The BC Centre on Substance Use (BCCSU) is a provincially networked organization with a mandate to develop, help implement, and evaluate evidence-based approaches to substance use and addiction. The BCCSU seeks to improve the integration of best practices and care across the continuum of substance use through the collaborative development of evidence-based policies, guidelines, and standards. With the support of the Province of BC, the BCCSU aims to transform substance use policies and care by translating research into education and care guidance, thereby serving all British Columbians. The BCCSU seeks to achieve these goals through integrated activities of its three core functions: research and evaluation, education and training, and clinical care guidance.-Leading an innovative multidisciplinary program of research, monitoring, evaluation and quality improvement activities to guide health system improvements in the area of substance use. Education and Training -Strengthening addiction medicine education activities across disciplines, academic institutions, and health authorities, and training the next generation of interdisciplinary leaders in addiction medicine. Clinical Care Guidance -Developing and helping implement evidence-based clinical practice guidelines, treatment pathways, and other practice support documents.# Disclaimer for Health Care Providers
The recommendations in this guideline represent the view of the provincial guideline committee, arrived at after careful consideration of the available scientific evidence and following external expert peer review. The application of the recommendations in this guideline does not override the responsibility of health care professionals to make decisions that are appropriate to the needs, preferences, and values of an individual patient, in consultation with that patient and their family members or guardian(s), and, when appropriate, external experts (e.g., specialty consultation). When exercising clinical judgment in the treatment of high-risk drinking and alcohol use disorder, BC health care professionals are expected to take this guideline fully into account while upholding their duty to adhere to the fundamental principles and values of the Canadian Medical Association Code of Ethics, especially compassion, beneficence, non-maleficence, respect for persons, justice and accountability, as well as the required standards for good clinical practice as set by the College of Physicians and Surgeons of British Columbia and any other relevant provincial regulatory body. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

# Legal Disclaimer
While the individuals and groups involved in the production of this document have made every effort to ensure the accuracy of the information contained in this treatment guideline, please note that the information is provided "as is". The Ministry of Health (MoH), the Ministry of Mental Health and Addictions (MMHA), and the BCCSU make no representation or warranty of any kind, either expressed or implied, as to the accuracy of the information or the fitness of the information for any particular use. To the fullest extent possible under applicable law, the MoH, MMHA, and the BCCSU disclaims and will not be bound by any express, implied or statutory representation or warranty (including, without limitation, representations or warranties of title or non-infringement).
The Guideline is intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guideline is not intended as a substitute for the advice or professional judgment of a health care professional, nor is it intended to be the only approach to the management of a clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.   3 Mindfulness-Based Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

# Table of Contents
Executive

# Psychosocial Treatment Interventions and
Co-occurring Mental Health Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 7.2.5 Psychosocial Treatment Interventions in Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 7.2.6 Psychosocial Treatment Interventions in Pregnant Individuals . . . . . . . . . . . . . . . . . . . . . . . . 83 7.2.7 Duration of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 7.2.8 Accessibility and Other Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 7.2.9 Section Summary and Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 7.3 Combining Pharmacotherapy and Psychosocial Treatment Interventions . . . . . . . . . . . 85 8. Community-Based Supports and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Supportive Recovery Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 8.3 Psychosocial Support Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 9. Managed Alcohol Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 10. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Appendix 1: Alcohol Use Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Step The 5As Model for Brief Alcohol Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Appendix 3: Withdrawal Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 A. Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 B. Selecting the Appropriate Care Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alternative Pharmacotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Appendix 5: Motivational Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Principles of Motivational Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Indigenous Peoples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sex and Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pregnant Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Co-occurring Mental Health and Substance Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Co-occurring Alcohol Use and Mental Health Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Co-occurring Substance Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 1 Summary 2 Summary of Principles of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Table 3 Summary of Canada's Low-Risk Alcohol Drinking Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Table 4 Age-Specific Thresholds for NIAAA Screening Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Table 5 Comparison of Pharmacotherapy Options for Outpatient Management of Alcohol Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Table 6 Comparison of First-Line Pharmacotherapies for AUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Table 7 Comparison of Select Alternative AUD Pharmacotherapy Options . . . . . . . . . . . . . . . . . . . . . . . 72 Table 8 Comparison of Selected Alcohol Use Screening Tools (Adults) . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Table 9 Comparison of Selected Alcohol Use Screening Tools (Youth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Table 10 

# List of Tables

# Executive Summary
Despite the relatively high prevalence of high-risk drinking, alcohol use disorder (AUD), and alcohol-related harms in British Columbia (BC), these conditions frequently go unrecognized and untreated in the health care system. Research has shown that primary care providers can play an important role in the early detection and treatment of high-risk drinking and AUD, and in connecting patients and families with specialized care services and recovery-oriented supports in their communities. However, the lack of an evidence-based guideline for the clinical management of high-risk drinking and AUD has resulted in low awareness and use of the full range of available treatment interventions among primary care providers in BC.
To address this gap, the BCCSU convened a provincial guideline committee to review the research evidence and reach consensus on recommendations for the clinical management of high-risk drinking and AUD. A set of 13 recommendations were derived by the committee, spanning the identification and clinical management of high-risk drinking and AUD in youth (aged 12-25 years) and adult patient populations, with a focus on primary care practice. The purpose of this guideline is to support health care providers with the implementation of evidence-based prevention, harm reduction, and treatment interventions for high-risk drinking and AUD in their scope of practice.
Specifically, this guideline aims to:
- Describe principles of care and general considerations for screening, intervention, management and continuing care of high-risk drinking and AUD
- Review strategies for alcohol use screening and brief intervention for adult and youth patients who are drinking above recommended low-risk limits
- Recommend a clinical algorithm for alcohol withdrawal management, where an individual's risk of developing severe complications is used to triage that individual to an appropriate care setting and management approach
- Provide guidance on outpatient withdrawal management, with attention to limiting or avoiding use of benzodiazepines where appropriate and indicated
- Recommend strategies for continuing AUD care supported by evidence, including use of pharmacotherapy, psychosocial treatment interventions, and specialist-led and community-based services and supports
- Provide advice for managing transitions along the continuum of care, with an emphasis on optimizing engagement and continuity of care where multiple referral partners are involved This guideline is intended to be a resource for physicians, nurses and nurse practitioners, pharmacists, allied health professionals, and all other clinical and non-clinical personnel involved in the care of individuals and families affected by alcohol use. This guideline is also intended to be used by policymakers and healthcare administrators in the development of strategies to address unmet alcohol treatment and care needs in BC in an evidence-based, cost-effective manner. 

# Quality of Evidence

# Strength of Recommendation

# Screening and Brief Intervention 1
Clinicians should provide education about Canada's Low-Risk Alcohol Drinking Guidelines to all adult and youth patients.

# LOW STRONG 2
All adult and youth patients should be screened annually for alcohol use above low-risk limits.

# MODERATE STRONG 3
All patients who are drinking alcohol above low-risk limits but do not have an alcohol use disorder (AUD) b should receive a brief counselling intervention.

# MODERATE STRONG
Withdrawal Management 4
Clinicians should use the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) to assess the risk of severe complications of alcohol withdrawal in patients with AUD, in order to select the most appropriate withdrawal management pathway.

# MODERATE STRONG 5
Patients at low risk of severe complications of alcohol withdrawal (PAWSS<4) who have no other concurrent conditions that would require inpatient management should be offered outpatient withdrawal management.
HIGH STRONG
Clinicians should consider prescribing non-benzodiazepine medications, such as gabapentin, carbamazepine, or clonidine, for the outpatient management of patients at low risk of severe complications of alcohol withdrawal.

# MODERATE STRONG 7
Patients at high risk of severe complications of withdrawal (PAWSS4) should be referred to an inpatient facility (i.e., withdrawal management facility or hospital) where they can receive a benzodiazepine treatment regimen under close observation, and emergency care can be administered immediately if needed.
HIGH STRONG
All patients who complete withdrawal management should be connected to continuing AUD care.

# LOW STRONG
Continuing Care 9
Adult patients with moderate to severe AUD should be offered naltrexone or acamprosate as a first-line pharmacotherapy to support achievement of patient-identified treatment goals.
A. Naltrexone is recommended for patients who have a treatment goal of either abstinence or a reduction in alcohol consumption.
B. Acamprosate is recommended for patients who have a treatment goal of abstinence.

# MODERATE STRONG 1 Introduction to the Guideline
This introduction describes the overall structure, scope and intended use of the guideline, and provides a brief overview of methods used to conduct the systematic review of the literature, develop recommendations for clinical practice, and assess quality of evidence and strength for each recommendation.

# Guideline Structure
This guideline consists of nine main sections, appendices, and a supplemental section. A brief description of each is provided below.

# Introduction:
This section provides a brief overview of the scope, intended use, and the methods used to develop the guideline.

# Background and Rationale:
This section outlines the risks, harms, and costs attributable to alcohol use in British Columbia, Canada, and globally that collectively underscore the need for an evidence-based guideline on the clinical management of high-risk drinking and alcohol use disorder.

# Working with Patients and Families Affected by Alcohol Use:
This section sets out general principles of care for working with patients and families affected by alcohol use, high-risk drinking, and alcohol use disorder. Overarching frameworks such as the social determinants of health, harm reduction, trauma-and violence-informed care, and Indigenous cultural safety are discussed, as well as models for providing care, including longitudinal care, continuum of care, and comprehensive medical management models. The section concludes with a review of the principles of patient-centred, recovery-oriented care, and best practices for the involvement of family in patients' treatment and recovery plans.

# Screening and Brief Intervention:
This section reviews the evidence and makes recommendations on the use of universal alcohol use screening and brief counselling interventions to reduce drinking in adult and youth patients exceeding low-risk drinking limits. Clinical signs and diagnosis of alcohol use disorder are also discussed.

# Withdrawal Management:
This section provides an overview of the pathophysiology, signs, and symptoms of alcohol withdrawal, and reviews the evidence for use of a simple scale to predict patients' risk of developing severe complications of alcohol withdrawal in order to determine an appropriate management plan. Recommendations are made for use of pharmacotherapy and supportive care to manage mild to severe alcohol withdrawal in outpatient and inpatient care settings. Medications reviewed include benzodiazepines, carbamazepine, gabapentin, and alpha-adrenergic agonists (i.e., clonidine).

# Continuing Care -Pharmacotherapy:
This section reviews the evidence and makes recommendations for use of pharmacotherapy as part of continuing care plans for alcohol use disorder, with special consideration of patients' treatment and recovery goals. Naltrexone, acamprosate, topiramate, gabapentin, and disulfiram are reviewed in depth. A brief review of emerging therapies, including baclofen, ondansetron, and combination therapy, is also included.

# Continuing Care -Psychosocial Treatment Interventions:
This section reviews the evidence and makes recommendations on the use of psychosocial treatment interventions as part of continuing care plans for alcohol use disorder. Primary care-led approaches, such as motivational interviewing and contingency management, and specialist-led approaches, such as cognitive-behavioural therapy, family-based therapy, and mindfulness-based interventions, are covered.

# Community-Based Programs and Supports:
This section reviews the evidence and makes recommendations on referring patients and families to community-based programs and supports for alcohol use disorder, including peer-support groups (e.g., Alcoholics Anonymous, SMART  Recovery), intensive outpatient programs, and inpatient treatment programs.

# Managed Alcohol Programs:
A brief overview of the evidence for the use of managed alcohol programs in outpatient and inpatient settings is provided in the section. Making an explicit recommendation on managed alcohol programs was outside the scope of this guideline, however, the committee wishes to acknowledge the important role of this intervention in reducing harm for certain patients with severe alcohol use disorder.

# Appendices:
The appendices include practical guidance, instructions, medication protocols, and external resources to support health care providers with implementing guideline recommendations in their practice.
The following topics are covered: Alcohol Use Screening, Brief Intervention for High-Risk Drinking, Withdrawal Management, AUD Pharmacotherapy, and Motivational Interviewing. Guidance for youth and pregnant patients is provided where appropriate.
Supplemental Content: Supplemental guidance and resources for working with specific patient populations, including Indigenous peoples, 2SLGBTQ+ populations, youth, pregnant patients, older adults, and patients with co-occurring mental health and substance use disorders is provided in this supplement.

# Scope of the Guidelines
The scope of these guidelines is the identification and clinical management of high-risk drinking and alcohol use disorder (AUD) in adults (individuals aged 25 years and older) and youth (individuals aged 11-25 years). The intended use is to support routine screening to identify high-risk alcohol use and diagnose AUD, and to promote the use of evidence-based prevention, risk and harm reduction, and treatment interventions within primary care and other clinical settings in British Columbia.
Specifically, these guidelines aim to:
- Describe principles of care and general considerations for screening, intervention, management, and continuing care for adult and youth patients who are drinking above recommended low-risk limits and meet diagnostic criteria for an AUD.
- Review strategies for alcohol use screening and brief intervention for adult and youth patients who are drinking above recommended low-risk limits.
- Recommend a clinical algorithm for alcohol withdrawal management, where an individual's risk of developing severe complications is used to triage that individual to an appropriate care setting and management approach.
- Provide guidance on outpatient withdrawal management, with attention to limiting or avoiding use of benzodiazepines where appropriate and indicated.
- Recommend strategies for continuing AUD care supported by evidence, including use of pharmacotherapy, psychosocial treatment interventions, and specialist-led and community-based services and supports.
- Provide advice for managing transitions along the continuum of care, with an emphasis on optimizing engagement and continuity of care where multiple referral partners are involved.

# Objective and Purpose
The objective of this guideline is to provide recommendations, supported by current and rigorously reviewed evidence, for the full spectrum of medical and psychosocial interventions available to treat patients with high-risk drinking and AUD. In doing so, the guideline aims to provide comprehensive education and clinical care guidance to health care providers spanning the addiction care continuum in the province, which will, in turn, improve access to evidence-based treatment for patients and families, and reduce the significant harms associated with alcohol use in British Columbia.

# Intended Audience
The guideline is intended to be a resource for physicians, nurses and nurse practitioners, pharmacists, allied health care professionals, and all other clinical and non-clinical personnel with and without specialized training in addiction medicine, who are involved in the care and management of individuals, families, and communities affected by alcohol use. In addition, this guideline is intended to be a resource for policy makers and health care administrators in the development of strategies and programs to best address unmet alcohol treatment and care needs within British Columbia in an evidence-based, cost-effective manner.

# Care Settings
While this guideline focuses on the clinical management of AUD in primary care settings (e.g., family practice clinics, community health centres, walk-in clinics, student health services), the recommendations also apply more broadly to other care settings and environments that may represent an individual's first contact with the health care system. Depending on the circumstances, an individual experiencing alcohol-related issues or consuming alcohol in a high-risk manner may be identified through routine intake, assessment, and monitoring procedures at a number of other care settings, including: emergency and assessment rooms, acute care settings (e.g., general, surgical, trauma or intensive care wards), sexual health services, trauma and anti-violence services, prenatal care clinics, and specialized mental health and addiction services (e.g., inpatient addiction medicine consult teams, outpatient rapid access addiction medicine clinics, community mental health and substance use programs). Clinical care teams and staff in these health care settings are encouraged to adapt and apply guideline recommendations as needed for their practice, supporting individuals and families affected by alcohol use in seeking help and accessing evidence-based treatment and services at multiple points of entry in the provincial health care system. 3 

# Patient Populations
The recommendations made in this guideline are applicable to the general adult patient population, which can include individuals who are drinking within recommended limits for low-risk drinking, those who are exceeding low-risk alcohol drinking limits, individuals diagnosed with AUD of any severity (mild, moderate, severe), 2 as well as individuals in recovery from an AUD. While much of the evidence reviewed in this guideline pertains to the general adult population, it is the consensus of the guideline committee that guideline recommendations are equally relevant and applicable to youth.
Additionally, while this guideline offers a brief overview of the available evidence for the clinical management of high-risk drinking and AUD in pregnant individuals c , the importance of specialist consultation in these cases is emphasized, as is the urgent need for more research in this area. For additional clinical guidance on the management of alcohol use during pregnancy and postpartum, clinicians can refer to the Alcohol Use and Pregnancy Consensus Clinical Guidelines 4 issued by the Society of Obstetricians and Gynaecologists of Canada.
In partnership with Perinatal Services BC, the BCCSU will be releasing guidance for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder in Pregnancy, which will be available at the following link once published: /.
The guideline committee also recognizes the need to develop and implement best practices for identifying, treating, and managing high-risk drinking and AUD in specific populations, including Indigenous peoples, women and girls, men and boys, 2SLGBTQ+ folks d , pregnant individuals, adolescents (age  and young adults (age , older adults (age 65 and over), and individuals with co-occurring mental health disorders. A brief overview on working with these specific patient populations, including links to additional resources, has been included as a Supplement.

# Methods