Unveiling the hidden struggle: Pharmacists are key allies in identifying and treating alcohol use disorder

Alcohol is a leading preventable cause of morbidity and mortality worldwide.1,2 It can have profound negative health impacts.1,2 In Canada, approximately 75% of people consume alcohol and, in 2017, alcohol led to 18,000 deaths and was associated with $5.4 billion in healthcare costs.2 Alcohol use can be challenging to discuss with patients given the societal and cultural perceptions of alcohol use. As accessible healthcare professionals, pharmacists have an essential role in providing holistic patient care, including screening for and treatment of alcohol use disorder (AUD).3,4 Imagine you are conducting a medication review with 52-year-old female patient, AB. She has a history of chronic low back pain and migraines for which she takes hydromorphone controlled-release 3 mg po twice daily, pregabalin 150 mg twice daily, and acetaminophen 500 mg po four times daily. AB discloses that she has been consuming a bottle of wine most nights for the past three years. She recognizes that this is an issue, but has been unsuccessful in past attempts to cut down. AB has been working with a counsellor to address contributing psychosocial factors, but has not disclosed her alcohol use to her family physician. She is interested in a medication to assist with reducing her alcohol use.Building a foundation of trust and nonjudgmental communicationBegin by acknowledging AB’s courage in discussing her struggles with alcohol. Express empathy, validate her feelings and highlight that seeking help is a commendable step towards better health. When addressing sensitive topics such as alcohol use, it is crucial to adopt a nonjudgmental stance. Avoid imposing personal opinions and remain open to understanding the patient’s perspective.5Screening The 2023 Canadian Clinical Guideline for High-Risk Drinking and Alcohol Use Disorder suggests open-ended questions to aid with screening for AUD, including the integration of AUD screening into routine clinician–patient interactions (such as during a medication review with AB).5 Initial screening can be as simple as a single question: “How many times in the past year have you consumed (4 for women/5 for men) or more drinks on any one occasion?”6 For patients that are challenging to engage, tools such as the AUDIT-C (https://www.mdcalc.com/calc/2021/audit-c-alcohol-use) can be helpful.5 It is important to be aware that screening alone does not improve patient outcomes and early intervention is key.5 Brief interventionWhen high-risk drinking is identified, one of the first steps is to provide a brief intervention to support positive behaviour change related to alcohol use.5 Motivational interviewing can be a useful technique to promote change in AUD behaviour and aims to understand and enhance patients’ intrinsic motivation for change.7 For example, motivational interviewing may help AB to articulate the concerns she has related to the relationship between her alcohol use and chronic pain. Additionally, providing evidence-based resources for patients such as helpwithdrinking.ca can be a useful first step to motivate patients to make a positive change related to their alcohol use. Referral for diagnosisPatients with identified high-risk drinking should be referred to a physician for an assessment for AUD.5 In AB’s case, a referral to her family physician for a comprehensive assessment would be crucial to screen for and provide management of alcohol-related complications, including alcohol withdrawal syndrome, as well as to identify the required information for selecting appropriate pharmacotherapy for long-term AUD management.5 Pharmacotherapies for AUDNaltrexone and acamprosate are first-line pharmacotherapies with proven effectiveness in reducing alcohol use and facilitating abstinence.5,8 The number needed to treat to prevent return to any drinking is 20 for naltrexone and 12 for acamprosate.8 Despite their established effectiveness and acceptable tolerability, a 2017 study in Ontario identified substantial underutilization of these agents, with less than 1% of public drug plan beneficiaries diagnosed with AUD being dispensed naltrexone or acamprosate a year after their diagnosis.9 As medication experts, pharmacists are well-positioned to address this healthcare gap by identifying patients who would benefit from pharmacotherapy for AUD.10 Key considerations for selecting naltrexone versus acamprosate are summarized in Table 1.5,8 For AB, it would be important to recognize that she would not be a good candidate for naltrexone, given her concurrent hydromorphone use; however, acamprosate would be a reasonable option for her to try.Ongoing support, monitoring, and celebrating progressPatients such as AB who embark on changing their alcohol use should be offered continuous support through regular follow-up to monitor and celebrate progress, address challenges, and adjust the treatment plan as needed.5 SummaryPharmacists can play a pivotal role in addressing AUD by providing a safe space for patients to discuss their substance use, integrating AUD screening into routine patient care, offering brief interventions, and providing referrals to appropriate supports. By establishing trust, practising nonjudgmental communication, integrating pharmacotherapy, and collaborating on patient goals, pharmacists can empower patients to overcome challenges and achieve alcohol abstinence for improved health and well-being. Katelyn Halpape is a clinical pharmacist at the Dube Centre for Mental Health in Saskatoon, SK, and an Assistant Professor in the College of Pharmacy and Nutrition at the University of Saskatchewan.ReferencesRehm J, Mathers C, Popova S, et al. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009;373:2223-33. Street A. Canada’s guidance on alcohol and health: final report. Canadian Centre on Substance use and Addiction. January 2023. (accessed November 6, 2023).Valliant SN, Burbage SC, Pathak S, et al. Pharmacists as accessible health care providers: quantifying the opportunity. J Manag Care Spec Pharm2022;28(1):10.18553/jmcp.2022.28.1.85. York MG, Caliendo T. Assessing substance use disorder in pharmacy practice. (accessed August 29, 2023). Canadian Research Initiative in Substance Misuse. Canadian clinical guideline. High-risk drinking and alcohol use disorder. October 2023. (accessed November 6, 2023). Mitchell AJ, Bird V, Rizzo M, et al. Accuracy of one or two simple questions to identify alcohol-use disorder in primary care: a meta-analysis. Br J Gen Pract 2014;64(624):e408-18. Substance Abuse and Mental Health Services Adminstration. Using motivational interviewing in substance use disorder treatment. (accessed November 6, 2023).Wood E, Bright J, Hsu K, et al. Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder. CMAJ 2023;195:E1364-79. Spithoff S, Turner S, Gomes T, et al. First-line medications for alcohol use disorders among public drug plan beneficiaries in Ontario. Can Fam Physician 2017;63(5):e277-83. Antrim A. Pharmacists play key role in management of alcohol use disorder, withdrawal syndrome. Pharmacy Times; December 5, 2022. (accessed November 2, 2023).

Unveiling the hidden struggle: Pharmacists are key allies in identifying and treating alcohol use disorder

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