New guidance on alcohol and health from the Canadian Centre on Substance Use and Addiction

Author

Dr. Paxton Bach (biography and disclosures)

Disclosures: Received honoraria from UBC CPD: member of the UBC CPD Scientific Planning Committee for an online module on the clinical management of high-risk drinking and alcohol use disorder for primary care providers. Previous honoraria for speaking engagements from BCCSU ECHO Program, Moms Stop the Harm, Prince Albert Addiction Medicine Network, American College of Academic Addiction Medicine, and the American Society of Addiction Medicine (no ongoing relationships and no funding received from for-profit organizations). Received funding from CIHR and Michael Smith Health Research BC for research grants not related to this content. Mitigating potential bias: Recommendations are consistent with published guidelines: CCSA and BC AUD Guidelines.

Acknowledgments:

Special thanks to Dr. Simon Moore for his assistance with this article. We also acknowledge the UBC CPD Scientific Planning Committee for their insights that informed the scope of this work.

What I did before

Alcohol use is a significant contributor to morbidity and mortality across North America, responsible for over 77,000 hospital admissions and more than $14 billion in direct costs per year in Canada alone.¹ As recently as 2018 clinical guidance by the Canadian Centre on Substance Use and Addiction (www.ccsa.ca) had established “low-risk drinking guidelines”, with a threshold of:

• 10 standard drinks per week for women (with no more than 2 drinks a day on most days) or
• 15 standard drinks a week for men (with no more than 3 drinks a day on most days)²

Counseling patients on low-risk drinking practices involved an exploration of:

• the definition of a “standard drink” (i.e., one 341 ml beer or cider, one 5oz glass of wine, or 1.5 oz of distilled spirit), along with
• a discussion of keeping consumption levels below these recommendations in order to reduce long-term health risks.

What changed my practice

In 2023, the Canadian Centre on Substance Use and Addiction made a series of revisions to their recommended “low-risk drinking guidelines”, which have significant implications on clinical practice.³ The process was informed by an extensive and updated review of the global evidence on the effects of alcohol on health, along with sophisticated mathematical modelling of alcohol-related harms. The results suggested that previous thresholds, despite being determined as low-risk, were still associated with significantly higher rates of alcohol-related harms.

The authors of the revised clinical guidance used a risk threshold of 1 in 1000 (i.e., equivalent to preventing a 1 in 1000 risk of premature death), and advised marked changes in the recommended consumption limits for everyone, stating that:

• >2 standard drinks per week is associated with increased health risks,
• 3–6 standard drinks per week should be considered “moderate risk”, and
• >7 drinks per week is considered “increasingly high risk”.

Alternatively, a risk threshold of 1 in 100 resulted in a recommendation of no more than 6 standard drinks per week for everyone.

Rather than establishing a “safe” threshold, the new guidance situates alcohol-related harms along a continuum, recognizing that negative health and social consequences of alcohol can arise even at rates previously consistent with low risk.

The public summary of the new recommendations states quite simply: “Drinking less is better.”

The reception for these new recommendations has been polarized, with many health professionals appreciating a more realistic reflection of alcohol-related harms, while others have expressed concern over what is interpreted by many to be overly stringent recommendations. Much of this controversy, however, has related to the strict interpretation of the threshold regarded as low-risk, rather than an acceptance that alcohol-related harms (similar to so many other areas of human behaviour) occur along a continuum, and patients deserve to be counseled accordingly.

What I do now

In light of the new recommendations:

1. I no longer discuss a specific threshold for “low-risk drinking”, but rather use the new guidance to frame a discussion around the health-related consequences of alcohol use.
2. I make it clear to patients that alcohol at almost any level may have negative impacts on health, but that these effects occur along a spectrum and it is up to every individual to decide for themselves how much they will consume.
3. I highlight very clearly that the new guidelines are not meant to be interpreted as strict rules, but that every individual has the right to make educated decisions about one’s own health, and these new data can contribute to that informed decision-making.
4. I also discuss alcohol consumption in the context of other co-morbidities and risk factors, as someone who is already at a higher risk of cancer, heart disease, or other chronic conditions may weigh the new guidance differently based on their individual circumstances, values, and goals.

An additional benefit of the new guidance is how it can align clinically with existing recommendations on screening for high-risk alcohol use, allowing providers to transition smoothly between these conversations.

In British Columbia, the current recommended screening tool for adult patients in primary care settings is the Single Alcohol Screening Question (SASQ), which simply asks:

“In the past year, how often have you consumed more than 3 drinks (for adult women) or 4 drinks (for adult men) on any one occasion?”

This can be prefaced by introductions such as “I talk to all my patients about alcohol and other substance use. Would it be alright for us to talk about this now?” A positive screen to this question should prompt greater exploration of an individual’s drinking habits (including considering the use of further screening and risk stratification tools such as the AUDIT-C), an evaluation for possible alcohol use disorder using the DSM-5 criteria, and it allows an opportunity to provide some counseling around the new recommended low-risk consumption limits and the rationale behind these suggestions.⁴

For those patients who are interested in learning more about available resources to help reduce their drinking, I also direct them to the website https://helpwithdrinking.ca/ which contains practical advice for patients, family members, and health-care providers consistent with current Canadian guidelines. For health-care providers specifically, there are at-a-glance sections on:

1. Screening
2. Diagnosis
3. Treatment algorithms and much more

Overall the new recommendations have been a surprise to many, as they are a departure from previous iterations of low-risk guidelines and differ significantly from recommended limits elsewhere around the world. Once the initial adjustment is made, however, they serve as a useful primer for a discussion of alcohol-related risks along a spectrum and can be a valuable educational tool to refer back to in both primary and specialty care settings.

References

1. Canadian substance use costs and harms. CSUCH. Accessed March 6, 2024. (View)
2. Canadian Institute for Health Information. Alcohol harm in Canada: examining hospitalizations entirely caused by alcohol and strategies to reduce alcohol harm. CIHI. 2017. Accessed March 6, 2024. (View PDF)
3. Paradis C, Butt P, Shield K, et al. Canada’s guidance on alcohol and health: final report. Canadian Centre on Substance Use and Addiction. January 2023. Accessed March 6, 2024. (View PDF)
4. British Columbia Centre on Substance Use. Provincial guideline for the clinical management of high-risk drinking and alcohol use disorder. BCCSU. December 2019. Accessed March 6, 2024. (View PDF)

Resources

1. Paradis C, Butt P, Shield K, et al. Canada’s guidance on alcohol and health: final report. Canadian Centre on Substance Use and Addiction. January 2023. Accessed March 6, 2024. (View PDF)
2. British Columbia Centre on Substance Use. Provincial guideline for the clinical management of high-risk drinking and alcohol use disorder. BCCSU. December 2019. Accessed March 6, 2024. (View PDF)
3. Canadian Research Initiative in Substance Misuse; British Columbia Centre on Substance Use. For health care providers. Help with Drinking. Accessed March 6, 2024. (View)
4. British Columbia Centre on Substance Use. 24/7 addiction medicine clinician support line. BCCSU. Accessed March 6, 2024. (View)

Resources for Pathways users

View all emailable AUD information for patients in Pathways
Examples:

1. Help With Drinking (HelpWithDrinking.ca) 
2. Alcohol Low Risk Drinking Guidelines (CCSA)
3. Alcohol Use Disorder Medication – Naltrexone (HelpWithDrinking.ca)
4. A ReThink of the Way We Drink Alcohol – Mike Evans Video (10 min.)

View all AUD clinician tools in Pathways
Examples:

1. Alcohol Use Disorder (AUD) Medication Table (BCCSU)
2. Child and Youth Substance Use Care Pathway

Resources for patients

1. Help with Drinking. Accessed March 8, 2024. (View)
   1. Where to start: Canadian Research Initiative in Substance Misuse; British Columbia Centre on Substance Use. Where to start. Help with Drinking. Accessed March 8, 2024. (View)
   2. Supporting loved ones: Canadian Research Initiative in Substance Misuse; British Columbia Centre on Substance Use. Resources for supporting a loved one. Help with Drinking. Accessed March 8, 2024. (View)
2. Canadian Centre on Substance Use and Addiction. Canada’s guidance on alcohol and health. CCSA. Accessed March 8, 2024. (View)
   1. 1. Drinking less is better: Canadian Centre on Substance Use and Addiction. Drinking less is better. CCSA. Accessed March 8, 2024. (View PDF)
      2. Youth and alcohol: Canadian Centre on Substance Use and Addiction. Drinking less is better. CCSA. Accessed March 8, 2024. (View PDF)

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New guidance on alcohol and health from the Canadian Centre on Substance Use and Addiction

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