Summary of recommendations
| Recommendation | Strength of recommendation* | Certainty of evidence (15) | |
|---|---|---|---|
| Screening† | |||
| 1 | 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. | Strong | Low |
| 2 | All adult and youth patients should be screened routinely for alcohol use above low risk.‡ | Strong | Moderate |
| Diagnosis | |||
| 3 | All adult and youth patients who screen positive for high-risk alcohol use should undergo a diagnostic interview for AUD using the DSM-5-TR criteria§ and further assessment to inform a treatment plan, if indicated. | Strong | Low |
| Brief intervention | |||
| 4 | All patients who screen positive for high-risk alcohol use should be offered brief intervention. | Strong | Moderate |
| Withdrawal management | |||
| 5 | Clinicians should use clinical parameters, such as past seizures or past delirium tremens, and PAWSS (16) to assess the risk of severe alcohol withdrawal complications and determine an appropriate withdrawal management pathway. | Strong | Moderate |
| 6 | For patients at low risk of severe complications of alcohol withdrawal (e.g., PAWSS < 4), clinicians should consider offering nonbenzodiazepine medications, such as gabapentin, carbamazepine or clonidine for withdrawal management in an outpatient setting (e.g., primary care, virtual). | Strong | Moderate (gabapentin) |
| Low (carbamazepine, clonidine) | |||
| 7 | 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. | Strong | High |
| 8 | All patients who complete withdrawal management should be offered ongoing AUD care. | Strong | Low |
| Treatment and ongoing care | |||
| Psychosocial treatment interventions | |||
| 9 | Adult and youth patients with mild to severe AUD should be offered information about and referrals to specialist-led psychosocial treatment interventions in the community. | Strong | Moderate |
| Pharmacotherapy | |||
| 10 | 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. | Strong | High |
| 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. | |||
| 11 | 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. | Strong (topiramate) | Moderate (topiramate) |
| Conditional (gabapentin) | Low (gabapentin) | ||
| 12 | Adult and youth patients should not be prescribed antipsychotics or SSRI antidepressants for the treatment of AUD. | Strong | Moderate |
| 13 | Prescribing SSRI antidepressants is not recommended for adult and youth patients with AUD and a concurrent anxiety or depressive disorder. | Strong | Moderate |
| 14 | Benzodiazepines should not be prescribed as ongoing treatment for AUD. | Strong | High |
| Community-based supports | |||
| 15 | Adult and youth patients with mild to severe AUD should be offered information about and referrals to peer-support groups and other recovery-oriented services in the community. | Strong | Moderate |
Note: AUD = alcohol use disorder, AUDIT = Alcohol Use Disorders Identification Test, AUDIT-C = AUDIT–Consumption, DSM-5-TR = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, PAWSS = Prediction of Alcohol Withdrawal Severity Scale, SSRI = selective serotonin reuptake inhibitor.
↵* See Box 3 for details.
↵† A clinical pathway from screening to treatment is depicted in Figure 2.
↵‡ Suggested screening tests include the Single Alcohol Screening Question, (17) AUDIT (17) and AUDIT-C. (14) Other validated screening tools may be used. Routine annual screening is suggested, although there is a lack of research evidence on the optimal frequency.
↵§ See Table 1 for sample interview questions for DSM-5-TR diagnostic criteria for AUD. (11)