CSAM-SCAM

Fundamentals

An Introduction &
Overview of Alcohol
Use Disorders and
At-risk Drinking

Presentation provided by
Ronald Fraser, MD, CSPQ, FRCPC
Asso. Professor , Dept of Psychiatry,
McGill University/Dalhousie University
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Disclosure of Commercial Support

 No support from commercial sources

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Faculty/Presenter Disclosure
 Financial conflicts of interest – co-owner and
clinical director of a private treatment facility,
360dtx
 Talk based on 2014 lecture by Sheryl Spithoff MD
CCFP (Thanks!)
 Additional slides from Dr. D. Charney and Dr. L.
Tourian

 Contact: [email protected]
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Overview
 Screening for unhealthy drinking
 Categorizing: at-risk, mild, moderate or severe alcohol use
disorders (AUDs)
 Brief interventions for at-risk drinking and mild AUDs
 Assessing a patient with a moderate or severe
AUD
 Managing patients with a moderate or severe AUD
 Counsel
 Prescribe
 Connect to other resources
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Background
 Alcohol use disorders (AUDs) affect about 6-7% of the
population
 About 2.6% of the population have a moderate or severe AUD
(Alcohol dependence in the DSM-IV)
 Huge burden of disease: Alcohol misuse is responsible for
5.5% of the overall burden of disease, 3rd after HTN and
smoking (Shield, 2010)
• Overall costs of alcohol misuse to Canadian society in 2002 was
14.6 billion (CCSA 2007)
 (CDS- Diabetes total costs in 2000 was 5.9 billion)
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Why is screening important?

 Many patients do not seek help
 Less than 1/3 patients asked MD for help (CASA 2012)
 50% said MD was not aware of their AUD

 Patients are frequently in contact with primary care

system
 Studies show about 50% - 75% are interested in
treatment if asked

 Interventions are effective!!

 Can be initiated with little delay - one of the most
important factors in patient engagement
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Screening youth
All patients 10 to 18 at least yearly
 http://pubs.niaaa.nih.gov/publications/Practitioner/
YouthGuide/YouthGuide.pdf

In the past 12 months, have you:

 Drank any alcohol (more than a few sips)
 Smoked any marijuana
 Used anything to get "high".
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Screening youth
 CRAFFT (two or more is a positive)
 C Have you ever ridden in a CAR driven by someone
(including yourself) who was ‘‘high’’ or had been using
alcohol or other drugs?
 R Do you ever use alcohol or other drugs to RELAX, feel better
about yourself, or fit in?
 A Do you ever use alcohol or other drugs while you are
ALONE?
 F Do you ever FORGET things you did while using alcohol or
other drugs?
 F Do your family or FRIENDS ever tell you that you should cut
down on your drinking or drug use?
 T Have you ever gotten into TROUBLE while you were using
alcohol or other drugs?
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Problematic alcohol use in students

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Screening over age 18

 Yearly
 More frequently if at higher risk
 Mental health problems, life stressors, history of
interpersonal trauma, poverty, other SUDs
 Medical problems associated with alcohol use
 Gastritis, elevated LEs, injuries etc

 How many ounces in a standard drink of wine?

Beer? Liquor?
ALCOHOL
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Canadian standard drink sizes

 13.6 grams of alcohol

 12 ounces of beer = 341 mls = 1 bottle (5%)
 5 ounces of wine = 150 mls (12%)
 1.5 ounces of hard liquor = 45 mls (40%)
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Screening options:
Single item screener

“How many times in the last year have you had (men=
5 or more) (women= 4 or more) drinks in one
occasion?”
 More than once is positive screen
 82% sensitive, 79% specific for unhealthy drinking (at-risk
and AUDs)
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Screening options: AUDIT-C

1. How often do you have a drink containing
alcohol?

2. How many standard drinks containing alcohol

do you have on a typical day?

3. How often do you have six or more drinks on

one occasion?
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AUDIT-C
Positive for unhealthy drinking

 Men > or = 4
 sensitivity 0.86, specificity 0.89

 Women > or =3 in women

 sensitivity 0.73, specificity 0.91
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Screening - Other options

 Other options include:
 CAGE- 2+ is positive
 Lifetime not active use
 Misses at-risk drinking

 T-ACE- alcohol use in pregnancy

 Tolerance (how many drinks does it take for you to feel high?
> 2 is one point)
 Annoyed
 Cut-down
 Eye-opener

 2+ is positive screen
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Categorizing
 AUDIT-10
 Screening test
 Higher sensitivity and specificity for unhealthy drinking
(>85%)
 Can also be used to categorize patients

 Category determines management approach

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Categorizing
 AUDIT-10- handout
 < 8 (< 6 for women) = lower risk drinking
 Low risk drinking guidelines (LRDG)
 6 to 13 for women, 8 to 15 for men = unhealthy
drinking (at-risk drinking or mild AUD)
 Brief intervention
 >13 for women, >15 for men = AUD (likely moderate
or severe AUD)
 AUD flow-sheet
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Low risk drinking guidelines

 Review low risk drinking guidelines
 Women:
 10 drinks a week, with no more than 2 drinks a day
most days, up to 3 for special occasions

 Men:
 15 drinks a week, with no more than 3 drinks a day
most days, up to 4 for special occasions

 Elderly- American guideline (no Canadian guideline)

 Men - no more than one per day
 Women - less than one per day on average
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At-risk Drinking and Mild AUDs

Brief counseling interventions for patients mild AUDs are
very effective
 Bertholet et al 2005: Systematic review and meta-analysis of
5639 patients in 17 trials
 Patients presenting to primary care NOT seeking help for
alcohol-related problems
 BI in primary care is effective at reducing alcohol consumption
at 6 and 12 months (by average 4 drinks per week)
 BI consisted of counseling intervention between 5 and 15
minutes, written materials, offer of follow-up session(s)
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Brief Intervention
 Adapted from the WHO guidelines
http://whqlibdoc.who.int/publications/2010/978924
1599399_eng.pdf
 Give feedback and advice. Encourage responsibility.
Demonstrate empathy.
 Review the Low Risk Drinking Guidelines
 Make it personal: link to health, employment or social
consequences in patient’s life
 Determine patient’s goals
 Advise patient to reduce drinking and give advice from
LRDG
 Offer a follow-up in 4 to 6 weeks
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Alcohol Use Disorder (AUD)

 Share diagnosis with the patient

 Advise to reduce or stop drinking

 Emphasize the effectiveness of treatment

 “Reducing how much you drink can be difficult. But we do have
treatments (medication and counseling) available that make it easier.”

 Book back for a further assessment

 “I’d like to talk to you some more about your alcohol use. How do you
feel about coming back to see me for an assessment?”
 Book a 30- 60 minute assessment, ideally within next 1-2 weeks
 Be prepared for no-shows- about 25% won’t show
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Not Ready
Declines appointment
 Safety - drinking and driving, children in home
 Offer lab tests
 Can try MI techniques - pros and cons of alcohol use
 “If you change your mind, I am happy to help”

No-shows
 Safety - drinking and driving, children in home
 Seek to re-engage
 Many reasons for no-shows besides ambivalence about change
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Assess
 History
 A complete history of alcohol use
 Need for medical detoxification

 Other substances
 Past medical history;
 Psychiatric history- present symptoms
 Psychosocial history, including childhood, adolescence,
adulthood, living situation, education, work, income etc;
 Family history: psychiatric disorders including addiction;
 Review of systems
 Make a diagnosis using DMS-5 criteria
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Assess Substance Use

 Alcohol
 Amount, duration, frequency, daily pattern of use (time of first
drink)
 Tolerance, withdrawal
 Cravings, consequences, quit attempts
 Ask about other substances (tobacco, cannabis, opioids,
stimulants, benzodiazepines etc)
 IVDU - ever, even once
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Determine Need for Medical Detoxification

 Need for medical detoxification: Patients who drink heavily daily, and drink to relieve
withdrawal symptoms
 Inpatient detox: All patients with past alcohol withdrawal seizures or severe
withdrawal require inpatient medical detoxification.
 Day detox- carefully selected patients
 No significant medical or psychiatric co-morbidities
 No poly-substance use
 Stable home situation with partner or friend to monitor
 (Under age 60)
 Non-medical detox
 Can go at least 3-4 days without drinking, and only have mild withdrawal symptoms
 However, as withdrawal can be unpredictable, advise all patients to go to the ED if
they develop more significant symptoms.
 Home detoxification with benzodiazepines is unsafe
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Alcohol withdrawal –
clinical presentation
1. Minor withdrawal – autonomic symptoms
2. Major withdrawal – 1 + hallucinations, seizures
+ disordered consciousness = Delirium tremens

Assesment of symptom severity: Clinical Institute Withdrawal

Assesment of Alcohol Scale (CIWA-Ar)
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Mental Health History

Mental health history
 40% have concurrent mental health disorder
 Ask all patients about previous mental health
problems and present symptoms
 Treat mood and anxiety disorders if the disorder
appears to be underlying (pre-dates the AUD and
persists in periods when patient is abstinent)
 CBT
 SSRIs, SNRIs
 Refer more complicated patients
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Assess: Exam and Labs

Targeted physical exam
 Vitals, mental status exam, brief neurological exam
 Signs of liver dysfunction

Lab tests
 CBC, GGT, AST, ALT
 Do additional labs if indications of liver dysfunction
 If IVDU ever- Hep C, Hep B, HIV (or in 1945 to 1965 birth cohort)
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Reporting to the MTO

 Ask all patients who drive, if they drink and drive.

 Report if any of the following:
 Patient reports (or family member reports that patient
is) drinking and driving
 Patient drinks throughout the day and drives
 Patient drove to the clinic intoxicated
 Patient has experienced withdrawal seizures and is still
drinking
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Making the DSM-5 diagnosis

1. Impaired control:
 (1) taking more or for longer than intended, (2) unsuccessful efforts
to stop or cut down use, (3) spending a great deal of time obtaining,
using, or recovering from use, (4) craving for substance.

2. Social impairment:
 (5) failure to fulfill major obligations due to use, (6) continued use
despite problems caused or exacerbated by use, (7) important
activities given up or reduced because of substance use.

2-3 = mild AUD, 4-5 = moderate AUD, 6+ = severe AUD

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Making the DSM-5 diagnosis

3. Risky use:
 (8) recurrent use in hazardous situations, (9) continued use despite
physical or psychological problems that are caused or exacerbated
by substance use.

4. Pharmacologic dependence:
 (10) tolerance to effects of the substance, (11) withdrawal
symptoms when not using or using less.*

2-3 = mild AUD, 4-5 = moderate AUD, 6+ = severe AUD

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Making the DSM-5 Diagnosis

Mild AUD
 Typically drink less than 40 drinks per week and do not have major
withdrawal symptoms.
 Alcohol has some harmful effects on their life.

Moderate AUD
 May be drinking daily or drinking intermittently but heavily (binge
drinking)
 May have some withdrawal symptoms
 Alcohol has harmful effects on their life

Severe AUD
 Typically drinking daily and consuming more than 40 drinks per week
 Often have severe withdrawal symptoms
 Significant life consequences
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Manage
AUDs- as a chronic disease
 Repeated alcohol use leads to persistent changes in
reward pathways in the brain
 Established environmental and genetic risk factors
 Responds to behavioural therapy, modification of
underlying risks factors, and medications
 Patients often have many cycles of remission and relapse
before long term remission
 At risk of relapse with life stressors
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More Severe AUDs: Manage

 Until recently, little evidence for effectiveness of primary
care treatment of more severe AUDs
 Fewer studies
 Mixed results

 Recommendation: refer to specialized treatment

 Limitations of specialized addiction care
 Patientsdecline referrals, have high no-show rates and loss to
follow-up
 50-75% do not show up for the first appointment
 Many do not provide medical treatment (Some have strong bias
against medical treatment)
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Recent Studies
 Primary care management is effective
 Ongoing brief counseling sessions and medications in primary
care is effective (O’Malley 2003) (Lee 2012) (Ernst 2008)
 Combine trial 2006: 1400 patients examined nine
combinations of pharmacotherapy, placebo and
behavioural interventions.
 Found that naltrexone and medical management had one the
three best outcomes.
 Medical management= what a primary care physician without
specialized addiction training would offer in a clinic visit
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Effectiveness Studies
 Some evidence that primary care treatment in “real world” settings
(patients’ own primary care clinic) out preforms specialized care

 Randomized clinical trial of 160 veterans with alcohol dependence (VA

trial) (Oslin 2014)
 Primary care-based alcohol care management with counseling and
medications (Naltrexone) in patient’s own primary care clinic
 Or referred to specialized addiction outpatient care (treatment as
usual)
 Primary care-based ACM increased retention in treatment
 1st month 60% primary care vs 25 % specialized care
 6th month 42% primary care vs 12 % specialized care
 Primary care-based ACM greater increase in days without heavy
drinking from about 45% in both groups to:
 45% to 82% in primary care
 45% to 72% specialized care
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Manage: moderate or severe AUDs

 Counsel
 Determine goals, develop a plan,
problem-solve (barriers to
change, triggers, cravings), give
advice

 Prescribe
 Create and review medication
adherence plan

 Connect to other resources

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Counsel
 Therapeutic relationship is one of the most important factors
in patient engagement with treatment
 Empathy, openness, flexibility
 Acknowledge:
 Behaviour change is very difficult particularly when coupled
with an addiction
 Difficulties in patient’s life
 Be aware of the incredible amount of shame and guilt
patients feel about their addiction
 Studies show this is a barrier to help seeking
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Counsel
 Enhance motivation - use MI techniques
 Give advice to change, present menu of change options
 Determine patient’s goals
 Reduced drinking is reasonable goal for mild or even moderate
AUD (and few life consequences)
 Some should be strongly encouraged to target abstinence
 Pregnant women
 Patients with health conditions exacerbated by alcohol
 Patients with severe AUD or those who are unable to reduce their
heavy drinking
 Determine barriers to change
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Counsel
Help patient develop coping mechanisms
 Avoiding triggers
- people, places, things
 Enhancing support network
 Developing and practicing refusal skills
 Help patient problem-solve and come up with solutions
 E.g. “Your work friends drink heavily when you go out with
them on Friday nights. Have you thought what you will do in
that situation?”
 Coping with cravings
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Coping with Cravings

Delay technique:
 "I will not act on this craving right away. I will wait 5 (or 10 or 15)
minutes to decide whether to act on this craving.”

Distract technique:
 Prepare a list of distractions ahead of time e.g. call a friend or
sponsor, go for a walk or run, do some housecleaning. Select
from list of distractions when having a craving.

Urge surfing technique:

 “Picture the urge as an ocean wave, and imagine yourself
surfing, using your breath as the surfboard...Ride this wave
through its peak and its decline, without being submerged or
wiped out by its enormity” (Bowen 2010)
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Counsel
Provide practical advice
 Make recovery your top priority in first few months
 Find methods to reduce stress such as exercise,
meditation; eat and sleep at regular hours
 Spend time with supportive family and friends
 Have a contingency plan to interrupt a slip or
relapse
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Counsel
 Advice for patients who would like to reduce drinking:
 Use the LRDG handout
 Startdrinking later in the evening or night
 Have non-drinking days
 Take a time out between drinks
 Alternate alcoholic drinks with non-alcoholic drinks
 Eat before and while drinking

 Record drinks on a calendar or log book

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Counsel: Specific Plan

Help patient create a specific quit/reduce plan
 Quitting
 Set quit date
 Detoxification plan if needed
 Integrated into treatment plan
 Reducing
 “This week I will start reducing my drinking to maximum 3 per
day. I will not drink alone. I will not have my first drink until
7pm. I will record my drinks on my day-planner.
 Next month I will limit my maximum to 2 drinks per day and
no more than 14 per week.”
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Prescribe
 Moderate or severe AUDs
 First-line medications are naltrexone (revia), acamprosate
(campral) and disulfiram
 Recent meta-analysis JAMA (Jonas 2014)
 Acamprosate: NNT for abstinence is 12
 Naltrexone: NNT to prevent heavy drinking is 12 and 20 to
achieve abstinence
 For comparison
 NNT with statin for secondary prevention of non-fatal
cardiac event is 25-40
 NNT for primary prevention is 60
 Disulfiram is effective when taken under supervision (Jorgenson
2011)
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Prescribe
Naltrexone
 Block opioid receptor and reduces euphoric effect from
drinking
 Reduces heavy drinking and helps patients achieve and
maintain abstinence
 Do not need to abstain from alcohol prior to starting
 Side effects - nausea, elevated liver enzymes
 Contra-indications
 On opioids
 Liver dysfunction
 Elevated liver enzymes - AST ALT (>3x normal)
 Pregnancy
 Monitoring: check LE at baseline, 4 w, then q 3 m
 Dosage: 25mg x 3d (reduce GI effects, then increase to
50mg/day, to max 150mg per day
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Prescribe
Acamprosate
 Antagonizes glutamate receptors (excitatory neurotransmitter)
 Does not reduce heavy drinking
 Helps patients maintain abstinence
 Only effective if patients have been abstinent for at least several days
 Side effects: nausea, agitation
 Contraindications:
 Significant renal disease
 Pregnancy

 Dosage: 666 mg tid, reduce dose to 333mg tid for renal

impairment or weight less than 60 kgs
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Prescribe
Disulfiram
 Blocks conversion of acetaldehyde to acetate and causes build-up of
acetaldehyde
 Sweating, palpitations, hypotension, can be fatal (rare)
 Effective when taken under supervision
 Better evidence than naltrexone & acamprosate in head to head trial
 Side effects- Hepatitis, neuropathy, depression, psychosis
 Contra indications: elderly, cardiac disease, liver dysfunction, psychosis,
cognitive dysfunction, pregnancy
 Dosage: 250 mg/d (range 125mg to 500 mg)
 MUST be abstinent for at least 2 days prior to initiation
 Reaction can happen up to 7 days after stopping medication
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Prescribe
 Off-label medications -
 Topiramate, ondansetron, baclofen
 Gabapentin for sub-acute withdrawal
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EAP requirements
 Naltrexone
 Alcohol dependence and in counseling

 Acamprosate
 Alcohol dependence and in counseling
 Abstinent for at least 4 days
 Contraindication or side effect from naltrexone

 Disulfiram - no coverage but cheap ($20 per month)

 Must be compounded - pharmacy.ca
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Connect
 Connect to additional resources
 Ideally within same clinic setting
 No-show rates are high outside of clinic setting
 Remain persistent

 Google!

 Addiction referral services

 DART- http://www.drugandalcoholhelpline.ca/
 MAARS - 416-599-1448
 CAAS - 1-855-505-5045
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Connect - Counselors
Counselors
 Should have specific addiction counseling training such as
 Relapse-prevention therapy, behavioural counseling, motivational
therapy and CBT for addictions
 Couple therapy
 Behavioral couple therapy for addictions has most evidence
 One partner without SUD
 Family therapy for youth
 Several programs such as multi-dimensional family therapy show
positive outcomes
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Connect – Case Management

 Support workers
 Support organizations
 e.g. COPA
 Age 55 and older with an addiction
 Support, counseling, outreach, case management,
crisis (within 24 hours), psychiatric assessments
 http://www.copacommunity.ca/?q=Our-Services
 Referral from HCP, self-referral, etc.
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Connect –
Day & Residential Treatment

 Day and residential treatment programs

 Most are 21 days with ongoing aftercare
 Drop-out rates are very high, but for those who
complete
 1/3 are abstinent
at one year
 The remainder show some reductions in alcohol use

 Careful with programs that are “abstinence based”

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Connect – Mutual Support

Mutual support groups such as AA, SOS

 May improve outcomes as patients who engage, do well
 Unclear if causation or correlation
 Advantages
 No wait list, informal social support, available after hours
 How to: during visit-go to website-
 Patient can call from your office
 Print off page with phone number
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Connect – Concurrent Services

 Concurrent disorders
 Patients do best with integrated and concurrent
services
 Can be difficult to access
 CAMH - CAITS program- patients to self-refer via intake
phone line
 Fred Victor - requires physician referral

 Trauma services - concurrent and integrated

 Seeking Safety program
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Connect - Addiction Medicine

Physician

 Addictionmedicine specialists
 For more complex patients
 Those not improving in primary care
 Patients who need detox
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Summary
 At-risk drinking and AUDs are very common in Canadian
society
 Primary care interventions are effective
 Screen and categorize using AUDIT-10
 Management has three components
 Counsel with goal setting, problem-solving and practical
advice
 Prescribe anti-alcohol medications for moderate and severe
AUDs
 Connect to other resources such as counselors, support
groups, trauma services, concurrent mental health
treatment and addiction medicine services
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THE END