder leads to better outcomes.
Patients with AUD should also be offered counselling to help them better understand themselves and to help re-map their minds for better lives going forward. Reconnecting to culture, family, and community, and to spiritual aspects of our lives can also be important to people’s recoveries, as can trauma therapies and therapy for PTSD.
Knowing what I now know about AUD and the very real hope there is for patients has been one of the most amazing things I have ever seen in medicine. Being able to share this information with you, my colleagues, is an honour.
Handouts for Patients
- A Sober Approach: Can Modern Medicine Help Alcoholics Recover? (NBC; 12-minute Video) (View) Accessed Nov 20, 2020
- Wasted… Nature of Things Documentary (CBC; 40 min Video) (View) Accessed Nov 20, 2020
- Pharmacotherapy Table BCCSU (View) Accessed Dec 7, 2020
References and Additional reading
- BCCSU AUD Guidelines (View) Accessed Nov 20, 2020
- The American Psychiatric Association Practice Guideline for The Pharmacological Treatment Of Patients With Alcohol Use Disorder 2018 (View) Accessed Nov 20, 2020
- Current Collaborative Prescribing Agreement (provides covered naltrexone or acamprosate to people in BC when MD/NPs sign once in career) (View) Accessed Nov 20, 2020
- PAWSS screening test (View) Accessed Nov 20, 2020
- Advances in Medications and Tailoring Treatment for Alcohol Use Disorder (View)
- Swift RM, Aston ER. Pharmacotherapy for alcohol use disorder: current and emerging therapies. Harv Rev Psychiatry. 2015;23(2):122-133. doi:10.1097/HRP.0000000000000079 (View)