Clerkship: Transition to Residency
Alcohol Use Disorder
Sean C. Haffey, MD MSc CCFP(AM)
24 March 2025
Introductions
• Trained at Queen’s for MD and residency
(FM)
• Addiction medicine PGY3/Enhanced Skills
in Toronto
• Practicing in academic family medicine
(Queen’s FHT) and outpatient substance
use disorders clinic
Learning Objectives
1. Review the phenomenology of substance use
disorders (SUDs).
2. Review the signs and symptoms of alcohol
intoxication and alcohol withdrawal syndrome
(AWS).
3. Provide tools to diagnose and screen for alcohol use
disorder (AUD).
4. Explore AUD treatment options for primary care
providers, particularly anticraving management.
5. Discuss an AUD case.
Disclosures
I have no conflicts of interest to disclose.
Some content / slides / cases provided by colleagues
at St. Michael’s Hospital and CAMH:
• Dr. Kit Fairgrieve
• Dr. Meldon Kahan
• Dr. Monique Moller
• Dr. Erin Lurie
• Dr. Ken Lee
Defining Our Terms
• Addiction: A primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in
these circuits leads to characteristic biological,
psychological, social and spiritual
manifestations. This is reflected in an
individual pathologically pursuing reward and/or
relief by substance use and other behaviors.1
1. ASAM. (2013). Terminology Related to Addiction, Treatment, and Recovery.
Retrieved from
[Link]
[Link]?sfvrsn=0
.
The Spectrum of Substance Use
SUDs: The Cardinal Features
DSM-5 (11 criteria) 4 C’s
• Impaired control 1. Continued use
• Social Impairment despite
• Risky/Hazardous Use Consequences
2. Inability to Cut
• Dependence
down
– Physiological 3. Cravings
– Psychological 4. Compulsive use
Alcohol
Alcohol
Mechanism of Action
1. GABAAR activation 2. NMDAR inhibition
Neuropharmacology
•
😆
Euphoria / elevated mood •
😱
Behavioural disinhibition • Decreased LoC
😬
• Anxiolysis • Drowsiness • Decr BP Hypotension
• Incr. sociability • Amnesia • Decr RR Apnea
• Drowsiness • Poor coordination, balance • Dysrhythmia (incr. risk of
• Behavioural disinhibition (“ataxia”) AFib)
• Impaired emotional • Emesis +/- asphyxiation
cognition
Long-term Sequelae
What can physicians do? How can we help?
Diagnosing & Screening for AUD
4C’s of SUD
1. Loss of CONTROL
2. Use despite
CONSEQUENCES
3. COMPULSIONS
4. CRAVINGS
DSM-V: Alcohol use disorder (over preceding 12mo)
Impaired control
1 Alcohol use in LARGER amounts over LONGER periods of time
2 Wanting to USE LESS with UNSUCESSFUL efforts to DECREASE or DISCONTINUE alcohol use
3 Spending lots of TIME obtaining, using and recovering from alcohol use
4 CRAVING or strong desire to use alcohol
Social impairment
5 Recurrent alcohol use resulting in failure to fulfill major role OBLIGATIONS
6 Continuing alcohol use despite SOCIAL or INTERPERSONAL problems
7 May give up or reduce important ACTIVITIES because of alcohol use
Risky Use
8 Recurrent alcohol use in situations where it is PHYSICALY HAZARDOUS
9 Continuing to use alcohol despite knowledge of PHYSICAL or PSYCHOLOGICAL PROBLEM likely caused or
exacerbated by alcohol use
Pharmacological criteria
10 Increased TOLERANCE either by
a) Need for increased amounts of alcohol to achieve the same effect or
b) Diminished effect with continued use of the same amount of alcohol
11 WITHDRAWAL by either
a) Characteristic withdrawal syndrome for alcohol or
b) Alcohol (or closely related substance such as benzodiazepine) taken to relieve or avoid withdrawal
Adapted from DSM 5
Diagnosing AUD: DSM-V
0 1 2 3 4 5 6 7 8 9 10 11
Mild Moderate Severe
Screening for AUD
Screening: AUDIT
Screening for AUD
Questions Positive Accuracy
AUDIT 10 Questions >8 suggests Sensitivity 90%
unhealthy alcohol Specificity 80%
use
>20 suggests alcohol
use disorder
Adapted from Kahan 2017 Management of Alcohol use disorders, opioid prescribing and opioid use
disorders in primary care: A pocket reference for family physicians.
Screening: AUDIT-c
AUD Identification Test - Concise
Screening: AUDIT-c
Questions Positive Accuracy
AUDIT 10 Questions >8 suggests Sensitivity 90%
unhealthy alcohol Specificity 80%
use
>20 suggests alcohol
use disorder
AUDIT-C 1) How often? >3 in women Sensitivity 73%
2) How many on a typical day? Specificity 91%
3) How often binge?
>4 in men Sensitivity 86%
Specificity 89%
Adapted from Kahan 2017 Management of Alcohol use disorders, opioid prescribing and opioid use
disorders in primary care: A pocket reference for family physicians.
Screening: AUDIT
Questions Positive Accuracy
Single Item “How many times in the past year have you had five If not 0 Sensitivity 82%
Screen (four for women) or more drinks a day” Specificity 79%
AUDIT-C 1) How often? >3 in women Sensitivity 73%
2) How many on a typical day? Specificity 91%
3) How often binge?
>4 in men Sensitivity 86%
Specificity 89%
AUDIT 10 Questions >8 suggests Sensitivity 90%
unhealthy alcohol Specificity 80%
use
>20 suggests alcohol
use disorder
NB – one question can screen for AUD (almost) as effectively as ten!
Adapted from Kahan 2017 Management of Alcohol use disorders, opioid prescribing and opioid use
disorders in primary care: A pocket reference for family physicians.
Screening: CAGE
• Have you ever felt the need to Cut down on
drinking
• Have you ever felt Annoyed by the criticism of
your drinking
• Have you ever felt Guilty about your drinking?
• Have you ever felt the need to drink a morning
Eye opener?
Adapted from Kahan 2017 Management of Alcohol use disorders, opioid prescribing and opioid use
disorders in primary care: A pocket reference for family physicians.
Questions Positive Accuracy
Single Item “How many times in the past year have you had five If not 0 Sensitivity 82%
Screen (four for women) or more drinks a day” Specificity 79%
AUDIT-C 1) How often? >3 in women Sensitivity 73%
2) How many on a typical day? Specificity 91%
3) How often binge?
>4 in men Sensitivity 86%
Specificity 89%
AUDIT 10 Questions >8 suggests Sensitivity 90%
unhealthy alcohol Specificity 80%
use
>20 suggests
alcohol use disorder
CAGE Cut down >2 men For Alcohol
Annoyed Abuse/Dependence
Guilty >1 women Sensitive 77%
Eye-opener Specific 79%
For unhealthy drinking
Sensitive 53%
Specific 70%
Alcohol Withdrawal Syndrome
Need to activate GABAAR’s!!! BZD +/- Barb’s
Alcohol Withdrawal Syndrome
Alcohol Withdrawal Syndrome
DTs can be lethal!
• Autonomic
hyperactivity (↑BP/
↑HR/ ↑T) eventually
leads to hemodynamic
instability (fatal
arrhythmia)
Alcohol Withdrawal Syndrome
• But who needs to be treated in the ED and/or
admitted??
PAWSS: Prediction of Alc WD Severity Score
• Estimates risk of complicated
AWS (hallucinosis, seizures, DTs)
• < 4 = “Average risk”
o LR 0.07 for complicated AWS
o Can likely be managed with
short tapering dose of
gabapentin or BZD at home
• >=4 = “High risk”
o LR 174 for complicated AWS
o Should NOT be treated at
home (go to the ED!)
AWS: Assessing & Treating
• Largely outside the scope of this talk
• Symptom-triggered BZDs
– Diazepam or lorazepam
• Occasionally require phenobarbital (a
barbiturate)
CIWA
• Symptom-triggered
BZD treatment
protocol
• Ubiquitously used in
ED and inpatient
settings
• Takes ~5mins to
complete
• Can be manipulated
Gray 2010 Feasibility and Reliability of the SHOT: A short scale
for measuring pretreatment severity of alcohol withdrawal in
the ED. Academic Emergency Medicine 177: 1048-1054
Cessation Management
Cessation Management
• Psychosocial
• Pharmacotherapy
• +/- Mutual Support (e.g. AA)
Cessation Management
• “Anti-craving” pharmacotherapy
• Numerous options, diverse mechanisms of action
• Goals:
– Reduce cravings to use alcohol (i.e. maintain
abstinence)
– Reduce amount of EtOH used if they do
consume (i.e. harm reduction)
Naltrexone
• Opioid (mu) receptor antagonist
• Mechanism – attenuation of mesolimbic response
to alcohol-associated cues
• Initiate – abstinence or harm reduction
• Administration
– 25 mg day 1-3 then 50 mg daily
– Evidence for up to 100 mg daily
– Daily or “pill in pocket” (Sinclair method)
Naltrexone
• NNT – 9 to prevent return to heavy drinking
• Side effects – Nausea, Dizziness, Vomiting,
Headache
• Contraindications
– Opioid use (prescribed or illicit) precipitated
WD!
– Hepatic dysfunction (LFTs >5x ULN)
– Pregnancy
• Cost - $6/day (LU 532)
Acamprosate
• Mechanism – glutamate antagonist
• Initiate – ideally after a few days of abstinence
• Administration – 333mg TID x4-5d then 666mg
TID
• NNT – 9 for additional prevention of drinking
• Side Effects – diarrhea, GI cramps
• Contraindicated – pregnancy, ESRD (CrCl <30)
• Cost – $6/day (LU 531)
Gabapentin
• Second Line!!
• Mechanism – indirect GABA modulation
• Method – abstinence, withdrawal or harm
reduction
• Initiation – varies widely
– therapeutic range 1800 mg/day (600 mg TID)
• NNT – 8 for abstinence, 5 for return to heavy
drinking
• S/E – dizziness, drowsiness, fatigue, headache,
Other Pharmacotherapy
• Disulfuram (Antabuse)
– ADH inhibition toxic!
• Topiramate
• Baclofen
• Injectable Naltrexone
• Nalmafene
• NAC
• Ondansetron
Screening, Brief Intervention & Referral
• SBIR Goal: reduce EtOH-related harms
• Framework – 15-min appointments
• Method
– Short counseling sessions
– Provide information/workbooks/tracking apps
– Increase motivation
– Teach behavioural skills (i.e. Motivational
Interviewing)
SBIR
• Low-risk Guidelines
• Alcohol = Health issue
• Commit to a Goal
• Stages of change
– CBT
– Motivational Interviewing
– Community Referral
– Treatment Program
Case
• Karen is a 42F presenting to your FM clinic today for help
with anxiety, fatigue and insomnia for “the past few years”.
• Her PMHx is significant for chronic back pain for which she
takes Tylenol 3’s originally prescribed by her previous FMD.
She has been on a stable dose for years and has never
exhibited aberrant use.
• You have her complete PHQ9 and GAD7 questionnaires and
her scores are 17 and 21, respectively.
• How would you proceed??
Case
• You administer the AUDIT-C questionnaire and she scores
9 (+).
• She discloses that her alcohol intake has increased
steadily over the past 10 years. Originally only enjoying an
occasional glass of wine on holidays, she was drinking 2-3
glasses nightly by the end of 2019. The pandemic
triggered a sudden severe increase in her alcohol intake
and she is now consuming 8-9 standard drinks daily, often
vodka or other spirits.
• What next steps would you take?
Case – Assess for AWS!
• You remember that complicated alcohol withdrawal
can be lethal and complete a PAWSS score on her.
– She scores 2 and therefore does not require urgent
care (i.e. not high risk for complicated AWS).
• Except for anxiety and sleep disturbance, she does
not report ever experiencing EtOH withdrawal..
• Are there any questions you have for her with
regards to safety?
Case
• Her last drink was last night at 10pm (it is now
10am). She has a driver’s license and vehemently
denies ever driving intoxicated or any history of
DUI’s. She only drinks when she is home for the
night and never during the day or at work. She
has never had a seizure, alcohol-related or
otherwise. She has 2 children aged 7 and 5.
What would you include in her management
plan?
Case
• Would you report to MTO?
• Would you trial an anticraving medication? Which
one(s)? How would you counsel her?
• What psychosocial interventions would you
discuss with her?
• What follow-up plan would you like to have in
place?
Thank you!
• Questions?
• Break
