META:PHI in Primary Care: Implementing Best Practices for Addictions

1. META:PHI in Primary Care: Implementing Best Practices for Addictions Managing Problematic Alcohol Use

2. What is META:PHI? Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration Collaborative project to implement integrated care pathways for addiction throughout Ontario Partnership between hospitals, withdrawal management services, FHTs, CHCs, and community agencies Goals: Improve care for patients with addictions Improve care provider experience Improve population health Reduce service use Provide sustainable care

3. How it works Patients presenting with addiction-related concerns receive evidence-based interventions and are referred to rapid access addiction medicine (RAAM) clinics for treatment RAAM clinics offer substance use disorder treatment on walk-in basis; no formal referral/appointment needed Patients stabilized at RAAM clinic referred back to primary care for long-term addiction treatment (with ongoing support from RAAM clinic as required) Key components: Integration of care at hospital, RAAM clinic, primary care Training, support, and mentorship from addictions specialists Capacity-building

4. Role of PCP With support from META:PHI team: Follow best practices for prescribing opioids Screen and diagnose patients for substance use disorders Refer patients to treatment at RAAM clinic when necessary Take over long-term addiction care for patients (with ongoing support from RAAM clinic doctor)

5. Practice goals for managing patients’ alcohol use

6. Practice goals Screen all patients for problematic alcohol use at least once per year Screen patients who present with medical or psychosocial problems that could be connected to problematic alcohol use Diagnose patients with at-risk drinking or alcohol use disorder (AUD) Offer brief advice for patients with at-risk drinking Offer patients with AUD appropriatecounselling, pharmacotherapy, and referral

7. Categories of alcohol use

8. Alcohol use categories Abstinence: Patient does not drink alcohol Low-risk drinking: Patient drinks within low-risk guidelines At-risk drinking: Patient drinks in excess of the low-risk guidelines but experiences minimal adverse effects Alcohol use disorder (AUD): Patient meets DSM-V criteria 2–3 = mild AUD 4–5 = moderate AUD 6+ = severe AUD

9. Canadian low-risk drinking guidelines Canadian Centre on Substance Use and Addiction, 2013

10. Summary Men Maximum of 3 drinks/day & 15 drinks/week Women Maximum of 2 drinks/day & 10 drinks/week Exceeding these limits increases risk of alcohol-related harm Trauma Fatigue Sleep disturbances Car accidents Low mood

11. AUD DSM-V criteria (1) Impaired control: Alcohol is taken in larger amounts or for a longer period than intended There is a persistent desire or unsuccessful efforts to cut down or control alcohol use A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or control alcohol use There are cravings or a strong desire to use alcohol

12. AUD DSM-V criteria (2) Social impairment: There is recurrent alcohol use resulting in a failure to fulfill important role obligations at work, school, or home There is continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol Important social, occupational, or recreational activities are given up or reduced because of alcohol use

13. AUD DSM-V criteria (3) Risky use: There is recurrent alcohol use in situations where it is physically hazardous Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is caused or exacerbated by alcohol

14. AUD DSM-V criteria (4) Physiological dependence: Tolerance: There is either a need for markedly increased amounts of alcohol to achieve intoxication or desired effect or there is a markedly diminished effect with continued use of the same amount of alcohol Withdrawal: There is either characteristic withdrawal syndrome for alcohol or alcohol is taken to relieve or avoid withdrawal symptoms

15. Screening for problematic alcohol use

16. Single-item screening test “How many times in the past year have you had 5 (men)/4 (women) drinks in one day?” Positive screen is once or more ???

17. Alcohol history Take an alcohol history for patients with a positive screen Helps determine between at-risk drinking and AUD Can track changes in patients’ consumption patterns Ask patients for daily or weekly amount “Would you say your drinking is closer to 14 drinks a week or 30 drinks a week?” “What is the most you would have in one day?” “How many bottles of wine/liquor do you consume in a week? What size bottles do you most often buy?” Convert responses to standard drinks: 12 oz. beer bottle, 5 oz. glass of wine, 1½ oz. liquor

18. At-risk drinking vs. AUD

19. Managing at-risk drinking

20. Inform Review low-risk drinking guidelines Link drinking with health status, mood, sleep, and energy Review precautions and contraindications to alcohol consumption Pregnancy, active peptic ulcer disease or gastritis, cirrhosis, alcohol or viral hepatitis, pancreatitis Potential adverse effects of alcohol use if patient has diabetes, bleeding disorders, or seizure disorders Potential adverse effects of alcohol use if patient is taking antidepressants, ASA, NSAIDs, opioids, benzodiazepines and other sedating drugs

21. Assess Assess patient’s state of change: “Are you willing to commit to cutting down on your drinking in the next month?” Not ready to change: Restate concern, encourage reflection, motivation, address barriers, reaffirm willingness to help Ready to change: Help set goals, agree to plan, educational materials, community resources, medications, follow-up

22. Create plan (1) Help patient set drinking goal: amount per occasion, frequency, and circumstances Strategies to reduce consumption: Drink no more than one standard drink per hour Start drinking later in the evening Sip drinks, don't gulp Avoid drinking on an empty stomach Dilute drinks with mixer Alternate alcoholic with non-alcoholic drinks 20-minute pause between the decision to drink and drinking

23. Create plan (2) Ask patient to keep a daily drinking diary Order GGT and MCV Elevated test results can motivate patient to change Changes can be tracked over time Arrange regular follow-up Ask about changes in consumption Ask about changes in health status, mood, energy, etc. Note successes Address challenges Keep patient engaged If problem persists or worsens, consider more intensive treatment

24. Managing alcohol use disorders

25. Present diagnosis (1) Be clear but sensitive: “I’m concerned about your use of alcohol. It is above the levels recommended by the low-risk drinking guidelines and appears to be causing you harm.” “Based on my assessment, you have an alcohol use disorder.” “Alcohol use disorders can be caused by many things, such as trauma (both in childhood and as an adult), genetics, mental health problems, and life stressors such as the end of a relationship or loss of a job.” “An alcohol use disorder is a chronic illness; it doesn’t mean that you’re weak, or that you’re not a good person.”

26. Present diagnosis (2) Offer help: “I know it can be very difficult to change your drinking patterns, but I can offer you some treatments that can help you (medications, counselling), and I can help connect you to treatment programs, counseling, or support groups.” “Within days or weeks of abstinence, most people have improved sleep, mood, and energy levels.” “This is a treatable condition. If you’re not ready to change right now, we can discuss it again at your next visit.”

27. Assess Assess patient’s state of change: “Are you willing to commit to cutting down on or stopping your drinking in the next month?” Not ready to change: Restate concern, encourage reflection, motivation, address barriers, reaffirm willingness to help Ready to change: Negotiate written goal • Abstinence is more likely to be successful • If reduced drinking goal is chosen, encourage a time-limited trial Treatment Agreement Goal: Abstinence Date: April 15 Plan:

28. Treatment protocol (1) Treat withdrawal if necessary Treat concurrent conditions (anxiety, depression, hypertension, liver disease) Prescribe anti-craving medication Encourage patient to make healthy lifestyle choices: Stay away from people/places associated with drinking Spend time with supportive family and friends Take daily walks Maintain regular sleeping/waking schedule Plan regular activities outside the house as feasible

29. Treatment protocol (2) Review options for formal treatment (residential, day, outpatient) Recommend AA or other community groups for support, practical advice, and a way to overcome loneliness and boredom Arrange follow-up; monitor drinking through self-report, GGT, MCV Acknowledge successes, even if partial or temporary If patient relapses, encourage contact and reconnection with treatment

30. Managing alcohol withdrawal

31. Indications for office withdrawal Patient reports frequent withdrawal symptoms (tremor, sweating, vomiting, anxiety, tachycardia, hypertension) Patient is committed to abstinence and willing to start psychosocial treatment and/or pharmacotherapy Patient has no history of seizures, DTs, or ED visits/ hospitalizations due to withdrawal Patient is not on high doses of opioids or sedating medications Patient does not have cirrhosis with liver dysfunction Patient has supports at home

32. Protocol (1) Advise patient to have their last drink the night before the morning appointment If patient shows up intoxicated, reschedule and/or refer to a withdrawal management centre (if available) Administer Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale q 1–2H Dispense diazepam 10–20 mg (or lorazepam 2–4 mg) for CIWA-Ar ≥ 10 Treatment is complete when CIWA-Ar < 8 on two consecutive occasions Ensure patient has minimal or no tremor

33. Protocol (2) Send patient to emergency department if: Worsening/no improvement despite 3–4 doses Patient displays marked tremor/vomiting/sweating or agitation/confusion Risk factors for electrolyte imbalance or arrhythmias (e.g., diuretics, heart disease, diabetes) Prior to discharge: Initiate anti-alcohol medication Advise patient to attend AA or another community service Schedule follow-up (within 1–2 days if lorazepam used) Ensure patient leaves accompanied by friend or relative

34. Indications for home withdrawal Office management not feasible A partner, relative, or friend agrees to dispense medication Patient has no history of seizures, DTs, or ED visits/ hospitalizations due to withdrawal Patient has treatment plan in place (anti-alcohol medication, ongoing counselling, psychosocial program, etc.) Age < 65 No hepatic decompensation (ascites, encephalopathy) Patient agrees not to drink while taking medication

35. Protocol Instruct patient to have last drink the night before Instruct patient to take diazepam 10 mg every 4 hours as needed for tremor (dispensed by partner, relative, or friend) Prescribe no more than 60 mg diazepam Reassess the next day (by phone or in person) Clinic visit within 2–3 days

36. CIWA-Ar scale (1)

37. CIWA-Ar scale (2)

38. Prescribing anti-craving medications

39. Role of anti-craving medications Should be routinely offered to patients with AUD Shown to reduce alcohol use Good safety profiles Help retain patients in treatment Choice of medication depends on individual considerations (e.g., cost, side effects) Titrate dose until cravings are mild and patient is abstinent, or until troublesome side effects emerge Maintain until patient has been abstinent for at least several months, has minimal cravings, has social supports and new ways of coping with stress, and is confident that medication is no longer needed to prevent relapse Usually at least 6 months

40. Medication availability Front-line medications naltrexone and acamprosate covered under ODB formulary with LU codes: Naltrexone: LU 532 “For the treatment of AUD in patients who meet clinical criteria for AUD; express a commitment to reduce or abstain from alcohol; and have confirmed participation in counselling and treatment for AUD” Acamprosate: LU 531 “For the treatment of AUD in patients who meet clinical criteria for AUD; express a commitment to abstain from alcohol; have been abstinent from alcohol for at least 3 days prior to starting acamprosate; and have confirmed participation in counselling and treatment for AUD” Disulfiram only available in Canada as compounded medication

41. Naltrexone

42. Acamprosate

43. Disulfiram

44. Gabapentin

45. Topiramate

46. Baclofen

47. Wrap-up: Key Messages

48. Our responsibility Treating addicted patients is our responsibility as health care providers Addiction is the same as any other chronic illness: patients need specialist referrals, medication, treatment of co-occurring conditions, and regular follow-up Effective addiction treatments are available Purpose of META:PHI project is to facilitate adoption of best practices and support clinicians

49. Resources META:PHI website: www.metaphi.ca META:PHI mailing list for clinical questions and discussion (e-mail sarah.clarke@wchospital.ca to join) META:PHI contacts:Medical lead: Dr. Meldon Kahan meldon.kahan@wchospital.ca Manager: Kate Hardykate.hardy@wchospital.ca Knowledge broker: Sarah Clarke sarah.clarke@wchospital.ca