New guidance to help family doctors detect and manage high-risk drinking addresses a crucial gap in knowledge among both patients and doctors, say its authors, who warn that a common practice to prescribe antidepressants can actually induce cravings for alcohol.
The advice is comprised of 15 recommendations on early detection of alcohol use disorder, withdrawal management, psychological interventions and community-based programs.
It urges routine screening for alcohol use and includes tips on what to avoid, such as prescribing antidepressants without ruling out problematic alcohol use first because selective serotonin reuptake inhibitors (SSRIs) can worsen alcoholism symptoms.
“Unfortunately, all the literature is pretty clear that this is not good practice, whereas those medications that are specifically made for the treatment of alcohol use disorder are almost not used.”
Antipsychotic medications should also not be prescribed off-label to treat alcohol addiction and can exacerbate symptoms, Rehm said.
The guideline was published Monday in the Canadian Medical Association Journal, or CMAJ.
It was developed by the Canadian Research Initiative on Substance Misuse (CRISM) and the BC Centre on Substance Use (BCCSU), with input from a committee of 36 members across the country, including clinicians, academics and people who have experienced alcoholism or are struggling with it.
2:06 Alcohol poses health risks even in small amounts: report
Rehm said committee members hope the guideline will be endorsed by medical associations across the country.
Rehm said screening would only take “half a minute.” Doctors are urged to ask patients how often in the past year they’ve had more than four drinks on one occasion if they’re female, or five drinks if they’re male.
Depending on alcohol use, physicians could advise patients on health risks, suggest ways to cut back or prescribe specific medications for alcohol use disorder. Patients may also be referred to treatment programs in or outside of hospital, based on whether they are at high or low risk of complications such as seizures.
Long-term treatment could also include cognitive behavioural or family-based therapy, peer groups or recovery programs.
Rehm said the treatment rate for alcohol use disorder in Canada is less than 10 per cent compared to an estimated 18 per cent in Britain, where a guideline for doctors was adopted in 2012. He’s not aware of any study that assesses whether more people have since been treated for alcohol use disorder.
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In some provinces, less than two per cent of patients are prescribed medications, such as naltrexone or acamprosate, intended for use with alcohol use disorder and recommended in the guideline, said Rehm, also a senior scientist at the Centre for Addiction and Mental Health and a professor at the University of Toronto’s Dalla Lana School of Public Health.
Patients who report symptoms including depression or insomnia without disclosing alcohol overuse or being asked about it are often prescribed SSRIs, such as Prozac, said Rehm. He said doctors should screen for any connections to alcohol use because 18 per cent of Canadians aged 15 and older will meet the clinical criteria for an alcohol use disorder at some point in their lifetime.
Amanda Hintzen of Toronto said she went to a family doctor when she was “in a spiral” from drinking excessively every day.
“I said, ‘I’m an alcoholic. What can you do to help me?’ I left there with three different prescriptions,” she said, listing one for anxiety, another for insomnia and a third for high blood pressure.
Alcohol affects multiple organs, including the heart and is associated with raised blood pressure. It can also affect sleep, mood and anxiety.
When Hintzen asked for naltrexone by name, she was initially “deterred” from that option, she said of the drug commonly prescribed for patients with moderate to severe alcohol use disorder.
“At that point, I was more dependent on it to function,” she said of alcohol. “The shakes started in the morning.”
Hintzen said she paid for two private rehabilitation programs, the second time in January 2022 where she met many others who had been prescribed medication not intended to treat alcohol addiction.
“Everybody’s on antidepressants. Everyone’s on anti-anxiety medication,” she said.
Dr. Evan Wood, co-chair of the guideline writing committee and an addiction medicine specialist in Vancouver, said most people seeking support for excessive alcohol use do not get evidence-based treatment.
“The guideline really does speak to the failure of institutions to really effectively address the high level of morbidity and mortality in Canada from alcohol use disorder,” said Wood, adding there’s also a need to train more health-care providers.
Alcoholism could be the underlying cause of conditions such as depression, insomnia, anxiety and high blood pressure, but doctors must talk to their patients to find out, Wood said.
“If you don’t stop and talk to people about alcohol, you’ll end up treating their blood pressure with antihypertensive medicine when all they really need to do is cut back on their alcohol use.”
The guidance comes nine months after the Canadian Centre on Substance Use and Addiction (CCSA) released updated guidance that warns of escalating health risks associated with more than two standard drinks per week. Potential health harms include heart disease and cancer, including breast cancer in women.
Wood said the new guideline, funded by Health Canada, will be posted online and webinars will be offered to doctors.
The Canadian government says it will donate up to 200,000 vaccine doses to fight the mpox outbreak in Congo and other African countries.
It says the donated doses of Imvamune will come from Canada’s existing supply and will not affect the country’s preparedness for mpox cases in this country.
Minister of Health Mark Holland says the donation “will help to protect those in the most affected regions of Africa and will help prevent further spread of the virus.”
Dr. Madhukar Pai, Canada research chair in epidemiology and global health, says although the donation is welcome, it is a very small portion of the estimated 10 million vaccine doses needed to control the outbreak.
Vaccine donations from wealthier countries have only recently started arriving in Africa, almost a month after the World Health Organization declared the mpox outbreak a public health emergency of international concern.
A few days after the declaration in August, Global Affairs Canada announced a contribution of $1 million for mpox surveillance, diagnostic tools, research and community awareness in Africa.
On Thursday, the Africa Centres for Disease Control and Prevention said mpox is still on the rise and that testing rates are “insufficient” across the continent.
Jason Kindrachuk, Canada research chair in emerging viruses at the University of Manitoba, said donating vaccines, in addition to supporting surveillance and diagnostic tests, is “massively important.”
But Kindrachuk, who has worked on the ground in Congo during the epidemic, also said that the international response to the mpox outbreak is “better late than never (but) better never late.”
“It would have been fantastic for us globally to not be in this position by having provided doses a much, much longer time prior than when we are,” he said, noting that the outbreak of clade I mpox in Congo started in early 2023.
Clade II mpox, endemic in regions of West Africa, came to the world’s attention even earlier — in 2022 — as that strain of virus spread to other countries, including Canada.
Two doses are recommended for mpox vaccination, so the donation may only benefit 100,000 people, Pai said.
Pai questioned whether Canada is contributing enough, as the federal government hasn’t said what percentage of its mpox vaccine stockpile it is donating.
“Small donations are simply not going to help end this crisis. We need to show greater solidarity and support,” he said in an email.
“That is the biggest lesson from the COVID-19 pandemic — our collective safety is tied with that of other nations.”
This report by The Canadian Press was first published Sept. 13, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
HALIFAX – The Nova Scotia government says it could be months before it reveals how many people are on the wait-list for a family doctor.
The head of the province’s health authority told reporters Wednesday that the government won’t release updated data until the 160,000 people who were on the wait-list in June are contacted to verify whether they still need primary care.
Karen Oldfield said Nova Scotia Health is working on validating the primary care wait-list data before posting new numbers, and that work may take a matter of months. The most recent public wait-list figures are from June 1, when 160,234 people, or about 16 per cent of the population, were on it.
“It’s going to take time to make 160,000 calls,” Oldfield said. “We are not talking weeks, we are talking months.”
The interim CEO and president of Nova Scotia Health said people on the list are being asked where they live, whether they still need a family doctor, and to give an update on their health.
A spokesperson with the province’s Health Department says the government and its health authority are “working hard” to turn the wait-list registry into a useful tool, adding that the data will be shared once it is validated.
Nova Scotia’s NDP are calling on Premier Tim Houston to immediately release statistics on how many people are looking for a family doctor. On Tuesday, the NDP introduced a bill that would require the health minister to make the number public every month.
“It is unacceptable for the list to be more than three months out of date,” NDP Leader Claudia Chender said Tuesday.
Chender said releasing this data regularly is vital so Nova Scotians can track the government’s progress on its main 2021 campaign promise: fixing health care.
The number of people in need of a family doctor has more than doubled between the 2021 summer election campaign and June 2024. Since September 2021 about 300 doctors have been added to the provincial health system, the Health Department said.
“We’ll know if Tim Houston is keeping his 2021 election promise to fix health care when Nova Scotians are attached to primary care,” Chender said.
This report by The Canadian Press was first published Sept. 11, 2024.
ST. JOHN’S, N.L. – Newfoundland and Labrador‘s chief medical officer is monitoring the rise of whooping cough infections across the province as cases of the highly contagious disease continue to grow across Canada.
Dr. Janice Fitzgerald says that so far this year, the province has recorded 230 confirmed cases of the vaccine-preventable respiratory tract infection, also known as pertussis.
Late last month, Quebec reported more than 11,000 cases during the same time period, while Ontario counted 470 cases, well above the five-year average of 98. In Quebec, the majority of patients are between the ages of 10 and 14.
Meanwhile, New Brunswick has declared a whooping cough outbreak across the province. A total of 141 cases were reported by last month, exceeding the five-year average of 34.
The disease can lead to severe complications among vulnerable populations including infants, who are at the highest risk of suffering from complications like pneumonia and seizures. Symptoms may start with a runny nose, mild fever and cough, then progress to severe coughing accompanied by a distinctive “whooping” sound during inhalation.
“The public, especially pregnant people and those in close contact with infants, are encouraged to be aware of symptoms related to pertussis and to ensure vaccinations are up to date,” Newfoundland and Labrador’s Health Department said in a statement.
Whooping cough can be treated with antibiotics, but vaccination is the most effective way to control the spread of the disease. As a result, the province has expanded immunization efforts this school year. While booster doses are already offered in Grade 9, the vaccine is now being offered to Grade 8 students as well.
Public health officials say whooping cough is a cyclical disease that increases every two to five or six years.
Meanwhile, New Brunswick’s acting chief medical officer of health expects the current case count to get worse before tapering off.
A rise in whooping cough cases has also been reported in the United States and elsewhere. The Pan American Health Organization issued an alert in July encouraging countries to ramp up their surveillance and vaccination coverage.
This report by The Canadian Press was first published Sept. 10, 2024.
