Screening for and Managing At-Risk Drinking and Alcohol Use Disorder (AUD) During COVID-19

Shift to

• Screening more often than yearly, particularly patients with mental health concerns or those who are going into self-isolation.
• Email or message the AUDIT-10: Self-report version to patients for completion. Please note the form is also available to complete on OCEAN.
• Use the Single Alcohol Screener (SASQ) for virtual appointments if time is limited.

Provider resources

• Single Alcohol Screener (SASQ) Ask: how many times in the past year have you had [4 (women) or 5 (men)] or more drinks on one occasion? Once or more is a positive screen.

Patient resources

• AUDIT-10: Self-Report version

Continue

• Use the AUDIT-10 to categorize people as low-risk (<8), risky (8-15) , high risk for AUD (>15).

Provider resources

• See screening for AUD of the CEP AUD tool for risk categorization.

Shift to

• Provide a 3-5 minute virtual brief intervention to those who score 8-15 on the AUDIT-10.

Provider resources

• See the conversations starters in the CEP AUD tool.
• See Portico Network for more information on brief interventions.

Patient resources

• Canada’s Low-Risk Drinking Guidelines (CCSA, 2018)
• Goal setting and drinking diary (CAMH)

Continue

• Diagnose patient with mild, moderate or severe AUD using the Diagnosing AUD section in the CEP AUD tool.
• Determine if patient needs medically managed withdrawal. If yes, see support a planned withdrawal.

Delay

• Postpone physical examinations and laboratory tests unless a patient has severe AUD, known liver disease or symptoms thereof and/or other end-organ damage.

Provider resources

• See physical examinations and laboratory tests in the CEP AUD tool for more information.
• To determine if your patient is likely to need medical management for withdrawal, see alcohol withdrawal in the CEP AUD tool.

Patient resources

• See the Local Services resource for information on laboratories available by region.

Continue

• Due to the history of discrimination in the health care system for patients with substance use disorders, it is important to demonstrate empathy and compassionate care to your patients.
• Offer frequent supportive counselling and follow-up visits until the patient is stabilized. The frequency of visits will depend on the patient, their needs and the severity of their AUD.
  • See Non-pharmacotherapy options in the CEP AUD tool for more information.
  • When patients are making changes and in periods of instability, visits should be every 1-2 weeks.
  • When patients are more stable, the visits may be less frequent.
• Offer harm reduction strategies and help patients to prepare for disruptions in their alcohol supply if self-isolation is required (see harm reduction).

Shift to

• Provide follow-up visits and counseling virtually when appropriate.

Provider resources

• Ontario providers, use the following billing codes when counseling your patients:
  • A680 – Initial Assessment, Substance Use Service provider: Physician; Fee: $144.75; Service description: This service is an assessment requiring a physician to spend a minimum of 50 minutes assessing a patient related to substance use. The 50 minutes must be spent in personal contact with the patient (and/or the patient’s representative), and this time must be exclusive of time spent rendering any other service to the patient.
  • K680 – Extended Assessment, Substance Use Service provider: Physician; Fee: $62.75 (per unit); Service description: The extended assessment for substance use is a time-based code for providing care to patients who are receiving therapy for substance use (not management of smoking cessation). The service specific elements of assessment (e.g., a direct physician encounter [by the physician submitting the claim] with the patient, including taking a patient history and performing the required physical examination, etc.). This service is payable in units of time. A unit is 30 minutes.
  • LU531 – Limited Use Acamprosate
  • LU532 – Limited Use Naltrexone
  • New virtual care fee codes

Patient resources

• Safer Drinking Tips During COVID-19 (UVIC, 2020) is a resource to help patients make a plan for safe drinking.

Shift to

• Offer and prescribe naltrexone or acamprosate virtually.

Delay

• Consider delaying testing of liver enzymes for up to two weeks after starting medication unless a patient has severe AUD, known liver disease or symptoms thereof and/or other end-organ damage.
• Consider previous lab results from all sources to see if a patient has completed liver enzyme tests in the past.

Provider resources

• See Pharmacotherapy options in the CEP AUD tool for more information on naltrexone and acamprosate.

Patient resources

• Information on naltrexone and acamprosate.

Shift to

• Connect patients to virtual mental health resources. See the virtual patient resources for at-risk drinking and AUD for more information.

Provider and patient resources

Information hubs that can be used to locate various services in Ontario:

• Call 211 Ontario
• ConnexOntario online directory or call 1-866-531-2600
• Drug Rehab Services Directory*

*Drug Rehab Services directory is a paid advertising directory and the CEP does not endorse the use of these paid advertisements

Continue

• Demonstrate understanding if patient is not ready to make changes. Not all patients will be receptive towards making a change and seeking treatment.
• Let your patient know that they can always get back in touch if their readiness for treatment changes. Use validated tools, such as Assessing Readiness to Change – Transtheoretical Model (PCNA), to assist in gauging your patients’ readiness.
• Maintain relationship with your patient, demonstrate empathy and respect for their decision.

Shift to

• Supporting patients with physical dependence on alcohol to create a personalized plan during the pandemic.
  • This plan can help to prepare patients if their alcohol supply is disrupted or if self-isolation is required to avoid precipitating withdrawal and/or patient consumption of toxic alcohols. Building a personalized plan with your patient can also help support their nutrition/food security, environment, and management of co-morbidities. Provide your patients with the Coping During COVID-19 (North Bay Parry Sound District Health Unit) resource for strategies to promote healthy living.

Provider and patient resources

• Consult the Managed Alcohol Programs in Canada (UVIC, 2020) resource to help patients access alcohol during the pandemic and utilize the Safer Drinking Tips during COVID-19 (UVIC, 2020) resource to help patients in creating a personalized plan.

Continue

• Emphasize to patients to not abruptly stop their drinking.
• If you do not have expertise in managing alcohol withdrawal, refer patients to a substance use specialist to manage the withdrawal process (where available). Connect with specialists using OTN eConsult.
  • If prescribing benzodiazepines, please consider the risks of benzodiazepine use in this patient population and consider the use of long-acting benzodiazepines, such as diazepam, over short-acting ones as they have been shown to be more effective at preventing complications.
• Refer a patient to the emergency department for urgent/emergent treatment.

Shift to

• Provide virtual assessments for those who are unlikely to need medical management.

Delay

• During the COVID-19 pandemic, access to non-medical withdrawal beds (detox beds) may be limited. Consider delaying outpatient or inpatient withdrawal management if this is the case and assist patients with a slow taper using supportive counselling and consideration of naltrexone. See additional guidance for planned alcohol reduction to achieve abstinence.

Provider resources

• To determine if your patient is likely to need medical management for withdrawal, see the Alcohol withdrawal section in the CEP AUD tool.
• For more information on withdrawal management, see Portico Network.

Patient resources

• Alcohol withdrawal resource – signs and symptoms of withdrawal (Fairview Health Services, 2020)