Managing At-Risk Drinking and Alcohol Use Disorder (AUD) During COVID-19
This resource is designed to support family physicians and primary care nurse practitioners in screening, diagnosing and treating at-risk drinking and AUD in adults (>18 years) during and beyond the COVID-19 pandemic.
Note: This resource is meant to supplement the CEP’s Alcohol Use Disorder tool (2018). Please refer to this tool for more information on the standard of AUD care.
Key considerations when managing at-risk drinking and AUD during the pandemic
- Increase the frequency of screening for at-risk drinking and AUD. Alcohol consumption has increased by 25% since the start of the COVID-19 pandemic. See Screen, categorize and diagnosis patients with AUD.
- Consider patient preferences, access to technology and technology literacy when reviewing virtual care options. With virtual care, it is essential to demonstrate empathy and support verbally. See Enhancing Management of Chronic Conditions Using Virtual Care During COVID-19 for more guidance.
- Pharmacotherapy and non-pharmacotherapy interventions can be initiated without laboratory tests and physical examinations in many cases. See manage with counselling and manage with first-line medications.
- Consider deferring outpatient or in-patient withdrawal management and assist patients with a slow taper using supportive counseling and consideration of naltrexone. See guidance for planned alcohol reduction to achieve abstinence.
- Encourage patients who may have a physical dependence on alcohol to prepare for a disruption in their alcohol supply. See harm reduction.
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Managing At-Risk Drinking and Alcohol Use Disorder (AUD) During COVID-19
For 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.
Click on the sections below for action-based guidance for managing at-risk drinking and AUD during COVID-19:
Screen, categorize and diagnosis patients with AUD New
Screen
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 screener (see p. 3) to patients for completion. Ask your patient if their email is secure before sending.
- Use the Single Alcohol Screener (SASQ) (see p. 30) for virtual appointments if time is limited.
Provider resources
- Single Alcohol Screener (SASQ) (see p. 30) 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
Screening with SASQ vs AUDIT-10
Evidence supports the use of brief instruments as an initial screener (SASQ), followed by a longer instrument with greater specificity (AUDIT) (USPSTF Recommendation Statement, 2018).
The SASQ has adequate sensitivity of 73% to 88% and specificity of 74% to 100% for detecting the full spectrum of unhealthy alcohol use in adults (USPSTF Recommendation Statement, 2018; USPSTF Evidence Report and Systematic Review, 2018).
When should the SASQ be used:
- The SASQ requires less than 1 minute to administer and is ideal for (USPSTF Recommendation Statement, 2018):
- Patient encounters with limited time.
- Universal screening during routine visits.
- When using the SASQ and the patient answers:
- No – make note of the patient’s response to the SASQ and follow-up is not required.
- Yes – follow-up using the AUDIT-10 either in-person or by sending it to your patient using a virtual modality such as email for a follow-up appointment.
Evidence supports the use of brief instruments as an initial screener (SASQ), followed by a longer instrument with greater specificity (AUDIT) (USPSTF Recommendation Statement, 2018).
The AUDIT-10 has a wide range of sensitivity of 38% to 73% but high specificity of 89% to 97% for detecting the full spectrum of unhealthy alcohol use in adults (USPSTF Evidence Report and Systematic Review, 2018).
When should the AUDIT-10 be used:
- The AUDIT-10 requires 2-5 minutes to administer and is ideal for (USPSTF Recommendation Statement, 2018):
- If the patient answers yes to the SASQ.
- If there is a history/current suspected problematic alcohol use, it should be the first and only screening tool used.
Categorize
Continue
- Use the AUDIT-10 to categorize people as low-risk (<8), risky (8-15) , high risk for AUD (>15).
Provider resources
- Refer to screening for AUD of the CEP AUD tool for risk categorization.
Patients who score 8-15 on the AUDIT-10 (risky alcohol use): Brief intervention
Shift to
- Provide a 3-5 minute virtual brief intervention to those who score 8-15 on the AUDIT-10.
Provider resources
- Refer to the CEP AUD tool for conversation starters.
- Refer to Portico Network for more information on brief interventions.
Patient resources
Patients who score >15 on the AUDIT-10 (high risk for AUD): Assess and diagnose
Continue
- Diagnose patient with mild, moderate or severe AUD using the Diagnosing AUD section in the CEP AUD tool.
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.
Note: Consider when a patient had their last physical examination and laboratory tests to determine an appropriate length of delay.
Provider resources
- Refer to the CEP AUD tool for more information on physical examinations and laboratory tests.
Patient resources
- Refer to the Local Services resource for information on laboratories available by region.
Manage and treat patients with AUD New
Manage with counseling
Continue
- Provide empathy and compassionate care to your patients.
- Offer frequent supportive counseling. Refer to Non-pharmacotherapy options in the CEP AUD tool for more information.
- Offer harm reduction strategies and help patients to prepare for disruptions in their alcohol supply if self-isolation is required (see harm reduction).
- Offer frequent 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.
- 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.
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.
Patient resources
- Safer Drinking Tips During COVID-19(UVIC, 2020) is a resource to help patients make a plan for safe drinking.
Manage with first-line medications
Shift to
- Offer and prescribe naltrexone or acamprosate virtually.
Delay
- Consider deferring 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
- Refer to Pharmacotherapy options in the CEP AUD tool for more information on naltrexone and acamprosate.
Patient resources
- Information on naltrexone and acamprosate.
Refer to mental health and addiction services
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:
- ConnexOntario online directory or call 1-866-531-2600
- Drug Rehab Services Directory
- Managed Alcohol Programs in Canada (UVIC, 2020)
Harm reduction
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.
Provider and patient resources
- Consult the BCCSU (2020) and FNHA (2020) resources on how to help your patient create a personalized plan.
Support a planned withdrawal
Continue
- Manage alcohol withdrawal the same as before the pandemic.
- 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.
- 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
- Consider deferring planned in-patient and outpatient withdrawal and assist patients with slowly tapering alcohol instead. 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, refer to Alcohol withdrawal of the CEP AUD tool.
Patient resources
Additional guidance for planned alcohol reduction to achieve abstinence New
If there is limited availability of non-medical withdrawal beds (detox beds) and formal medically monitored and managed alcohol withdrawal programs, but the patient is intent on reducing or discontinuing alcohol use during the pandemic, then consider guiding them through a slow taper instead:
- Tapering should take a gradual approach of weeks to months.
- Consider prescribing naltrexone to assist with alcohol cravings.
- Advise patient to monitor and record their alcohol intake closely.
- Consider a slow taper of 10% of intake every 4-5 days, but directed by patient goals and symptoms.
- Monitor patient virtually at least weekly and assess for withdrawal symptoms within 12 hours of the last reduction.
- Familiarize the patient with the signs and symptoms of withdrawal.
- Refer to Alcohol withdrawal of the CEP AUD tool.
- Provide patient resources, such as an alcohol withdrawal resource (Fairview Health Services, 2020), that can help patients know the signs of alcohol withdrawal and when to go to an emergency department.
- Let your patient know that if this method of a planned alcohol reduction is not successful an alternative is outpatient or in-patient medically-assisted
If tapering needs to be done rapidly (e.g. surgery), consider following the HAMS guidelines (2015)* on tapering and adapting it to your patient’s needs. The method of rapid tapering requires more frequent and closer monitoring than a slow taper for severe withdrawal symptoms. Daily virtual visits for check-ins are recommended to assess for alcohol withdrawal symptoms.
*This resource is recommended by clinical consensus due to its utility. If you use the HAMS resource, please note that it was last updated in 2015 and is based on limited evidence. While the HAMS resource does not meet all of the CEP’s inclusion criteria for high-quality evidence, clinical experts feel that it has merit in the time of the COVID-19 pandemic.
Virtual patient resources for at-risk drinking and AUD New
Due to the COVID-19 pandemic, many resources to support patients are now available virtually. The following is a list of virtual resources that you can use in the management of your care.
General
Tips for safer drinking during the pandemic
(e.g. establishing safer drinking habits, managing alcohol supplies, understanding withdrawal)
- Canada’s Low-Risk Alcohol Drinking Guidelines Patient Resource (CCSA, 2018) on how to limit drinking and practice safe drinking tips.
- Knowing Your Limits with Alcohol: A Practical Guide to Assessing Your Drinking (CCSA, 2019) provides tips and guidance for individuals considering changing their alcohol consumption to a lower-risk level.
Apps that can help track alcohol consumption and help with reduction
- Drink Less is an app that helps identify your current blood alcohol concentration, and evaluate and monitor your alcohol usage (Android and iOS app; no costs affiliated; privacy policy that ensures user information is secure).
- Saying When is an app that helps individuals interested in quitting drinking or just cutting down to get their drinking under control (Android and iOS app; no costs affiliated; privacy policy that ensures user information is secure).
Family, friends and caregivers
- Resources for family and caregivers whose loved ones are living with an addiction.
- Al-Anon has information and groups for family and loved ones of a person with heavy drinking/AUD.
- Drug Rehab Services has a directory to locate Couple Counselling and Family Counselling.
Psychological and social interventions for addictions
Ontario MHA Information hubs
- ConnexOntario online directory or call 1.866.531.2600 for mental health and addictions services.
- Drug Rehab Services directory identifies local services in your area.
- eMentalHealth directory for youth and young adults specific resources and programs.
- 211Ontario is an online database of programs and resources in your local community. It can be used to find counsellors and therapy in your area.
Addiction treatment programs (day programs)
- ConnexOntario for availability of remotely offered addiction treatment programs in your local area.
- Drug Rehab Services directory for a list of alcohol detoxification centers in Ontario.
Community reinforcement therapy
- Togetherall is an online peer-to-peer support community for your mental health (costs may be affiliated).
- Alcoholics Anonymous is a peer-based support group to help members stay sober and help others achieve sobriety (no costs affiliated).
- SMART Recovery is a peer-based support groups that offers self-empowered addiction recovery. SMART Recovery Online is now available (no costs affiliated).
- In the Rooms is an online recovery tool that offers 130 weekly online meetings for those recovering from addiction and related issues (no costs affiliated).
Counselling
- Breaking Free is an evidence-based digital behaviour change program that allows people to recognize and actively address the psychological and lifestyle issues that are driving their use of alcohol (note: it is always free to those who use it, but they need a service code to set up an account. Service codes are provided by licensed organizations, such as healthcare providers and addiction services, who want to make Breaking Free available to those in their care).
- Inkblot helps match people with a therapist based on an individual’s personal preferences (costs affiliated – check health coverage plan to see if it will cover the costs).
Mental health resources for substance use
- AbilitiCBT is an internet-based CBT (iCBT) program that you can access from any device at any time (no costs affiliated for Ontario residents).
- Beacon provides digitally-delivered CBT with the one-on-one support of a dedicated therapist all along the way (no costs affiliated for Ontario residents).
- Wellness Together Canada connects individuals to mental health and substance use support (including CBT), resources, and counselling with a mental health professional (no costs affiliated).
Motivational enhancement therapy
- ConnexOntario or 1.866.531.2600 to connect with a System Navigation Specialist who can direct you to local programs offering motivational interviewing in your area.
- Psychology Today Locate motivational interviewing centres in Ontario usingo their nline directory of professionals (costs affiliated – check health coverage plan to see if it will cover the costs).
- Addiction Rehab Toronto motivational interviewing is available (costs affiliated – check health coverage plan to see if it will cover the costs).
Trauma therapy
- CAMH (2019) has compiled a comprehensive list of trauma programs available in the province. Note: availability of online offerings must be checked with the individual trauma program.
- Psychology Today: locate trauma and PTSD therapists in Ontario using their online directory of professionals (costs affiliated – check health coverage plan to see if it will cover the costs).
Identifying signs of withdrawal
- Alcohol withdrawal resource (Fairview Health Services, 2020) that can help patient’s familiarize themselves with the signs of alcohol withdrawal and when to know to go to the ED.
Harm reduction
- Safer Drinking Tips During COVID-19 Resource (UVIC, 2020) helps individuals make a plan for safer drinking in case of reduced alcohol availability during the pandemic.
- Managed Alcohol Programs (UVIC, 2020) in your community.
Acknowledgement and legal New
This Resource was developed by the Centre for Effective Practice and Department of Family and Community Medicine, University of Toronto. Clinical leadership for the development of the Tool was provided by Dr. Sheryl Spithoff and Dr. Jose Silveira and by the Managing At-Risk Drinking and Alcohol Use Disorder (AUD) During COVID-19 Working Group. The Managing Chronic Conditions during COVID-19 Advisory Committee provided feedback and input. This Resource was also subject to external review by health care providers and other relevant stakeholders. The development of this Resource was funded by the Government of Ontario as part of the Knowledge Translation in Primary Care.
Clinical Leads
• Sheryl Spithoff ATRIBUTIONS (Co-Clinical Lead)
• Jose Silveira ATRIBUTIONS (Co-Clinical Lead)
Working Group
• XXXX
Advisory Committee
• Noah Ivers, MD, PhD
• Tara Kiran, MD, MSc, CCFP, FCFP
• Daniel Pepe, MD, CCFP
• Sarah Newbery MD, CCFP, FCFP, FRRMS
• Nicole Nitti, MD, CCFP(EM), FCFP
• Anna Holland MD, CCFP (AM)
• Mia Biondi PhD, NP-PHC
• Jennifer Young, MD, FCFP-EM (Ontario College of Family Physicians)
• Kevin Samson MD (Association of Family Health Teams of Ontario)
• Danika Voisin (eHealth Centre of Excellence)
• Laurie Poole RN, MHSA (Ontario Health, OTN)
• Reza Talebi MD, MSc (OntarioMD)
• Maurine Parzen RN, PhD (Patient Representative)
Thank you to everyone who supported the development of this resource.
Managing At-Risk Drinking and Alcohol Use Disorder (AUD) During COVID-19 is a product of the Centre for Effective Practice and the Department of Family and Community Medicine, University of Toronto. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the Managing At-Risk Drinking and Alcohol Use Disorder (AUD) During COVID-19 Resource for commercial purposes or any modifications of the Resource are subject to charge and use must be negotiated with the Centre for Effective Practice (Email: info@cep.health).
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