It’s one of the biggest health issues Canadians face. It’s responsible for 7% of all premature deaths in this country. The direct health system costs amount to three billion dollars a year. But its most devastating impacts are felt by those with the condition and their families.
If excessive alcohol consumption didn’t jump to your mind, you’re not alone. In health care, alcohol use disorders are too often underdiagnosed and too often undertreated.
“If you go to emergency departments at night, you will see that a large number of the admissions are alcohol related – people who are impaired, people who have had a road accident or were involved in violence,” says Bernard Le Foll, a clinician scientist who specializes in addiction at the Centre for Mental Health and Addiction (CAMH) in Toronto. “Many of these could be prevented.”
Alcohol use disorders run the gamut from binge drinking on weekends to chronic alcoholism. According to a study published this year, 40% of Canadians exceed the national low-risk drinking guidelines, which recommend no more than 10 drinks a week for women and 15 for men, with no more than two drinks a day on most days. That said, to meet the criteria for a disorder, “the alcohol use must interfere with one’s ability to function,” explains Laura Calhoun, provincial medical director of Addictions and Mental Health at Alberta Health Services. In other words, a disorder is diagnosed once one’s alcohol use is damaging relationships or affecting a person’s ability to work or take part in leisure activities.
From screening to treatment, we look at why health care providers have been slow to adopt proven approaches when it comes to risky and harmful drinking.
Why don’t family doctors screen for alcohol addiction?
Before a condition can be treated, it has to be diagnosed. But most Canadian doctors aren’t asking their patients how much they drink. Before a recent intervention in Alberta, an unpublished survey of around 500 family doctors found they asked about drinking habits 30% of the time, according to Doug Stich, director of Toward Optimized Practice, an initiative funded by the Alberta Medical Association improve primary care. In Ontario, out of 119 doctors who filled out a survey, only 7% said they always screened for alcohol using a standard screening tool, though more screened with informal questions.
The biggest reason many family doctors don’t screen is they don’t feel comfortable diagnosing or treating alcohol addiction, says Meldon Kahan, an addictions doctor and director of the Substance Use Service at Women’s College Hospital. While education about diagnosing and treating alcohol and substance abuse is improving in medical schools and residencies, it’s still “spotty and piecemeal,” he explains. When family medicine residents across Canada were asked whether training in substance use was available to them in 2010, only 48% said yes.
“Family doctors are really busy and swamped with all kinds of issues so they’re more likely to focus on something they feel confident they can help with,” explains Calhoun.
On-the-job training and support can increase primary care doctors’ confidence and screening rates, however. The Alberta Screening and Prevention program was launched in 2013 to improve screening rates for several common conditions, including alcohol disorders. So far, the physicians who have joined the program have increased their screening for alcohol use to 55% of their patients, on average, says Stich. Out of around 3,000 family doctors in the province, just over 500 physicians have joined the program.
It is not just family doctors who should screen for excessive alcohol use, of course. Patients presenting to the emergency department, to a midwife, psychologist or other specialist all have an opportunity to ask about drinking levels – but just like family doctors, often don’t feel they have the time to do so.
The Brief Intervention: A key opportunity, too often lost
In addition to identifying people who need specialized addiction support, screening is important to help identify those whose alcohol use can be addressed by primary care providers. Many who drink above the low-risk guidelines may not be addicted to alcohol, but drink in ways that could affect their sleep, blood pressure and a host of other health issues, explains Kahan. To help this group, Canada’s National Alcohol Strategy recommends what’s known as “brief interventions” by health professionals.
According to Sheryl Spithoff, a family and addiction medicine doctor at Women’s College Hospital Hospital in Toronto, a brief intervention can be five to 20 minutes. “It involves saying ‘I’m concerned that you’re drinking more than the low-risk guidelines’ and asking questions to help patients recognize any health effects or social effects they might be experiencing,” she says. Often, patients don’t recognize that their drinking poses a health risk and the conversation can be a wake-up call.
The evidence shows that brief interventions can be effective. One review found they helped a group of people who drank 22.5 drinks a week on average to reduce that by about three drinks a week. Another review found the reduction effect is far greater when brief interventions are targeted at mild and moderate alcohol use disorders. (Those with severe disorders require more help to improve.)
To help guide primary care health professionals through alcohol screening, brief interventions, and treatment options, Alberta Health Services is promoting the Screening, Brief Intervention and Referral web-based tool developed by the College of Family Physicians of Canada and the Canadian Centre on Substance Abuse.
Canada’s National Alcohol Strategy recommends screening and brief interventions in community or walk in clinics and even the emergency room.
Pharmaceutical options are rarely prescribed, difficult to access
For those who need more than brief interventions, evidence shows that pharmaceutical medications can help. The drugs naltrexone and acamprosate have the most evidence behind them. Though not a cure all, one review found that naltrexone helps one in 12 people stop drinking heavily, while acamprosate helped one in 12 remain abstinent from alcohol.
In a study of almost 1,400 patients at 11 US facilities, patients treated with medications by their primary care doctor did just as well as patients who went to one-on-one specialized cognitive behavioural therapy twice a month, on average.
But many doctors don’t feel that they have enough knowledge to prescribe anti-craving drugs, Kahan says. In the survey of over 100 doctors mentioned earlier, only 29% reported they had enough knowledge about pharmacotherapies for alcohol addiction to make them comfortable prescribing them.
Access to drugs is also limited at specialized addiction centres, whether outpatient or inpatient programs, says Kahan. “The belief among many [addiction] providers is that alcohol use disorders are exclusively psychosocial. Patients are expected to fight it on their own.”
Making matters worse, the anti-craving drugs naltrexone and acamprosate aren’t covered by many provincial benefits programs. In Ontario, the drugs aren’t on the public benefits list. Instead, doctors have to fill out forms requesting drug funding on behalf of each patient. “The process is difficult. It can take two months to get an approval,” says Kahan. Research by Spithoff and colleagues conducted at the Institute for Clinical Evaluative Studies (ICES) has found that only 36 of more than 16,000 Ontarians who were diagnosed with an alcohol disorder and were on public benefits filled a prescription for either naltrexone or acamprosate.
Because of this waiting period, the window of time a person is willing to try pharmaceutical options can end before a prescription is even filled, explains Kahan. “Your motivation to enter treatment waxes and wanes and when you do want treatment, it’s kind of an emergency,” he says.
David Jensen, spokesperson for the Ministry of Health, explains that the drugs are only funded through Exceptional Access because the program requires doctors to demonstrate “that patients are receiving not only the drugs, but other supportive care required for appropriate treatment.” (Jensen did say, however, that the requirements for naltrexone and acamprosate are being reviewed given that they are based on evidence reviews conducted in 1996 and 2008 respectively.)
Kahan takes issue with the government’s reasoning. “It’s like saying you can’t start an anti-depressant unless the patient is engaged in counselling,” he says. Formal counselling programs are not available to everyone, he points out, but that doesn’t mean another form of therapy shouldn’t be used in the meantime. Plus, “even if you do get the patient to counselling, they still have to wait another two months” for drug access to be approved.
The situation is worse in Alberta, where the anti-craving drugs aren’t even available under special authorization.
The good news is that family doctors don’t need extra education to prescribe medications like naltrexone. “The drugs are easier to prescribe then medication for diabetes or blood pressure that are used routinely by the general practitioner,” says Le Foll.
Three years ago, Le Foll and his team at CAMH launched the Alcohol Research and Treatment Clinic, funded by the Ministry of Health, to improve access to and research on various pharmacotherapies for alcohol misuse. In the future, Le Foll says his clinic plans to reach out to family practitioners to raise awareness and comfort levels in prescribing anti-craving medications for alcohol addiction.
Improving the health care response to alcohol addiction
For the most part, in Canada, people who are addicted to alcohol have few treatment options.
Specialized rehabilitation centres are few and far between. “Their waiting lists are long,” says Kahan. Expanding access to such centres may help, but these programs alone can’t solve the problem of alcohol addiction.
For one, the centres are often far from peoples’ homes and patients can be reluctant about opening up about their addiction to a new provider. “For many patients, their family doctor is who they’re comfortable with, and they don’t necessarily want to start all over again with someone new who they don’t know,” explains Didier Jutras-Aswad, psychiatrist and director of addiction psychiatry at the University of Montreal Hospital Centre.
Most specialized treatment centres also don’t have providers who are trained in wider mental health diagnosis and treatment, Jutras-Aswad adds – which is a problem considering alcohol addiction can often be related to other conditions like depression or post-traumatic stress disorder.
There have been gradual improvements. In Ontario, the CAMH Integrated Care Pathway was launched in 2013 to provide both pharmacotherapy and cognitive behaviour therapy for depression and alcohol addiction at the same time. This fall, the integrated treatment program will launch at one family health team and two more hospitals in Ontario.
In Alberta, in addition to promoting screening and brief interventions, the province is working to improve access to addiction counselling in communities, either through training family doctors or organizing counsellors to routinely visit primary care offices, says Calhoun.
For those who work with people struggling with alcohol cravings, much more needs to be done, however. Most family medicine doctors don’t receive adequate education and training in addiction care. In many provinces, including Ontario, there are no province-wide incentives or supports to increase the low alcohol screening rates. And whether people are seeking help at the primary care level or in specialized treatment centres, anti-craving drugs too often aren’t prescribed and aren’t funded through most provincial drug benefit formularies.
These many barriers led Spithoff and colleague Suzanne Turner to call the health system’s failure to address at-risk drinking and alcohol addiction a “travesty” in the Canadian Medical Association Journal.
Le Foll agrees. The preponderance of alcohol use disorders, he says, “is like a health care emergency that has been here for many years,” one that health providers too often think they can’t change. “It’s not something that is a given; it’s something we can act on.”