Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder.

Published in the Canadian Medical Association Journal on October 16th, 2023.

Original Guideline DOI Link

Guideline PDF Link

Full Guideline PDF Link

The general approach here is to provide the guideline recommendations in a straightforward text format, with detailed content from the full guideline included below. Text formatting is superior to visual formatting as used in PDF's with many tables because it can be reformatted to fit any size screen and is accessible to text to speech technologies that greatly enhance accessibility.

Pleae refer to the original guideline before using clinically, as this text is provided for convenience only, and is not guaranteed to be free from transcription errors.

Guideline Scope:

The 2023 Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder guideline provides direction on the identification and clinical management of high-risk drinking and AUD in adults (aged ≥ 26 yr) and youth (aged 11–25 yr).

Guideline Recommendations:

Recommendation 1: Ask Patients About Canada's Guidance on Alcohol.

When appropriate, clinicians should inquire about current knowledge of and offer education to adult and youth patients about Canada’s Guidance on Alcohol and Health, in order to facilitate conversations about alcohol use. (LOW, STRONG)

Recommendation 2: Routine Screening.

All adult and youth patients should be screened routinely for alcohol use above low risk. (MODERATE certainty of evidence, STRONG recommendation)

Ask permission to ask about alcohol (builds trust and comfort).

Screen with the Single Alcohol Screening Question (SASQ)

“In the past year, how often have you had more than 4 drinks (females) or 5 drinks (males) on any 1 occasion?”

• In Canada, a standard drink is 17.05 ml or 13.45 g of pure alcohol.

  • E.g. 341 ml (12 oz) of 5% beer.
  • E.g. 142 ml (5 oz) of 12% wine.
  • E.g. 43 ml (1.5 oz) of 40% spirits.

• If 1 occasion or more, ask further screening questions using the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol Use Disorders Identification Test–Consumption (AUDIT-C).

• For moderate risk of AUD: In addition to further screening, provide brief advice on the health risks and suggestions on how to cut back.

• For high risk of AUD: Diagnose using DSM-5-TR criteria and treat.

The AUDIT has better test characteristics, but the AUDIT-C is much shorter.

Risk stratification based on more detailed screening:

• Low risk for AUD: Indicated by an AUDIT score of 0–7 or AUDIT-C score of 0–4.
• Moderate risk for AUD: Indicated by an AUDIT score of 8–15 or an AUDIT-C score of 5–7.
• High risk for AUD: Indicated by an AUDIT score ≥ 16 or AUDIT-C score ≥ 8.

See Additional Materials below for more details.

Recommendation 3: Interview High-Risk Patients.

All adult and youth patients who screen positive for high-risk alcohol use should undergo a diagnostic interview for AUD using the Diagnostic and statistical manual of mental disorders, 5th ed, Text Revision criteria and further assessment to inform a treatment plan if indicated. (MODERATE certainty of evidence, STRONG recommendation).

See below for example diagnostic interview and full diagnostic criteria.

Recommendation 4: Brief Intervention for High-Risk Patients.

All patients who screen positive for high-risk alcohol use should be offered brief intervention. (MODERATE certainty of evidence, STRONG recommendation)

The FRAMES Model for MI-Based Brief Interventions

FRAMES is a mnemonic: Feedback, Responsibility, Advice, Menu, Empathic, and Self-effic

• Feedback: Provide individualized feedback on screening or assessment results. Asking open-ended questions about how the patient feels or thinks about the feedback can aid discussion.
• Responsibility: Using a strengths-based, patient-centred approach, emphasize that responsibility for making the choice to change behaviour ultimately rests with the individual.
• Advice: Seek permission from the patient first before giving advice. Provide clear advice that reducing or stopping alcohol use will reduce risk of future problems related to alcohol use. Many patients are unaware that their current drinking patterns could potentially lead to health or other problems, or make existing problems worse. Increased awareness of their personal risk can provide reasons to consider changing behaviour.
• Menu: Review a “menu” of different options for reducing or stopping alcohol use and encourage the patient to choose the strategies that best fit their values, preferences, circumstances, and needs. Providing choice reinforces a patient’s sense of control and responsibility and can strengthen motivation to change. Using a shared decision- making framework, encourage the patient to set goals that are realistic and meaningful to the patient.
• Empathetic: Use a warm, empathetic counselling style, which involves listening, understanding, and reflecting that understanding back to the patient (e.g., “reflective listening”), and is associated with improved BI outcomes.
• Self-Efficacy: Encourage and reinforce the patient’s self-efficacy and confidence in their ability to change. Individuals who believe that they can make changes are much more likely to do so than those who feel powerless or helpless to change their behaviour.

Recommendation 5: Withdrawal Risk Stratification.

Clinicians should use clinical parameters, such as past seizures or past delirium tremens, and the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) to assess the risk of severe alcohol withdrawal complications and determine an appropriate withdrawal management pathway. (MODERATE certainty of evidence, STRONG recommendation)

Clinicians should use clinical parameters, such as past seizures or past delirium tremens, and the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) to assess the risk of severe alcohol withdrawal complications and determine an appropriate withdrawal management pathway (strong recommendation, moderate-certainty evidence).

• PAWSS >= 4 findings = high risk of alcohol withdrawal.
• PAWSS <= 3 findings = low risk of alcohol withdrawal.

Recommendation 6: Low Withdrawal Risk Management.

For patients at low risk of severe complications of alcohol withdrawal (e.g., PAWSS < 4), clinicians should consider offering non-benzodiazepine medications, such as gabapentin, carbamazepine, or clonidine for withdrawal management in an outpatient setting (e.g., primary care, virtual).
(Gabapentin: MODERATE certainty of evidence, STRONG; Carbamazepine, Clonidine: LOW certainty of evidence, STRONG recommendation)

Recommendation 7: High Withdrawal Risk Management.

For patients at high risk of severe complications of withdrawal (e.g., PAWSS ≥ 4), clinicians should offer a short-term benzodiazepine prescription ideally in an inpatient setting (i.e., withdrawal management facility or hospital). However, where barriers to inpatient admission exist, benzodiazepine medications can be offered in outpatient settings if patients can be closely monitored. (HIGH certainty of evidence, STRONG recommendation)

Recommendation 8: Provide Ongoing Post-Withdawal Care.

All patients who complete withdrawal management should be offered ongoing AUD care. (LOW certainty of evidence, STRONG recommendation)

Recommendation 9: Psychosocial Treatments.

Adults and youth with mild to severe AUD should be offered information about and referrals to specialistled psychosocial treatment interventions in the community. (MODERATE certainty of evidence, STRONG recommendation).

• Research indicates that cognitive behavioural therapy and family based therapy have small to medium beneficial impacts on AUD outcomes.

Recommendation 10: First-Line Pharmacotherapy.

Adult patients with moderate to severe AUD should be offered naltrexone or acamprosate as a first-line pharmacotherapy to support achievement of patient-identified treatment goals.

• A. Naltrexone is recommended for patients who have a treatment goal of either abstinence or a reduction in alcohol consumption.
• B. Acamprosate is recommended for patients who have a treatment goal of abstinence. (HIGH certainty of evidence, STRONG recommendation).

Recommendation 11: Second-Line Pharmacotherapy.

Adult patients with moderate to severe AUD who do not benefit from, have contraindications to, or express a preference for an alternate to first-line medications can be offered topiramate or gabapentin.
(Topiramate: MODERATE certainty of evidence, STRONG recommendation; Gabapentin: LOW certainty of evidence, CONDITIONAL recommendation)

Recommendation 12: No SSRI or Antipsychotics for AUD.

Adult and youth patients should not be prescribed antipsychotics or SSRI antidepressants for the treatment of AUD. (MODERATE certainty of evidence, STRONG recommendation)

Recommendation 13: Avoid SSRI to treat AUD concurrent anxiety or depression.

Prescribing SSRI antidepressants is not recommended for adult and youth patients with AUD and a concurrent anxiety or depressive disorder. (MODERATE certainty of evidence, STRONG recommendation)

Recommendation 14: No Long-Term Benzodiazepines.

Benzodiazepines should not be prescribed as ongoing treatment for AUD. (HIGH certainty of evidence, STRONG recommendation)

Recommendation 15: Offer Peer-Support and Recovery-Oriented Programming.

Adults and youth with mild to severe AUD should be offered information about and referrals to peersupport groups and other recovery-oriented services in the community. (MODERATE certainty of evidence, STRONG recommendation)

Additional Content

Diagnostic criteria review:

The diagnosis of AUD can be made when a patient has a problematic pattern of alcohol use over a year that leads to clinically significant impairment or distress, involving at least 2 of the 11 DSM-5-TR criteria.

Patients are diagnosed with mild AUD if they have 2–3 of 11 criteria; moderate AUD with 4–5 of 11 criteria; and severe AUD with 6 or more of 11 criteria for at least 12 months.

These criteria are:

1. the patient often takes alcohol in larger amounts or over a longer period than they had intended
2. the patient has a persistent desire or has been unsuccessful in their efforts to cut down or control their use of alcohol
3. the patient spends a great deal of time trying to obtain alcohol, using alcohol or recovering from using it
4. the patient has troublesome craving (desire or urges) to use alcohol
5. the patient’s recurrent use of alcohol results in their being unable to fulfill major obligations in their roles at work, school or home
6. the patient continues to use alcohol despite experiencing ongoing or recurrent problems (social or interpersonal) that are caused or worsened because of their alcohol use
7. the patient has given up or reduced social, occupational or recreational activities important to them because of their alcohol use
8. the patient uses alcohol regularly in situations where it is a hazard to them physically
9. the patient continues to use alcohol even though they know they have a persistent or recurrent problem (physical or psychological) that is likely to have been caused by or worsened by alcohol use
10. the patient has tolerance to alcohol use that is demonstrated either by a need for substantially increased amounts to achieve intoxication or the effect that the patient desires, or a substantially decreased effect with their using the same amount of alcohol
11. the patient has experienced withdrawal that is demonstrated either by taking alcohol or something similar (e.g., a benzodiazepine) to relieve or avoid withdrawal symptoms, or by having the characteristic withdrawal syndrome.

Patients are diagnosed with mild AUD if they have 2–3 criteria; moderate AUD with 4–5 criteria; and severe AUD with 6 or more criteria for at least one year.

Risks associated with use:

Mathematical modelling revealed that 2 standard drinks per week is associated with a 1 in 1,000 mortality related to an alcohol condition, while 6 standard drinks per week is associated with a 1 in 100 risk.

Observational cohort studies have found that average long-term alcohol consumption levels as low as 1 or 2 standard drinks per day are directly or indirectly linked to increased risk of at least 8 different types of cancer (oral, pharynx, larynx, esophageal, liver, breast, colon and rectal cancers) as well as numerous other serious medical conditions (e.g., epilepsy, hemorrhagic stroke, cardiac dysrhythmias, liver cirrhosis, and hypertension).

In addition, there are a number of serious medical conditions directly attributed to long-term alcohol consumption, including AUD, alcohol-related psychosis, nervous system degeneration, polyneuropathy, myopathy, cardiomyopathy, gastritis, liver diseases (e.g., hepatitis), and pancreatitis.

Generally, there is a continuum of risk from negligible to low (≤ 2 standard drinks per week), through moderate (3–6 standard drinks per week) to high (≥ 7 standard drinks per week), with increasingly higher levels of risk with every additional drink.

Definitions:

High-risk Alcohol use: A pattern of alcohol use associated with the development of negative physical and/or mental health consequences.

• Adverse social consequences are common.
• Indicated by an AUDIT score ≥ 16 or AUDIT-C score ≥ 8.

Standard Drink:

• In Canada, a standard drink is 17.05 ml or 13.45 g of pure alcohol.
  • E.g. 341 ml (12 oz) of 5% beer.
  • E.g. 142 ml (5 oz) of 12% wine.
  • E.g. 43 ml (1.5 oz) of 40% spirits.

AUDIT/AUDIT-C: standard drink size = 10g of ethanol.

Blackouts:

Blackouts can be an indicator of severe intoxication or long-term alcohol use, as a considerable degree of alcohol tolerance is required to ingest the amount of alcohol that could trigger a subsequent episode of amnesia without loss of consciousness. Blackouts are transient episodes of retrograde amnesia typically without loss of consciousness that accompany various degrees of alcohol intoxication.

Alcohol Withdrawal Seizures:

Withdrawal seizures are typically generalized brief tonic-clonic seizures that occur 6–48 hours after reduction or discontinuation of alcohol use. Patients may mistake other experiences, such as tremor, for a seizure; it is important to define what is meant by a withdrawal seizure and differentiate it from other withdrawal symptoms. As patients with AUD are at increased risk of idiopathic epilepsy or seizure for other reasons, clinicians should clearly define withdrawal seizures as those that occur within 1–2 days of ceasing or greatly reducing alcohol use.

Delirium Tremens (DTs):

Delirium tremens is a severe consequence of alcohol withdrawal that requires immediate hospitalization and management; if left untreated, the risk of death is approximately 3–5%. Symptoms include profound disorientation, confusion, and agitation, accompanied by severe autonomic hyperactivity.276 In colloquial language, delirium tremens or “DTs” has come to loosely represent general symptoms of alcohol withdrawal.

Screening Tools:

Single Alcohol Screening Question:

"In the past year, how often have you consumed more than 4 drinks (for adult women) or 5 drinks (for adult men) on any one occasion?”

• Any response greater than “never” or “zero times” to the question SASQ question would be considered a potential indication of high-risk drinking or AUD. A review of validation studies for this SASQ

Hazardous Drinking Sensitvity: 84%.
Hazardous Drinking Specificity: 78%.
Alcohol Use Disorder Sensitivity: 88%.
Alcohol Use Disorder Specificity: 67%.

CAGE Tool

1. Have you ever felt you ought to Cut down on your drinking?
   1. Have people Annoyed you by criticizing your drinking?
   2. Have you ever felt bad or Guilty about your drinking?
   3. Have you ever had a drink in the morning (Eye-opener) to steady your nerves or get rid of a hangover?

At a cut-point of 2 or more “yes” responses, the CAGE has an estimated sensitivity of 84% and specificity of 85% for the detection of AUD in primary care patients.

CAGE (2+) AUD Sensitivity: 84%.
CAGE (2+) AUD Specificity: 85%.

Note: As a standalone screening tool, the CAGE is less sensitive and specific than the SASQ and the AUDIT/AUDIT-C for detecting AUD. Using the SASQ followed by the CAGE increases the overall sensitivity for detection of AUD to over 90% and only requires an average of 3–4 questions to be asked per patient.

AUDIT-Consumption (AUDIT-C) Tool

The condensed AUDIT-C consists of 3 questions about alcohol consumption:

1. “How often do you have a drink containing alcohol?”
2. (0) Never
3. (1) Monthly or less .
4. (2)2 to 4 times a month.
5. (3)2 to 3 times a week.
6. (4) 4 or more times a week.
7. “How many units of alcohol do you drink on a typical day when
8. (0) 1 or 2.
9. (1) 3 or 4.
10. (2)5 or 6.
11. (3)7, 8, or 9.
12. (4) 10 or more.
13. “How often do you have six or more drinks on one occasion”
14. (0) Never.
15. (1) Less than monthly.
16. (2) Monthly.
17. (3) Weekly.
18. (4) Daily or almost daily.

Interpretation:

• In men, a score of 4 or more is considered positive for hazardous drinking.
• In women, a score of 3 or more is considered positive for hazardous drinking. If score is positive, proceed to diagnosis and assessment for AUD.

AUDIT-C Hazardous Drinking Sensitvity: 86%.
AUDIT-C Hazardous Drinking Specificity: 78%.

AUDIT Tool

Questions:

1. How often do you have a drink containing alcohol?
2. (0) Never [Skip to Qs 9-10]
3. (1) Monthly or less .
4. (2)2 to 4 times a month.
5. (3)2 to 3 times a week.
6. (4) 4 or more times a week.
7. How many drinks containing alcohol do you have on a typical day when you are drinking?
8. (0) 1 or 2.
9. (1) 3 or 4.
10. (2) 5 or 6.
11. (3) 7, 8, or 9.
12. (4) 10 or more.
13. How often do you have six or more drinks on one occasion?
14. (0) Never
15. (1) Less than monthly
16. (2) Monthly
17. (3) Weekly
18. (4) Daily or almost daily
19. How often during the last yer have you found that you were not able to stop drinking once you had started?
20. (0) Never.
21. (1) Less than monthly.
22. (2) Monthly.
23. (3) Weekly.
24. (4) Daily or almost daily.
25. How often during the last year have you been unable to do what was normall expected from you because of drinking?
26. How often during the last year have you needed a first drink in the morning to get yourself going ater a heavy drinking session?
27. (0) Never
28. (1) Less than monthly
29. (2) Monthly
30. (3) Weekly
31. (4) Daily or almost daily
32. How often during the last year have you had a feeling of guilt or remorse after drinking?
33. (0) Never
34. (1) Less than monthly
35. (2) Monthly
36. (3) Weekly
37. (4) Daily or almost daily
38. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
39. (0) Never
40. (1) Less than monthly
41. (2) Monthly
42. (3) Weekly
43. (4) Daily or almost daily
44. Have you or someone else been injured as a result of your drinking?
45. (0) No.
46. (2) Yes, but not in the last year.
47. (4) Yes, during the last year.
48. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?
49. (0) No.
50. (2) Yes, but not in the last year.
51. (4) Yes, during the last year.

Total score:

• A score of 0–7 is considered low-risk alcohol use.
• A score of 8–15 is considered moderate-risk alcohol use.
• A score of 16 or more is considered a positive screen for high-risk drinking. Proceed to assessment and diagnosis for AUD.

AUDIT Hazardous Drinking Sensitivity: 97%
AUDIT Hazardous Drinking Specificity: 78%
AUDIT Harmful Drinking Sensitivity: 95%
AUDIT Harmful Drinking Specificity: 85%

Youth AUDIT High-risk use Sensitivity: 33%.
Youth AUDIT High-risk use Specificity: 99%.

Note: AUDIT/AUDIT-C: standard drink size = 10g of ethanol. Note that this differs from Canada’s Guidance on Alcohol and Health, where standard drink size = 13.45g of ethanol.

NIAAA Youth Screening Tool

This guideline recommends using the NIAAA youth screening tool for youth patients (aged 11–18 years).

For youth aged 11–14 (Grades 6–8), it is recommended to first ask about alcohol use among friends as a less intimidating introduction to the topic, followed by personal use questions (i.e. question 1, then question 2).

NIAAA Youth Screening Tool Questions (Ages 11-14):

1. “Have any of your friends consumed alcohol in the past year?”
2. “Have you consumed any alcohol in the past year?"

For patients aged 14–18 (Grades 9–12), the screening questions should be asked in reversed order (i.e., question 2 then 1).

NIAAA Youth Screening Tool Questions (Ages 14-18):

1. “Have you consumed any alcohol in the past year?"
2. “Have any of your friends consumed alcohol in the past year?”

If patient reports drinking, ask patient to estimate the number of drinking days they have had in the past year and assess risk based on the following thresholds for high-risk drinking:

• 11 years: 1 day.
• 12–15 years: 6 days (about every other month).
• 16 years: 12 days (about monthly).
• 17 years: 24 days (about twice monthly).
• 18 years: 52 days (about weekly).

[The NIAAA Youth Screening Tool, with] a threshold of ≥ 3 drinking days per year had a 91% sensitivity and 93% specificity for detection of AUD among youth aged 12–17 (n = 942) and a positive predictive valueo of 44% and negative predictive valuep of 99%.

Clark DB, Martin CS, Chung T, et al. Screening for Underage Drinking and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Alcohol Use Disorder in Rural Primary Care Practice. J Pediatr. 2016;173:214-20. doi:10.1016/j.jpeds.2016.02.047

Note: The NIAA tool was validated to age 9, but Canadian 2023 guideline specifically only recommends for ages 11-18.

Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar)

Questions:

NAUSEA AND VOMITING
— Ask “Do you feel sick to your stomach? Have you vomited?”

• 0 no nausea and no vomiting
• 1
• 2
• 3
• 4 intermittent nausea with dry heaves
• 5
• 6
• 7 constant nausea, frequent dry heaves and vomiting.

TREMOR
— Arms extended and fingers spread apart.

• 0 no tremor
• 1 not visible, but can be felt fingertip to fingertip
• 2
• 3
• 4 moderate, with patient’s arms extended 5
• 6
• 7 severe, even with arms not extended

PAROXYSMAL SWEATS

• 0 no sweat visible
• 1 barely perceptible sweating, palms moist
• 2
• 3
• 4 beads of sweat obvious on forehead 5
• 6
• 7 drenching sweats

TACTILE DISTURBANCES
— Ask “Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?”

• 0 none
• 1 very mild itching, pins and needles, burning or numbness
• 2 mild itching, pins and needles, burning or numbness
• 3 moderate itching, pins and needles, burning or numbness
• 4 moderately severe hallucinations
• 5 severe hallucinations
• 6 extremely severe hallucinations
• 7 continuous hallucinations

TREMOR
— Arms extended and fingers spread apart.

• 0 no tremor
• 1 not visible, but can be felt fingertip to fingertip
• 2
• 3
• 4 moderate, with patient’s arms extended 5
• 6
• 7 severe, even with arms not extended

AUDITORY DISTURBANCES
— Ask “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things youknow are not there?”

• 0 not present
• 1 very mild harshness or ability to frighten
• 2 mild harshness or ability to frighten
• 3 moderate harshness or ability to frighten
• 4 moderately severe hallucinations
• 5 severe hallucinations
• 6 extremely severe hallucinations
• 7 continuous hallucinations
• PAROXYSMAL SWEATS
• 0 no sweat visible
• 1 barely perceptible sweating, palms moist
• 2
• 3
• 4 beads of sweat obvious on forehead 5
• 6
• 7 drenching sweats

VISUAL DISTURBANCES
— Ask “Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know arenot there?”

• 0 not present
• 1 very mild sensitivity
• 2 mild sensitivity
• 3 moderate sensitivity
• 4 moderately severe hallucinations
• 5 severe hallucinations
• 6 extremely severe hallucinations
• 7 continuous hallucinations

ANXIETY— Ask “Do you feel nervous?” Observation.

• 0 no anxiety, at ease
• 1 mild anxious
• 2
• 3
• 4 moderately anxious, or guarded, so anxiety is inferred 5
• 6
• 7 equivalent to acute panic states as seen in severe
• delirium or acute schizophrenic reactions

HEADACHE, FULLNESS IN HEAD
— Ask “Does your head feel different? Does it feel like there is a band around your head?”
Do not rate for dizziness or light-headedness.
Otherwise, rate severity

• 0 not present
• 1 very mild
• 2 mild
• 3 moderate
• 4 moderately severe
• 5 severe
• 6 very severe
• 7 extremely severe

AGITATION

• 0 normal activity
• 1 somewhat more than normal activity
• 2
• 3
• 4 moderately fidgety and restless
• 5
• 6
• 7 paces back and forth during most of the interview, or constantly thrashes about

ORIENTATION AND CLOUDING OF SENSORIUM

• Ask “What day is this? Where are you? Who am I?
• 0 oriented and can do serial additions
• 1 cannot do serial additions or is uncertain about date
• 2 disoriented for date by no more than 2 calendar days
• 3 disoriented for date by more than 2 calendar days
• 4 disoriented for place/or person

CIWA-Ar Interpretation:

Score from 0 to 10 = Mild withdrawal severity.
Score 11 to 19 = Moderate withdrawal severity.
Score 20 or more = Severe withdrawal.

Patients scoring less than 10 do not usually need additional medication for withdrawal.

Sullivan JT, Sykora K, Schneiderman J, Naranjo CA & Sellers EM. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol Scale CIWA-Ar. Br J Addict. 1989;84:1353-1357

Prediction of Alcohol Withdrawal Severity Scalebh (PAWSS)

PART A: THRESHOLD CRITERIA – Yes or No (no points)

• Have you consumed any amount of alcohol (i.e., been drinking) within the last 30 days? -OR-
• Did the patient have a positive (+) blood alcohol level (BAL) on admission?

If the answer to either is YES, proceed to next questions.

PART B: BASED ON PATIENT INTERVIEW – 1 point each
Have you been recently intoxicated/drunk, within the last 30 days?
Have you ever undergone alcohol use disorder rehabilitation treatment or treatment for alcohol use disorder?* (i.e., in-patient or out-patient treatment programs or AA attendance)
Have you ever experienced any previous episodes of alcohol withdrawal, regardless of severity?
Have you ever experienced blackouts?
Have you ever experienced alcohol withdrawal seizures?
Have you ever experienced delirium tremens or DTs?
Have you combined alcohol with other “downers” like benzodiazepines or barbiturates, during the last 90 days?
Have you combined alcohol with any other substances, during the last 90 days?*

PART C: BASED ON CLINICAL EVIDENCE – 1 point each

1. Was the patient’s blood alcohol level (BAL) greater than 200mg/dL? (SI units 43.5 mmol/L)
   -OR-
   Portable breath alcohol concentration device indicates equivalence to BAL greater than 200mg/dL
   -OR-
   *Have you consumed any alcohol in the past 24 hours?

2. Is there any evidence of increased autonomic activity?
   e.g., heart rate >120 bpm, tremor, agitation, sweating, nausea

Due to the common absence of a BAL the committee has added this modification. Please see next page.
Interpretation: Maximum score = 10. This instrument is intended as a SCREENING TOOL. The greater the number of positive findings, the higher the risk for the development of alcohol withdrawal syndrome (AWS).
A score of ≥4 suggests HIGH RISK for moderate to severe (complicated) AWS; prophylaxis and/or inpatient treatment are indicated.

Example DSM-5-TR Alchol Use Disorder Diagnostic Interview Questions:

“In the past year...”

1. Did you drink more or for a longer time than you had originally planned to?
2. Did you try to cut back or stop drinking, but weren’t able to?
3. Did you spend a lot of your time drinking or recovering from drinking?
4. Were you so preoccupied with wanting a drink that you found it hard to think about anything else?
5. Did you have a hard time doing your job properly or going to school because of alcohol? Taking care of your family and home?
6. Did you keep drinking even though you knew it was causing problems in your relationships?
7. Did you give up on activities or hobbies, or seeing friends because of drinking?
8. Did you get into dangerous situations more than once because of your drinking? Such as drinking and driving, unsafe sex, other situations where you could have been hurt?
9. Did you keep drinking even though it was making you feel depressed or anxious, or making a physical health problem worse?
10. Did you feel tense and anxious because it takes more drinks than it did in the past to feel intoxicated? Do you find that drinking the same amount as in the past doesn't relieve your stress or have the same effects?
11. Did you ever have shaky hands, sweats, anxiety, hearing voices, nausea or a seizure, hours after you’d stopped drinking? Do you ever have a drink to prevent those symptoms from happening?

Overview of Pharmacotherapy Options for Withdrawal Management

Benzodiazepines

1. Class: Benzodiazepines.
2. Potentiate the effects of alcohol; can lead to serious safety risks, including over sedation, falls, delirium, respiratory depression (e.g., non-fatal or fatal overdose), and prolonged hospitalization.
3. Contraindications
4. Severe respiratory insufficiency.
5. Sleep apnea.
6. Myasthenia gravis.
7. Narrow angle glaucoma.
8. Cautions:
9. Lactose intolerance.
10. Liver dysfunction.
11. Renal impairment.
12. Breast feeding.
13. Side-Effects:
14. Drowsiness, dizziness.
15. Less common: changes in skin colour, nausea, headache, blurred vision, tremors, hypotension, GI disturbances, memory loss.
16. Sample Alcohol Withdrawal Protorol: Example four-day fixed and flexible protocols for diazepam (Valium)

Diazepam Fixed Schedule:

• Day 1: 5–10mg QID.
• Day 2: 5–10mg TID.
• Day 3: 5–10mg BID.
• Day 4: 5–10mg HS.

Diazepam Flexible Schedule:

• Day 1: 5–10mg q 4-6h PRN based on symptoms. i.e. Pulse rate >100 beats per minute, diastolic BP > 90mmHg, or symptoms of withdrawal (e.g., shakes, anxiety, hallucinations).
• Day 2: 5–10mg q 6-8h PRN.
• Day 3: 5–10mg q 12h PRN.
• Day 4: 5–10mg HS, PRN.

Lorazepam Fixed Schedule:

• Day 1-2 1–2mg q 4h
• Day 3-4 0.5–1mg q 4h

Fixed dosing is intended for outpatients and should be individually tailored to the extent possible, with adjustments made following daily check-ins.

Flexible dose schedules should be used in inpatient settings where close monitoring is feasible and dosage should be based on symptom severity. In outpatient settings, flexible dosing should only used with patients with expected reliability and ability to adhere to clinical recommendations.

Note: In inpatient and outpatient settings, benzodiazepines should be offered for a maximum of 7 days and should be tapered. Shorter durations are preferred.

### Carbamazepine

1. Class: Anticonvulsant.
2. No well-described safety risk for those actively drinking.
3. Contraindications:
4. Hepatic disease
5. Bone marrow depression
6. Serious blood disorder
7. Atrioventricular heart block.
8. Cautions:
9. Associated with rare blood dyscrasias and Stevens Johnson Syndrome, which usually develops within the first few months of taking this medication.
10. Onset of potentially serious blood dyscrasias may be rapid, patients should be informed of early toxic signs of a potential hematological problem.
11. Patients should be advised to immediately consult their physician if they experience reactions such as fever, sore throat, rash, ulcers in the mouth, easy bruising, petechial or purpuric hemorrhage.
12. The HLA-B*15:02 and HLA-A*31:01 alleles increase risk of carbamazepine toxicity. Consider monitoring patients for adverse reactions to carbamazepine if there is an elevated risk of carrying the HLA-B*15:02 or HLA-A*31:01 allele.
13. Side-Effects:
14. Dizziness, pruritus, ataxia, headache, drowsiness, nausea (all usually minor and temporary).
15. Sample Dosing Protocols
16. Day 1: 200mg QID
17. Day 2: 200mg TID
18. Day 3: 200mg BID
19. Day 4–5: 200mg OD

Note: This protocol applies to immediate-release (IR) tablets. For withdrawal management, most clinical trials have used a standard tapered 5-day regimen. There is no PRN alcohol withdrawal regimen for carbamazepine.

Gabapentin

1. Class: Anticonvulsant.
2. Alcohol Abstinence recommended during treatment due to risk of additive CNS-depressive effects. Note: Studies suggest at therapeutic doses gabapentin is not likely to increase sedation or motor impairment.
3. Contraindications:
4. Hypersensitivity to gabapentin
5. Cautions:
6. Renal Impairment.
7. Side-Effects:
8. Higher doses may cause ataxia, slurred speech, drowsiness.

Note: Gabapentin side-effect profile is better than other anticonvulsants

Valproic Acid

1. Class: Anticonvulsant.
2. No safety risk if taken concurrently with alcohol
3. Contraindications:
   • Mitochondrial disease.
   • Hepatic disease or dysfunction.
   • Urea cycle disorders.
   • Cautions:
   • Pregnant or intending to become pregnant.
   • Older adult patients (> 65 years of age).
   • Side-Effects:
   • Somnolence, GI disturbances, confusion, tremor.
   • Example Dosing: If CIWA <10 prior to treatment:
   • Day 1–5 Start at 250mg TID x 5 days
   • If withdrawal symptoms persist, titrate to 500mg TID x 1-3 days
   • Once stabilized, reduce to 250mg for days 4–5 Day 6 Discontinue medication If CIWA ≥10 prior to treatment:
   • Days 1–3: Start at 500mg TID
   • Days 4–5: Reduce to 250mg TID
   • Day 6: Discontinue medication

Clonidine

1. Class: alpha-adrinergic agonist.
2. With alcohol: Risk of additive effect on lowering blood pressure.
3. Contraindications:
4. Sinus node function impairment.
5. Severe bradyarrhythmia.
6. Galactose intolerance.
7. Cautions:
8. Hypotension in sensitive patients.
9. Side-Effects:
10. Hypotension, dry mouth, dizziness, fatigue, headache, nausea, vomiting, constipation, malaise, sleep disorder, sedation, erectile dysfunction.
11. Example Dosing:
12. Start: 0.1-0.2mg BID (last dose at HS)
13. Titrate: Can add 0.2mg OD PRN
14. Final Dose: 0.1-0.6mg BID

Clonidine Notes:

• As a standalone treatment, clonidine should only be used for treating mild withdrawal symptoms in patients at low risk of severe complications (PAWSS < 4).
• Safe to use with benzodiazepines or other anticonvulsants (gabapentin, carbamazepine, valproic acid) as an adjunct treatment for alcohol withdrawal.
• Patients and families should receive education on the signs and symptoms of hypotension.
• To ensure blood pressure control during sleep, it is recommended that the last dose of the day be taken immediately before going to sleep.

Overview of Pharmacotherapy for Alcohol Use Disorder

First-Line Treatments for Alcohol Use Disorder:

Naltrexone is well-tolerated with alcohol and contraindicated in patients with hypersensitivity to it, current opioid use, acute opioid withdrawal, and acute hepatitis or liver failure. Caution is advised in cases of renal impairment, severe hepatic impairment, concomitant use of hepatotoxic drugs, and for pregnant or breastfeeding women, as well as pediatric patients. Side effects like nausea and headaches are usually mild and can be mitigated by starting with low doses and abstaining from alcohol.

• Opioids should be stopped 7–10 days prior to treatment with naltrexone.

Naltrexone can be prescribed as OD or PRN. As needed (PRN) prescriptions are usually taken prior to drinking or when the patient is experiencing significant cravings.

• Start: 25mg OD for 3-4 days
• Titrate: to 50mg OD, if needed. A slower titration may be indicated if intolerable GI symptoms or headache occur during initiation.

Limited evidence suggests a higher dose of naltrexone may be safe, with safety and tolerability demonstrated at an increased dosage of 100–150mg/ day. Dose may be increased to a maximum of 150mg per day if liver enzymes are within normal range and patient is continuing to experience cravings at 50mg per day.

Note that the product monograph recommends a dose of 50mg/day to treat alcohol use disorder.

Acamprosate, meanwhile, has no major safety risk with alcohol use but is contraindicated in individuals with severe renal impairment or who are breastfeeding. It requires caution in patients with moderate renal impairment and in special populations such as the elderly, children, and pregnant women. Side effects typically include gastrointestinal symptoms and are generally transient. The cost for both medications can vary depending on the coverage and jurisdiction.

• No safety risk with mild renal impairment (creatine clearance 50–80mL/min).
• Moderate impairment (creatine clearance 30–50mL/min) requires dose reduction.
• Contraindicated in severe renal impairment (creatine clearance ≤ 30mL/min).
• No hepatic toxicity
• Motivation and treatment readiness may be particularly important factors for adherence, as acamprosate must be administered at a dosage of nearly 2g split into 3 doses per day due to its low bioavailability.
• Start at maintenance dosage: 2 x 333mg tablets TID.

Second-Line Treatments for Alcohol Use Disorder:

Topiramate

1. Contraindications
2. Topiramate hypersensitivity
3. Pregnant or planning to become pregnant.
4. Narrow angle glaucoma.
5. Nephrolithiasis
6. Cautions:
7. Concomitant use of valproic acid.
8. Conditions or therapies that predispose patients to acidosis (renal disease, severe respiratory disorders, status epilepticus, diarrhea, surgery, ketogenic diets, certain drugs).
9. Side effects
10. CNS-related: psychomotor slowing, difficulty concentrating, speech/language problems, somnolence, fatigue, and mood disturbance. Most are mild to moderate in severity and occur early in treatment.
11. Start at low dose and titrate up to a stable dose over several weeks to avoid or reduce severity of side effects
12. Coverage:
13. Consult the regional drug formulary for details.
14. Concurrent alcohol use
15. No well-described safety risk • No interaction with alcohol and can be initiated while a patient is still drinking
16. Safety and other considerations:
17. Due to risk of fetal harm, advise people of childbearing potential to use effective contraceptive.
18. No safety risk with liver disease.
19. Monitor for signs of hyperammonemia (unexplained vomiting, lethargy, confusion, changes in mental status, hyperthermia) and metabolic acidosis (hyperventilation, fatigue, anorexia, cardiac arrhythmias, stupor).
20. Dosing: Some individuals experience significant side effects, particularly at higher doses or with more rapid increases in dosage.
21. Gradual dose titration over several weeks is strongly recommended (e.g., approximately 4–8 weeks to full dose).
22. The recommended initial target dose for topiramate monotherapy in adults is 100mg/day, administered in 2 divided doses, as needed and tolerated.
23. Week 1 Topiramate 25mg PO QHS.
24. Weeks 2–3 Topiramate 25mg PO QAM and QHS.
25. Weeks 3–4 Topiramate 50mg PO QAM and QHS.
    If doses above 100mg/day are required, the dosage may be increased at weekly intervals in increments of 50mg up to a maximum of 400mg/day.
26. Increases over 100mg/day should be performed in specialist settings.
27. Studies have demonstrated better safety and tolerability of topiramate at lower doses (50–100mg/day), with side effects increasing at higher doses.
28. Dose and titration rate should be guided by side effects and clinical outcome.
29. Some patients may benefit from a slower titration schedule or smaller increments in dose.
30. Daily doses above 400mg have not been adequately studied.

Gabapentin

1. Contraindications
2. Gabapentin hypersensitivity
3. Cautions:
4. Geriatric (> 65 years of age) and paediatric patients (< 18 years of age)
5. Pregnant and breastfeeding patients
6. Concomitant use of opioids and other CNS depressants.
7. Compromised respiratory function.
8. Neurological disease or cognitive impairment.
9. Renal impairment.
10. Side effects:
11. Ataxia, slurred speech, and drowsiness • Most are mild to moderate in severity, and occur early in treatment.
12. Concurrent alcohol use:
13. Safe to start while patients are using alcohol, but outcomes may be improved if patient has been abstinent for ≥ 3 days.
14. Abstinence is recommended after starting treatment due to potential risk of combined CNS-related side effects.
15. Higher than therapeutic dose and concurrent alcohol use can increase the risk of respiratory depression, profound sedation, syncope, and death.
16. Observe patients carefully for CNS depression and adjust the dose of gabapentin as necessary.
17. Completion of withdrawal management is not required prior to treatment start.
18. Safety and other considerations.
19. Patients with compromised respiratory function, respiratory or neurological disease, renal impairment and older adults are at higher risk of experiencing severe adverse effects on the CNS.
20. Prescribe cautiously to older adults, and those with renal or cognitive impairment and provide close follow up.
21. Do not prescribe to actively delirious patients.
22. Safe to use in patients with liver disease.
23. Dosage adjustment may be required with older adults and patients with renal impairment.
24. Prescribers should review gabapentin’s drug–drug interactions when considering this medication as treatment for AUD
25. Sample Dosing Protocol
26. Start 100–300mg TID.
27. Titrate If patient experiences anxiety or cravings, PRN to 1800mg max daily.
28. If patient continues to experience insomnia, a higher HS dose may be warranted.

Note: This protocol applies to immediate-release (IR) tablets.

Disulfiram

1. Contraindications:
2. Concurrent or recent use of metronidazole, alcohol or alcohol-containing preparations.
3. Alcohol intoxication.
4. Severe myocardial disease, coronary occlusion.
5. Active psychosis.
6. Hypersensitivity to disulfiram or to other thiuram (rubber) derivatives
7. Cautions:
8. Pregnant and breastfeeding patients.
9. Pediatric patients.
10. Disorders including diabetes mellitus, hypothyroidism, seizure disorders, cerebral damage, chronic or acute nephritis, hepatic cirrhosis or insufficiency, abnormal EEG results, or co-occurring substance use disorders.
11. Side effects:
12. In the absence of alcohol, most common side effects are drowsiness, skin eruptions (acne, dermatitis), fatigue, erectile dysfunction, headache, and a metallic or garlic-like aftertaste.
13. A less common but serious side effect is hepatic toxicity (cholestatic or fulminant hepatitis, hepatic failure resulting in transplantation or death), which can occur in patients with and without prior history of abnormal liver function
14. Coverage Consult the regional drug formulary for details. Note: This medication is no longer commercially sold and must be compounded at a community pharmacy. Prescribers should contact the patient’s pharmacy in advance to ensure that it is available or can be accessed.
15. Concurrent alcohol use:
16. Due to severity of disulfiram–alcohol reaction, patients must not consume alcohol while taking disulfiram.
17. Safety and other considerations:
18. Obtain full informed consent of patient before prescribing disulfiram.
19. Educate patients and families on side effects and risks associated with the disulfiram–alcohol reaction.
20. Patients must abstain from using alcohol for at least 12 hours before taking disulfiram.
21. The disulfiram–alcohol reaction can present as an emergency situation.
22. Patients should carry an identification card on their person listing symptoms of disulfiram–alcohol reaction and their clinician’s contact information in the event of emergencies.
23. Perform baseline and follow-up liver function tests and monitor CBC and blood chemistries due to risk of hepatoxicity.
24. Patients and families should be advised to immediately report early signs or symptoms of hepatitis.
25. Sample Dosing Protocol
26. Disulfram 250mg OD, administered as a single daily dose in morning or evening
27. Patients experiencing daytime sedation can be instructed to take their dose in the evenings.
28. If sedation persists, dose can be reduced to 125mg.
29. Patients who can still drink alcohol without experiencing a disulfiram–alcohol reaction despite good adherence (very rare) can be increased to 500mg daily.
30. Do not exceed a daily dose of 500mg.

Original Guideline DOI Link