Alcohol Use Disorder (AUD)

Last Updated: September 30, 2019

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This tool is designed to support primary care providers (family physicians and primary care nurse practitioners) in screening, diagnosing and implementing pharmacotherapy treatments for adult patients (>18 years) with Alcohol Use Disorder (AUD). Primary care providers should routinely offer medication for moderate and severe AUD.

Pharmacotherapy alone to treat AUD is better than no therapy at all.1

Pharmacotherapy is most effective when combined with non-pharmacotherapy, including behavioural therapy,
community reinforcement, motivational enhancement, counselling and/or support groups.2,3

People living with AUD must be provided with nonjudgmental and supportive care

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Screening for AUD

All patients should be screened routinely (e.g. annually or when indicators are observed) with a recommended tool like the AUDIT.2,3 It is important to screen all patients and not just patients eliciting an index of suspicion for AUD, since most persons with AUD are not recognized.4

Consider screening for AUD when any of the following indicators are observed:

  • After a recent motor vehicle accident
  • Frequent work avoidance (off work slips)
  • Rosacea
  • Rhinophyma
  • High blood pressure
  • Cardiac arrhythmia
  • Insomnia
  • Exacerbation of sleep apnea
  • Liver disease
  • Chronic pain
  • Social problems
  • Legal problems

Special patient populations

A few studies have reviewed AUD in specific patient populations, including youth, older adults and pregnant or breastfeeding patients. The AUDIT screening tool considered these populations in determining the sensitivity of the tool.

Select special population to view screening tools

Screening tools

Pharmacotherapy

There are no medications approved for the treatment of AUD in youth. Pending clinical judgment, it may be appropriate to treat older youth with pharmacotherapy. Off-label agents should be avoided, especially agents with probability of diversion.

Screening tools

Older adults are less likely to disclose alcohol use. Take care in screening older adults: offer restated questions and show sensitivity.

Pharmacotherapy

To avoid adverse events, combine pharmacotherapy with:

  • Frequent renal function tests
  • Reduced dosage (disulfiram)
  • Care to prevent drug interactions (Older adults may take more prescription medications than other patients)
  • For women and men over age 65, an AUDIT score of 7 or more is an indication of hazardous alcohol use.8

Provider support

Screening tools

Pharmacotherapy

There are no medications approved or recommended for the treatment of AUD in pregnant or breastfeeding patients.

Provider support

Tips for screening

AUD is a psychiatric illness defined as alcohol use that causes clinically significant impairment or distress.15 It is characterized by impaired control over drinking and ongoing drinking, despite harmful consequences.15 Primary care providers or clinical staff should administer the screening process in a friendly and non-judgmental manner.

Before screening:8

  • Take time to reassure the patient about the confidentiality of their answers
  • Indicate that the purpose of the screening is essential to their overall health status

Note: Patients should not be intoxicated at the time of the screen. If a patient is intoxicated at the time of their scheduled appointment, maintain a high index of suspicion for AUD.

Talking points
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Talking points

Motivational interviewing can help encourage patients to make personal changes that they deem as important for reaching a particular goal.

Principles of motivational interviewing are:

  • Express empathy through reflective listening
  • Explore the discrepancy between a patient’s goals or values and their current behavior
  • Avoid arguments and confrontation
  • Adjust to patient resistance rather than opposing it directly
  • Support self-efficacy and optimism 8

Alcohol Use Disorder Identification Test (AUDIT)

The AUDIT was developed specifically to identify patients with recent heavy drinking as well as alcohol dependence. The AUDIT was designed to consider cultural appropriateness and cross-national applicability and is appropriate for male and female patients across all age groups.8

For collaborative screening
For self-directed screening

The AUDIT can be administered either by the provider using the Interview Version or by the patient using the Self-Reported Version. It is up to the providers clinical judgment and experience with the patient to determine which version is most appropriate.

If time is limited during a patient encounter, a primary care provider can use the modified AUDIT-C. The AUDIT-C is a three-question alcohol screen that can help identify patients who have active AUD.

Results

A score of 8 or more indicates harmful alcohol use. 16

A male patient with a score of 4 or more OR a female with a score of 3 or more indicates hazardous or active AUD.

However, if a patient’s point total reflects Question 1 alone (i.e. Questions 2 and 3 total zero), then assume that the patient is drinking below the recommended limits. Review the patient’s alcohol intake over the past few months to confirm accuracy.

Often there is an underestimate of potential harm associated with AUD and an overestimate of the harm with regards to reporting to appropriate authorities. It is important to remember reporting obligations.

Discussion results

When a patient receives screening results that may indicate harmful alcohol use, it is essential to remain non-judgmental and discuss practical ways to cope. Screening is only the first step. The goal of this short discussion is to help set and record goals together. 2,5,9 Listen reflectively and repeat what the patient says to you. Follow-up with the patient within 14 days after screening and regularly after that.1,5,9,15

Pharmacotherapy is recommended for patients identified as high-risk users and dependent on alcohol.

Click risk score to view interventions, resources and talking points

Intervention: 8,18

  • Simple advice
  • Discuss the benefits of low-risk drinking

Patient resource:

Intervention: 8,18

  • Simple advice
  • If the patient is receptive, offer tips for reducing alcohol consumption

Patient resource:

Provider resource

Intervention: 8,18

  • Simple advice + brief counselling + monitoring
  • Brief counselling is more in depth and tailored than brief intervention, and requires follow-up
  • Express concern
  • Discuss harms associated with alcohol consumption
  • Tailor counselling to situation and stage of change (from no interest to action planning)
  • Conduct laboratory testing to corroborate heavy drinking assumption: 1,4
    • GGT (alcohol elevates GGT through enzyme induction)
    • MCV (alcohol retards the maturation of red cells in bone marrow, causing slight enlargement)
    • Monitor every 2-3 months

Provider resource

Intervention: 8,18

  • Further laboratory testing to corroborate heavy drinking diagnosis: 1,4
    • GGT (alcohol elevates GGT through enzyme induction)
    • MCV (alcohol retards the maturation of red cells in bone marrow, causing slight enlargement)
    • Monitor every 2-3 months
    • Thiamine supplements (200mg) 19
    • Withdrawal management by a specialist may be necessary

Diagnosing AUD

Once you have identified that your patient might have AUD through the AUDIT or the AUDIT-C, then the DSM-5 criteria can be used to diagnose your patient.

DSM-5 Criteria for AUD21

To confirm a diagnosis of AUD, at least two of the following criteria need to be met. Ask your patients, in the past 12-months have you:

  • Had times when you ended up drinking more, or longer than you intended?
  • More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
  • Spent a lot of time drinking? Or being sick or getting over the after effects?
  • Experienced craving — a strong need, or urge, to drink?
  • Found that drinking — or being sick from drinking — often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
  • Continued to drink even though it was causing trouble with your family or friends?
  • Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
  • More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?
  • Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?
  • Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
  • Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, or sweating? Or sensed things that were not there?

Severity of AUD is based on the number of criteria met

Mild:

2 to 3 criteria

Moderate:

4 to 5 criteria

Severe:

6 + criteria

Tool tip

Once there is a diagnosis of AUD, the initial goals of treatment should be agreed on by the patient and the primary care provider. It is important to discuss the patient’s legal obligations, as well as risks to self and others that result from the continued use of alcohol.

Work with the patient to develop a documented, comprehensive and person-centred treatment plan that includes evidence-based non-pharmacotherapy and pharmacotherapy options.

Refer to Specialist 1,2,3

Refer to a specialist, including mental health care specialists, hepatologists, addiction treatment specialists, etc. Referral to specialists should be based on availability and access. Consider other options such as OTN eConsult, ConnexOntario, phone consult and Peer Connect Mentorship. Patients with comorbidities may benefit from the concurrent treatment of conditions from the same provider. These may include patients with:

  • Psychosis
  • Complex opioid addictions
  • Post-traumatic stress disorder
  • Liver failure
  • Risk of withdrawal from other substances in addition to alcohol

Pharmacotherapy options

Talk with your patient about the various available pharmacotherapy options. Consider the advantages and disadvantages of each therapy for your patient. Generally, naltrexone oral and acamprosate are the recommended first line options.2,3 Note that these options do not eliminate or diminish withdrawal symptoms.

Recommended pharmacotherapy

Naltrexone Oral

Patient Type9,11

  • For patients with strong cravings and suffer recurrent binges.
  • Effective treatment to help stop or reduce alcohol use
  • Patients do not have to be abstinent before treatment

What it does1,5,9,19,22,25,26-29

  • Blocks opioid receptor and reduces euphoric effects of drinking
  • Reduce desire to drink and help to remain abstinent

Laboratory Work Required for Medication Initiation,2,9,10,22

  • Urine drug screen to verify abstinence from opioids
  • LFTs: alanine aminotransferase, aspartate aminotransferase, gamma glutamyl transferase, alkaline phosphatase, bilirubin, total protein, albumin, prothrombin time

Laboratory Work1,9,10,22

  • LFTs
  • Naltrexone Oral

    Dosage/Duration 1,5,9,19,22,23,30

    • Start patient on 25 mg/d for 3 days. Then, depending on patient response, increase to 50mg/d to a max of 150 mg/d.

    Treatment Duration

    • Patients are usually on medication from about 3 months to 1 year

    Product monograph

    • LU Code: 532
    • Coverage: covered under Ontario Drug Benefits and most private plans.
    • Generic: Available
    • Cost (30-day supply): $50 – $100*

    Warning: patients cannot be raking opioids or opioid agonist therapy

    View contradictions, side effects, and interactions
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    Contradictions, side effects, and interactions

    Contraindications and Precautions 1,2,5,9,19,22,26

    • Taking opioids
    • Elevated liver enzymes
    • Liver failure
    • Pregnancy

    Side Effects, Risks and Notes 1,5,26

    • GI upset
    • Elevated liver enzymes
    • Must monitor liver enzymes (discontinue if levels rise > 3 times baseline) Interactions
    • Thioridazine, opioids, some cough and diarrhea medication

    Interactions

    • Thioridazine, opioids, some cough and diarrhea medication

    Tapering:
    There is no withdrawal syndrome associated with discontinuing oral naltrexone, and it is not necessary to taper the dose.

Acamprosate

Patient Type9,11

  • For patients who are committed to abstinence but suffer from withdrawal symptoms such as insomnia and anxiety
  • May be appropriate for patients with mild to moderate liver disease and those who take opioids

What it does 1,5,9,19,22,25,26-29

  • Antagonizes glutamate receptors
  • Reduces discomfort caused by the imbalance of brain chemicals (due to heavy drinking) and makes it easier not to drink
  • Safe for patients with liver disease

Laboratory Work Required for Medication Initiation1,2,9,10,22

  • Renal function tests: urea, electrolytes, serum creatinine

Laboratory Work1,9,10,22

  • Not necessary unless evidence of renal impairment
  • Acamprosate

    Dosage/Duration 1,5,9,19,22,23,30

    • Each tablet is 333 mg. The full dose is 666 mg tid.
    • To reduce probability of nausea and diarrhea it is helpful to start with 333 mg (1 tablet) tid for several days.

    Treatment Duration

    • Patients are usually on medication from about 3 months to 1 year

    Product monograph

    • LU Code: 531
    • Coverage: covered under Ontario Drug Benefits and most private plans.
    • Generic: Not vailable
    • Cost (30-day supply): ≥ $100*

    Patients should abstain at least 4 d before initiation 1,25

    View contradictions, side effects, and interactions
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    Contradictions, side effects, and interactions

    Contraindications and Precautions 1,2,5,9,19,22,26

    • Renal disease
    • Pregnancy

    Side Effects, Risks and Notes 1,5,26

    • GI upset
    • Nervousness

    Interactions

    • Over-the-counter medications (e.g. cough syrups with alcohol), some vitamins and herbal products

    Tapering:
    There is no withdrawal syndrome associated with discontinuing oral naltrexone, and it is not necessary to taper the dose.

Disulfiram 2,5,9,22,25

Disulfiram is only available through select compounding pharmacies. This drug interferes with the body’s process to metabolize alcohol, and as a result, makes the patient feel sick after alcohol consumption. Disulfiram is designed to help patients stay in a state of enforced sobriety and absolute abstinence is required.1,5,9,19,22,25-29 If this medication is prescribed, consider having the patient carry a wallet information card to identify medication use to emergency health care personnel. This medication does not take away craving or withdrawal symptoms.

Off-Label Pharmacotherapy Options

Gabapentin 2,9,22

Gabapentin is not indicated for the treatment of AUD and therefore should be considered off-label treatment.

  • Has few contraindications
  • How it works with AUD is not fully known (possibly normalizes the brain chemicals disturbed by heavy drinking)
  • Sometimes is considered a drug of abuse, with increasing “street value”
  • Gradually taper medication use if stopping is necessary due to a risk of seizures 1,5,19,25-29
Topiramate 2,9,22

Topiramate is not indicated for the treatment of AUD and therefore should be considered off-label treatment.

  • Numerous contraindications and interactions with other medications
  • Mechanism of action is unknown
  • Sometimes considered for patients who have experienced alcohol-related seizures
  • Regular blood work is required 1,5,19,25-29
  • May cause angle-closure glaucoma and kidney stones

Non-pharmacotherapy options

AUD is treated most effectively when pharmacotherapy is combined with other treatments.1,3 Non-pharmacotherapy treatments help patients target behaviours that relate to drinking, develop skills needed to stop or reduce drinking, set reachable goals, build support networks and address triggers that might cause a relapse.1

The goal is to improve health and wellness to live a full and self-directed life.

Types of behavioural treatments

Cognitive–Behavioral Therapy (CBT)

This therapy is designed to address feelings and situations (triggers) that may lead to a relapse. Coping skills are learned in one-on-one or small group settings to change or address thought processes to manage the stress of triggers experienced in everyday life.

Resources
Motivational Enhancement Therapy

This therapy is individualized for patients to consider their reasons for seeking treatment, form a plan to make changes in their life and to develop coping skills necessary to adhere to their plan. It is intended to be conducted over a short period of time.

Resources
Marital and Family Counseling

This therapy involves family members to increase support for the individual with AUD and to enhance the family’s understanding of the plan to address AUD. Strong family support increases the chances of maintaining abstinence.

Resources
Community Reinforcement Therapy

This therapy involves group meetings with others who want to do something about their drinking problem. It is peer guided and selfsupporting (e.g. Alcoholics Anonymous).

Resources

Alcohol withdrawal

Withdrawal symptoms usually start within 8 hours after the last drink but can occur days later. Symptoms typically peak by 24 to 72 hours but may continue for weeks.19

Alcohol withdrawal that requires treatment is rare in people who consume fewer than six drinks per day. Older adults are an exception and may develop significant withdrawal symptoms even if fewer than six drinks per day are consumed.

Past withdrawal predicts future episodes. Patients with a history of delirium tremens and withdrawal seizures are at high risk of reoccurrence if they return to drinking and stop again.19

Screen for Alcohol Withdrawal

The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is a validated instrument to monitor the severity of a patient’s withdrawal.3 It consists of 10 items to assess symptoms, such as anxiety and hallucinations, as well as signs, such as tremor and sweating. The CIWA-Ar takes about 5 minutes for a primary care provider to administer.

A patient with a CIWA-Ar score of < 10 does not require medications to manage withdrawal symptoms, unless tremor is present.

A patient with a CIWA-Ar score of > 10 has a potential need for medication to manage their withdrawal symptoms.

Treatment for Alcohol Withdrawal

Benzodiazepines are the first-line treatment for the withdrawal symptoms of alcohol withdrawal. Long-acting benzodiazepines, such as diazepam, may be more effective than short-acting in preventing complications. For more information on the treatment of alcohol with benzodiazepines, please visit CAMH. 19

If a benzodiazapine has been initiatied, treatment is complete when the patient is comfortable, with minimal tremor, and the CIWA-Ar score is less than 8 on two consecutive readings.

Refer to Specialist 3

Refer to substance use specialist to manage withdrawal process (where available) or nearest emergency department for critical treatment:

  • History of delirium tremens or withdrawal seizures
  • Inability to tolerate oral medication
  • Co-occurring medical conditions that would pose serious risk for ambulatory withdrawal management (e.g. severe coronary artery disease, congestive heart failure, liver cirrhosis)
  • Severe alcohol withdrawal (i.e. CIWA-Ar score ≥20)
  • Risk of withdrawal from other substances in addition to alcohol (e.g. sedative hypnotics)

Resources

Screening Tools
  • AUDIT Tool – considered a standard screening tool to identify people at risk of alcohol problems
  • AUDIT-C – is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorder (including alcohol abuse or dependence)
  • Paddington Alcohol Test (PAT) – for use with specific triggers (e.g. fall, assault, collapse, self-neglect, repeat attender for unknown injury/illnesses)
Self-Help Book
  • Mind-Body Workbook for Addiction: Effective Tools for Substance-Abuse Recovery and Relapse Prevention – useful to both patients
    and providers with a mind-body technique to help patients stay sober, manage emotions and stress
Provider Tools

References