5/21/2017 AlcoholrelatedDisorders

AlcoholrelatedDisorder
LisaLefebvre,MDCM,MPH,FCFP,DABAM,FASAM,CCSAM,MRO
DateofRevision:May2017
CPhAacknowledgesthecontributionofDr.JamesR.KennedyasthepreviousauthoroftheDrugWithdrawal
Syndromeschapter.

Introduction
Treatmentofalcoholrelateddisordersrequiresabiopsychosocialapproach.Alcoholrelateddisordersare
commonandhaveasignificantimpactonhealth,productivityandsocialproblemssuchasdomestic
violence,impaireddrivingandcrime.Thisdiscussionwillfocusonatriskdrinkingaswellastwo
componentsofalcoholrelateddisorders:alcoholusedisorderandalcoholwithdrawal(seeTable1for
diagnosticcriteria).Otheralcoholrelateddisorderssuchasalcoholintoxication,otheralcoholinduced
disordersandunspecifiedalcoholrelateddisorderwillnotbediscussed.

Atriskdrinkingisapatternofdrinkingthatdoesnotmeetcriteriaforalcoholusedisorder,butexceeds
recommendedsafelimitsforalcoholconsumption.AccordingtotheCanadianLowRiskAlcoholDrinking
Guidelines,2safelimitsare:
Women:10drinksperweekor2drinksperday
Men:15drinksperweekor3drinksperday

Complicationsofalcoholusedisordermayinclude:3

Poornutrition(thiaminedeficiency,lowpotassium,lowmagnesium,lowphosphorus)
Liverdisease
Bleedingdiathesis(increasedINR,impairedplateletfunction/thrombocytopenia)
Tremor,ataxia,seizures,Wernickesencephalopathy
Autonomicdysfunction(hypertension,dehydration,pyrexia)
Neuropathy
Trauma
Increasedriskofcertaincancers(mouth,throat,liver,colonandbreast)
Infections(aspirationpneumonia,cellulitis)
Psychosis(hallucinations,delusions)andpsychiatriccomorbidities(depression,anxiety)
Insomniaandsleepapnea

Table1:DiagnosticCriteriaforSelectAlcoholRelatedDisorders
AlcoholrelatedDisorder DiagnosticCriteria

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AlcoholUseDisorder Aproblematicpatternofalcoholuseleadingtoclinicallysignificant
Severitybasedon impairmentordistress,asmanifestedbyatleast2ofthefollowing,
numberofdiagnostic occurringwithina12monthperiod:
criteriamet Alcoholistakeninlargeramountsoroveralongerperiodthan
2 3:Mild wasintended
Persistentdesireorunsuccessfuleffortstoreduceorcontrol
45:Moderate
alcoholuse
6:Severe Significanttimeisspentinactivitiesnecessarytoobtainoruse
alcoholandrecoverfromitseffects
Cravingorastrongdesire/urgetousealcohol
Failuretofulfillwork,schoolorhomeobligationsorreduced
recreationalactivitiesduetotheeffectsofalcohol
Continuedalcoholusedespitehavingpersistentsocial,
interpersonal,physicalorpsychologicalproblemscausedor
exacerbatedbytheeffectsofalcohol
Recurrentalcoholuseinsituationsinwhichitisphysically
dangerous
Signsoftolerance,asdefinedbyeither:
anincreaseintheamountofalcoholrequiredtoachieve
thedesiredeffect(orintoxication)
withcontinueduse,thesameamountofalcoholhasa
reducedeffect
Withdrawalsymptoms,asmanifestedbyeither:
thecharacteristicfeaturesofalcoholwithdrawalsyndrome
(asdescribedbelow)arepresent.
alcohol(oracloselyrelatedsubstancesuchasa
benzodiazepine)istakentorelieve/avoidwithdrawal
symptoms

AlcoholWithdrawal 1.Cessationof(orreductionin)heavyandprolongedalcoholuseand
2.Twoormoreofthefollowingsymptoms(developingwithinseveral
hourstoafewdaysafteralcoholcessation/reduction)causing
clinicallysignificantdistressorimpairmentoffunctioning:
Autonomichyperactivity(e.g.,sweating,pulse>100bpm)
Increasedhandtremor
Insomnia
Nausea/vomiting
Transientvisual,tactileorauditoryhallucinations
Psychomotoragitation
Anxiety
Generalizedtonicclonicseizures

AdaptedwithpermissionfromtheDiagnosticandStatisticalManualofMentalDisorders:DMS5.5 th ed.Copyright2013
AmericanPsychiatricAssociation.

GoalsofTherapy
Changepatternofalcoholuseaccordingtopatientgoals(completeabstinenceorreduction)
Assessforandtreatmedicalcomplicationsand/orpsychiatriccomorbidities
Assessandaddresssafetyissues(e.g.,abilitytocarefordependents,highriskactivitiessuchas
drivingoroperatingheavymachinery)
Assessforandtreatalcoholwithdrawal
Facilitateintegratedpharmacologicandnonpharmacologictreatment
Preventrelapse

Investigations
MoreinformationontheassessmentofpatientswithalcoholrelateddisorderscanbefoundinFigure1.
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Detailedhistoryandphysicalexaminationtoassessuse(e.g.,amount,frequency,duration)ofalcohol
andothersubstances(opioids,sedativehypnotics,marijuana,tobacco).Assessimpactonfunction
(occupational,social,familial),historyofalcoholwithdrawalsymptoms,aswellascomorbidmedical
andpsychiatricconditions(SeeTable1fordiagnosticcriteriaforalcoholusedisorderandalcohol
withdrawal)
Screeningtoolsareusefulfordetectingthoseatriskofalcoholusedisorder.Allpatientsshouldbe
screenedatregularintervals,evenifanalcoholproblemisnotsuspected.Theonequestionscreen
canbeusedforaquickassessment4ifpositive,followupwiththeAlcoholUseDisorderIdentification
Test(AUDIT)5
ToolssuchasCIWAAr6areeffectiveforscoringtheseverityofalcoholwithdrawal.
Laboratorytestsand/orimagingareusedtoassesscomorbidities/complicationsrevealedfromthe
historyandphysical.Inthosewithalcoholrelateddisorders(suspectedorconfirmed)testsmaybe:
routine(pregnancytest,completebloodcount,renal/liverfunction,electrolytes,magnesium,
phosphorus)orasindicated(chestxray,CTofhead,abdominalultrasound)
Toxicology,includingurinetestingfordrugsofabuseethanolanditsmetabolite,ethylglucuronide.
Bloodalcohollevelsareusefulinemergencysituations.

TherapeuticChoices
Thebestpracticeforthetreatmentofalcoholusedisorderistheintegrationofpharmacologicand
nonpharmacologictreatment.Itisalsoimportanttorecognizethatsubstanceusedisordersarerelapsing
andremittingconditions.Communicatetopatientsthatrelapseisanormalpartofthisdisorderandthatthe
practitionerisavailabletohelpthemifthisshouldoccur.Formoreinformationonthemanagementof
patientswithalcoholusedisorder,seeFigure1.

NonpharmacologicChoices

Anonjudgmentalapproachthatviewsalcoholusedisorderasamedicalconditionandnotamoral
failingisrecommended
ConsiderthestagesofchangeandhowreadythepatientisfortreatmentseeTable2.Formore
informationontheModelofBehaviourChange,seeFacilitatingBehaviourChange.Motivational
interviewingisatechniquethatcanbehelpfulinassistingapatienttomoveintotheactionstageof
change.7,8
Intheprimarycaresetting,briefinterventionsalone(suchasthemotivationalinterviewing
describedinTable2)havedemonstratedefficacyinreducingalcoholconsumptioninpatientswho
arenotdiagnosedwithalcoholusedisorders,butareatriskdrinkers.9Atriskdrinkersmayalso
benefitfrombriefadviceandeducationregardingtheCanadianLowRiskAlcoholDrinking
Guidelines.2
Severalpsychosocialtreatmentoptionsareavailable(psychoeducation,relapsepreventiontraining,
traumatherapy,cognitivebehaviouraltherapy,motivationalenhancementtherapy,interpersonal
therapy,networksupport10(e.g.,AA,12step),groupandfamilytherapies).11Thereislittle
evidencetosupportthesuperiorityofanysinglemodality.12Acombinationofcognitivebehavioural
therapyandmotivationalenhancementtherapyhasdemonstratedasignificantincreasein
abstinencerates.13
Thecombinationofmotivationalinterviewingandcognitivebehaviouraltherapyiseffectivein
patientswithcomorbiddepressionandanxiety,whichisacommonpresentationinalcoholuse
disorder.14

Table2:StageofChangeMotivationalInterviewingApproach
Stageof MotivationalInterviewingApproach
Change7,8

Precontemplation Encouragepatientstoopenlydiscusstheiralcoholuse
Discusshealthconsequencesofheavyalcoholuse,butavoid
confrontationalorjudgmentalcommentsorbodylanguage.

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Stageof MotivationalInterviewingApproach
Change7,8

Contemplation Encouragepatientstolistpros/consofalcoholusecreateadecisional
balanceweighingouttheitemsoneachside.
Beunderstandingifthepatientexpressesambivalence,andbe
encouraging.Providepositivereinforcementofanychangetalk.

Preparation Workonpracticalelementsofplanningthequitattempt.Discuss
treatmentoptionsincludingpsychosocialtreatment,needforwithdrawal
managementandanticravingmedications.Addressanyconcernsand
provideinformationonoptions.

Action Monitorprogress.Providepositivereinforcementforanysuccesses.
Troubleshootanydifficultiesencountered.

Maintenance Continuetoprovidepositivereinforcementofsuccesses.Workon
relapsepreventionskillsandselfmanagementtechniques.Builda
communitybasedsupportnetworktosustainmotivationtomaintain
success.

Relapse Normalizerelapseasapartofanychangeprocessandmore
particularly,aspartofthediseaseofaddiction.
Framerelapseasalearningopportunityandnotasafailure.Excessive
guiltcanleadtoshame,whichmayworsentherelapse.
Reassesscurrentstageofchangeusemotivationalapproachestohelp
movepatientbackintopreparationphase.

PharmacologicChoices

MedicationsusedinthemanagementofalcoholwithdrawalarelistedinTable3thoseusedforalcohol
usedisorderarelistedinTable4.

Generalprinciples:

Assessneedfortreatmentofwithdrawalsymptoms
Initiatepharmacotherapytoassistwithreductionorcessation
Medicationismosteffectivewhenusedincombinationwithpsychosocialtreatment

Heavyalcoholconsumptioncanleadtothiamine(vitaminB1)deficiencythroughpoordietaryintakeand
interferencewithvitaminabsorption.ThiaminedeficiencyputspatientsatriskofWernickeKorsakoff
Syndrome,whichcanbefatal.Thiaminereplacementisrecommendedforallpatientswhoconsume
significantamountsofalcohol.Giventhepoorqualityofstudiesofthistreatment,expertconsensus
recommendsadoseof200mgperday.17

AlcoholWithdrawal

Approximatelytwothirdsofpatientswithmildtomoderatewithdrawalsymptomscanbemanaged
withsupportivemeasuresandmonitoring.18Pharmacologictreatmentisalwaysrequiredfor
moderatetoseverealcoholwithdrawalandmayberequiredforaboutonethirdofpatientswithmild
tomoderatesymptoms.Mostcasesrespondwelltobenzodiazepinesastheyreducethe
hyperactivityofGABAreceptorsthatoccursduringwithdrawal.Abenzodiazepineprotocol,with
dosingbasedonthepatientsCIWAArscorecanbeusedintheprimarycaresettingtoalleviate
withdrawalsymptoms.19Formoreinformationonhowtopreparethepatientforofficebased
withdrawal,seewww.porticonetwork.ca/web/alcoholtoolkit/treatment/alcoholwithdrawal.Patients
shouldbecounselledontheriskofrespiratorydepressionifalcoholrelapseoccursduring(orshortly
after)benzodiazepinetreatmentduetotheirsynergisticeffect.Fordosinginformation,seeTable3.

Largerdosesofbenzodiazepinesand/oradditionofadifferentGABAinhibitorydrugsuchas
phenobarbitalmayberequiredforresistantalcoholwithdrawal(<5%ofcases)andpatientswill

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requiremonitoringinacriticalcarearea.15,16

AlcoholUseDisorder

Evidencesupportstheuseofpharmacotherapyforalcoholusedisorders.19,20

Naltrexoneisanopioidantagonist,thoughttodecreasetheeuphoriarelatedtoendogenousopioid
releaseupondrinkingalcohol,thusmakingdrinkinglesspleasurable.Itisthereforeusefulinpatients
whowishtoabstainfromdrinkingorreduceconsumptionwithoutcompletelyabstaining.Naltrexone
alsoreducescravingsforalcohol.Inametaanalysis,naltrexonedemonstratedgreaterefficacyin
decreasingheavydrinkingandcravingsthanacamprosate.21Administeredinaprimarycaresetting,
naltrexonehasbeenshowntobeaseffectiveasspecialistadministeredcognitivebehavioural
therapy.22Naltrexoneiscontraindicatedinpatientsonopioidtherapyduetoprecipitationofopioid
withdrawalapatientmustbeopioidfreefor7dayspriortonaltrexoneinitiation.Usewithcautionin
thosewithhepaticdysfunctionduetotheriskofhepatotoxicity.

AcamprosateisaglutamateandGABAmodulator,whichisbelievedtounderlieitsabilitytorelieve
symptomsofalcoholwithdrawalandreducetheeuphoriceffectsofalcohol.Acamprosatehas
demonstratedefficacyinmaintainingabstinencefromalcohol,whencombinedwithpsychosocial
programs.23Itisthetreatmentofchoiceforpatientswithhepaticinsufficiency,sinceitisrenally
excreted.Acamprosatemayalsobethedrugofchoiceinpatientswhoseaimiscompleteabstinence
fromalcohol.Inametaanalysis,acamprosatedemonstratedgreaterefficacyinmaintaining
completealcoholabstinencethennaltrexone.21

Preliminarystudieshaveinvestigatedtheconcurrentuseofnaltrexoneandacamprosate,butfurther
researchisrequired.23

Disulfiramisanirreversibleinhibitorofaldehydedehydrogenase,anenzymeinvolvedinthe
metabolismofalcohol.Ifapatientondisulfiramtherapydrinksalcohol,acetaldehydelevelsincrease,
causingthedisulfiramreaction(e.g.,nausea,flushing,vertigo,arrhythmias,andrarely,death).
Disulfiramisanaversivetherapy,meaningthatpatientsstopdrinkingoutoffearofexperiencingthis
veryunpleasantreaction.Lowqualitystudieshaveshownthatsuperviseddisulfirammaybe
beneficialinpatientswithaparticularlylonghistoryofalcoholusedisorder.24Contraindicatedin
thosewithhepaticdysfunctionduetotheriskofhepatotoxicity.Disulfiramisnotasextensively
studiedasothertherapies,norisitcommerciallyavailableinCanada.Itmaybeaccessibleatselect
compoundingpharmacies.

Anticonvulsantmedications(e.g.,topiramate,gabapentin)havebeeninvestigatedforthetreatment
ofalcoholusedisorder.25Theproposedmechanismofactionissimilartothatofacamprosatei.e.,
modulationofglutamatereceptorsandattenuationofwithdrawalandcravings.Efficacyofthese
agentsisequivocal,andadverseeffectsmayincludecognitivedysfunction.25Anticonvulsant
medicationsrequireslowtitrationintothetherapeuticrangetomitigatesideeffects.Astudy
investigatinggabapentinforalcoholusedisorderdemonstratedahigherabstinenceratethanplacebo
(17%vs.4%),althoughthedropoutratewashigh.26

ChoicesduringPregnancyandBreastfeeding
Alcoholconsumptionduringpregnancyincreasestheriskoffetalalcoholspectrumdisorder(FASD),
alcoholrelatedbirthdefectsandspontaneousabortion.

Alcoholwithdrawalcarriesarisktobothmotherandbaby,andshouldtakeplaceinamedicallysupervised
inpatientsetting.TheCIWAArscaleisutilizedandbenzodiazepineloadingprotocolsaresimilartothose
usedforthenonpregnantpopulation.

Therearenostudiesinvestigatingthepharmacologictreatmentofalcoholusedisorderinpregnancy.27The
safetyofacamprosate,disulfiramandnaltrexoneinpregnancyhasnotbeenestablishedandthus
prescribersmustcarefullyweightherisksofusingsuchmedicationsagainsttheriskofcontinuedalcohol
use.19

Withrespecttobreastfeeding,disulfiramiscontraindicated.19Althoughnaltrexoneappearstobeminimally
excretedintobreastmilk,28limiteddataexistregardingthesafetyofbothacamprosateornaltrexoneinthe
breastfeedingmotherandthusprescribersmustassessthebenefitsversustherisksoftreatment.19,29

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ManagementoftheFrailElderly
Olderpatientsaremoresensitivetotheeffectsofalcoholduetoavarietyoffactorsincludinglowerlevels
oftheenzymesthatmetabolisealcohol,lowertotalbodywaterandconcurrentmedicalconditions.Elderly
patientstendtohavemoreseverealcoholwithdrawalsymptomsandmayexperiencemedicalcomplications
ofalcoholusemorefrequentlythanyoungerpatients.Inwithdrawalmanagement,avoiddiazepamwhichis
renallyexcretedandmayresultinaccumulationofbothdiazepamanditsactivemetabolites.Lorazepamis
thepreferredchoiceforwithdrawalmanagementinthispopulation.Elderlypatientsmaybenefitfrom
relapsepreventionmedicationscarefullyconsidertheincreasedpotentialforadversereactionsanddrug
interactionsinthispopulation.

TherapeuticTips
Forscreening,assessmentandtreatmenttoolsandresources,visittheonlineDealingwithAlcohol
ProblemsToolkit:www.porticonetwork.ca/web/alcoholtoolkit
Studieshaveshownthattheprimarycaresettingisidealfortreatingalcoholrelateddisordersdueto
increasedaccessibility,continuityofcareandthepreestablishedrelationshipbetweenthefamily
physicianandpatient.3,9,22
Acombinationofpharmacologicandnonpharmacologictherapyisthetreatmentofchoiceforalcohol
usedisorders
Thetreatmentofconcurrentmentalhealthproblemssuchasdepressionandanxietyshouldbe
integratedintothetreatmentofalcoholusedisorderandtreatmentforbothconditionsshouldoccur
simultaneously.

Algorithms
Figure1:AssessmentandTreatmentofPatientswithAlcoholUseProblems

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DrugTables
Table3:PharmacologicManagementofAlcoholWithdrawal
Class Drug Indications Dosage Comments Costa

Barbiturates phenobarbital15,16 Severewithdrawal 60mg Highdose po:$

Phenobarb, refractoryto Q2030min maybe iv:$$$
generics benzodiazepine pooriv required(up
therapy(>50mg tototalof
diazepamgivenin1 1000mg).
hor>200mgin3h). Shouldbe
usedina
criticalcare
area.

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Class Drug Indications Dosage Comments Costa

Benzodiazepines diazepam Autonomic CIWAAr Goalis $

Valium,generics hyperactivity, score10: suppression
agitation/tremor, 20mgQ12 of
hallucinations, hpountil symptoms
seizures. symptoms withnomore
resolveand thanmild
CIWAAr sedation.
score<8on IfCIWAAr
2 score
consecutive increases
readings,at and/ordoes
least1h notimprove
apart. after4
doses,refer
to
emergency
department.

Benzodiazepines lorazepam Autonomic CIWAAr Goalis $

Ativan,generics hyperactivity, score10: suppression
agitation/tremor, 12mg of
hallucinations, Q24hpo symptoms
seizures. orSLuntil withnomore
symptoms thanmild
resolveand sedation.
CIWAAr IfCIWAAr
score<8on score
2 increases
consecutive and/ordoes
readings,at notimprove
least1h after4
apart. doses,refer
to
emergency
department.
Lorazepam
ispreferred
inelderly
andpatients
withhepatic
dysfunction.

Vitamins thiamine(vitamin Treatment/prevention 200mg Best $

B1) ofWernicke dailypo,iv practiceis
Thiamiject, Korsakoffsyndrome. orimfor to
generics durationof administer
withdrawal thiamineto
allpatients
withalcohol
withdrawal.

a Costofasingleadministrationincludesdrugcostonly.

Legend:$<$1$$$15$$$$510
Table4:PharmacologicManagementofAlcoholUseDisorder
Class Drug Dosage Adverse Drug Comments Costa
Effects Interactions

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Aldehyde disulfiram 250 Metallic Acetaldehyde Not ~$7

Dehydrogenase 500mg aftertaste, accumulation commercially
Inhibitors poonce dermatitis. withthe availablein
daily concurrentuse Canada.May
ofalcohol, beaccessible
paraldehyde inselect
andcertain compounding
formulationsof pharmacies.
carbocisteine, Usedmostly
lopinavir, inpatients
ritonavir, whohave
sertralineand usedit
tipranavirthat historically
maycontain withsuccess.
largeamounts Patients
ofalcohol. shouldbe
Metronidazole counselledon
is the
contraindicated symptomsof
within2wkof adisulfiram
disulfiramuse reactionand
dueto howitcanbe
increasedrisk fatal.
ofpsychoses,
confusion,
hallucinations,
delusions.
Increased
serum
concentration
ofphenytoin,
avoid
combinationif
possible.

Glutamate acamprosate 666mg Diarrhea, None. Maybe ~$160

Antagonists Campral poTID vomiting, preferredin
abdominal patientswith
pain, goalof
pruritus, abstinence.
rash. Treatmentof
Suicidality choicefor
(suicidal patientson
thoughts/ opioid
attempts/ therapy.
completed Start
suicide) treatment
hasbeen after4days
reported ofalcohol
abstinence.

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Opioid naltrexone 50mg Abdominal Contraindicated Treatmentof ~$220

Antagonists Revia, poonce cramps, withconcurrent choicein
generics daily pain, opioidtherapy patientswho
nausea. dueto wishtoreduce
precipitationof usebutnot
opioid abstaingiven
withdrawal. potentialrisk
Patientmust of
beopioidfree hepatotoxicity.
for7days Usewith
priorto cautionif
initiationof LFTsmore
treatment than5the
upperlimitof
normal.

a Costof30daysupplyincludesdrugcostonly.

SuggestedReadings
Jonas,DE,AmickHR,FeltnerCetal.Pharmacotherapyforadultswithalcoholusedisordersinoutpatient
settings:asystematicreviewandmetaanalysis.JAMA2014311(118):1889900.

SpithoffS,KahanM.Primarycaremanagementofalcoholusedisorderandatriskdrinking:Part1:
screeningandassessment.CanFamPhys201561(6):50914.

SpithoffS,KahanM.Primarycaremanagementofalcoholusedisorderandatriskdrinking:Part2:
counsel,prescribe,connect.CanFamPhys201561(6):51521.

U.S.DepartmentofHealthandHumanServices.SubstanceAbuseandMentalHealthServices
Administration,NationalInstituteonAlcoholAbuseandAlcoholism.Medicationforthetreatmentofalcohol
usedisorder:abriefguide.HHSPublicationNo.(SMA)154907.Rockville(MD):SAMHSA2015.Available
from:store.samhsa.gov/shin/content/SMA154907/SMA154907.pdf.

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