In this episode, Drs. Blair Bigham and Mojola Omole delve into the pressing issue of alcohol use disorder (AUD) in Canada with Dr. Evan Wood, the lead author of the “Canadian guideline for the clinical management of high risk drinking and alcohol use disorder” published in CMAJ.
They explore the concerning prevalence of AUD in Canada, contrasting it with other countries and shedding light on the diagnostic criteria that underscore the significance of assessing clinically significant impairment or distress.
Dr. Wood clarifies the hurdles faced in identifying and treating AUD, highlighting the shortfall in healthcare provider education and resources. He underscores the importance of routine screening for alcohol use by physicians and offers invaluable tips to improve recognition of this pervasive disorder.
Dr. Wood outlines the recommended pharmacotherapies as stipulated in the guideline. He points out the frequency with which ineffective, or even harmful, treatments are prescribed for mood symptoms related to AUD and calls on physicians to follow evidence-based approaches.
Dr. Wood concludes by emphasizing the necessity of constructing a comprehensive system to tackle alcohol use disorder head-on in Canada, fostering a thorough understanding of this widespread health challenge among the medical community.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
In this episode, Drs. Blair Bigham and Mojola Omole delve into the pressing issue of alcohol use disorder (AUD) in Canada with Dr. Evan Wood, the lead author of the “Canadian guideline for the clinical management of high risk drinking and alcohol use disorder” published in CMAJ.
They explore the concerning prevalence of AUD in Canada, contrasting it with other countries and shedding light on the diagnostic criteria that underscore the significance of assessing clinically significant impairment or distress.
Dr. Wood clarifies the hurdles faced in identifying and treating AUD, highlighting the shortfall in healthcare provider education and resources. He underscores the importance of routine screening for alcohol use by physicians and offers invaluable tips to improve recognition of this pervasive disorder.
Dr. Wood outlines the recommended pharmacotherapies as stipulated in the guideline. He points out the frequency with which ineffective, or even harmful, treatments are prescribed for mood symptoms related to AUD and calls on physicians to follow evidence-based approaches.
Dr. Wood concludes by emphasizing the necessity of constructing a comprehensive system to tackle alcohol use disorder head-on in Canada, fostering a thorough understanding of this widespread health challenge among the medical community.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
And I'm Mojola Omole. This is the CMAJ podcast.
Dr. Blair Bigham:
So, Jola, we're talking about the new alcohol guidelines published in CMAJ, formally titled: “Canadian guideline for the clinical management of high risk drinking and alcohol use disorder.”
Dr. Mojola Omole:
So I'm really excited to delve more into this article because previously CMAJ released an article looking at the guidelines to the amount of alcohol, the quantity of alcohol use. And this one really just focuses on treatment for alcohol use disorder, how to recognize alcohol use disorder, which is very different from what we previously were taught in medical school. So I'm really just interested in updating my knowledge and just getting to go a little bit deeper into that.
Dr. Blair Bigham:
Definitely, let's get to it and speak with the author.
Dr. Blair Bigham:
Dr. Evan Wood is the lead author of the new Guideline for the clinical management of high risk drinking and alcohol use disorder. He's an addiction medicine physician and Canada Research Chair at UBC. He joins us from Vancouver. Evan, hello.
Dr. Evan Wood:
Hello.
Dr. Blair Bigham:
Let's start by getting a sense of the scope of the problem. How prevalent is alcohol use disorder right now?
Dr. Evan Wood:
Yeah, so surveys in Canada suggest that when you consider the entire grab bag of mild, moderate, and severe alcohol use disorder, it's estimated that almost one in five adult Canadians in their lifetime will meet the diagnostic criteria for having an alcohol use disorder.
Dr. Blair Bigham:
And how does that compare to, say, the United States or Britain?
Dr. Evan Wood:
Yeah. My co-chair, Dr. Jürgen Rehm does a lot of international work, and so he would be best positioned to compare the international data. The US doesn't do great. The UK doesn't do great. But if you look at a broader range of countries with similar GDP to Canada, we don't do great. So yeah, we're a country that has a culture that reflects a lot of heavy alcohol use and subsequent alcohol use disorder. And compared to a lot of our peers internationally, the problem is greater in Canada.
Dr. Mojola Omole:
It's interesting because when you travel to Europe, I just always got the sense that they drank more.
Dr. Blair Bigham:
Yeah, it seems that way. Whenever you're out at a cafe, wine is cheaper than water.
Dr. Mojola Omole:
Yeah, everybody's having a glass of wine.
Dr. Evan Wood:
Yeah, and I think there's cultural norms around that too, in terms of keeping alcohol use under control and having a glass of wine with dinner as a fairly standard part of some cultures. Whereas the kind of heavy alcohol use, where you might come home from work on a Friday and have 12 beers and watch the hockey game, is obviously a different pattern of use.
Dr. Blair Bigham:
So let's talk about the definition. And before we do, I'm curious, is the definition an international one or is it a Canadian one? And how do you break it down into those buckets of mild, moderate, severe?
Dr. Evan Wood:
Yeah, so we use the DSM-V, the Diagnostic and Statistical Manual of Mental Disorders, which is the American Psychiatric Association standard. So there's a threshold criteria of clinically significant impairment or distress. So just using a lot of alcohol does not equal an alcohol use disorder, and studies have really clearly shown that. You have to have this sort of threshold criteria of clinically-significant impairment or distress secondary to your alcohol use. And then there's 11 criteria that essentially measure the sort of social and health impacts of alcohol use, as well as some physiologic impacts. And depending on how many of those 11 criteria have, two to three it's mild, three to six it's moderate, and six or above is severe.
Dr. Blair Bigham:
Can you give me an example of just one or two of those criteria just so we get a flavor?
Dr. Evan Wood:
Yeah, so the physiologic ones can be craving or tolerance to alcohol use. Those are really important, actually, to clarify because sometimes I'll see someone say, "Well, yeah, I think I'm probably tolerant to alcohol," but the criteria really have to be a contribution to clinically-significant impairment or distress. So craving, if you can't think of anything else, you're really distressed with these intrusive thoughts about drinking that's craving. That's pathologic. If you're tolerant to the effect, the classic example of pathologic tolerance would be chasing the dragon in heroin addiction when people are, "I used to be able to do a point of heroin in the morning and that would cover me all day, and now I can't even get out of bed without doing a point of heroin." And after using heroin, to go after it again and again, that's pathologic tolerance.
But there's health consequences and there's social consequences. So inability to function at work, home, or school, secondary to alcohol use, is one of the criteria. So it's those types of things that then contribute to clinically-significant impairment or distress. And again, depending on how many of those criteria people have, that makes the diagnosis.
Dr. Blair Bigham:
So all those, "How many drinks do you have in a week?" or, "How many times do you binge?" that has nothing to do with the actual disorder? Those 11 criteria, it doesn't matter how much you drink, it matters how much it affects you. Is that right?
Dr. Evan Wood:
That's right. That's right. Yeah, so binge use isn't part of the criteria. The amount of use is not part of the criteria. And there's some really elegant studies that have shown that using a lot of alcohol is a precondition for alcohol use disorder, but not sufficient to make the diagnosis.
Dr. Blair Bigham:
So how good are we as physicians, or as a country, of identifying people who are either at risk or suffering from alcohol use disorder?
Dr. Evan Wood:
This has been an area where there's been a huge amount of research to look into different screening tools because it's time-consuming to have that conversation with people and to go through that DSM-V diagnostic exercise, like I was describing. So there are screening tools that can try and parcel out who is high risk versus low risk. And then those that are high risk, you can move on to a more fulsome diagnostic interview. So there are ways of doing it that the guideline quite nicely describes, and I would say on average, Canadian physicians probably don't do a very good job speaking to their patients about alcohol. Some certainly would, and there'd be people listening to this like, "Well, I talked to every single one of my patients that comes in the door about how much alcohol they use," and I'm sure there's many physicians that do that and they should be applauded for that. But there's a lot of stigma around alcohol and people are in a hurry.
The primary care system in Canada is groaning, and if someone comes in and their finger is infected, and they're looking for an antibiotic, and they're worried about what's going on with their finger, you may not say, "Well, how many drinks do you have per day? Well, tell me about your drinking habits," and these things that might go below the radar. So the guideline really is encouraging that in the same way we talk to people about their cholesterol or other things, like blood pressure, and routinely screen for these types of things, alcohol should be in that mix too.
Dr. Mojola Omole:
And I would say that I'm actually uncomfortable with it. I always ask, as part of my breast cancer screening, "How much alcohol do you take in a week?" and I'm always like, "Just roughly." Because if they tell me it's 12 or 20, beyond me seeing guidelines that you should have less, I feel uncomfortable with their answer. So I can imagine, as a primary care practitioner, how that must be.
Dr. Evan Wood:
Yeah, I think it opens up a whole can of worms. And frankly, because this issue has been neglected by the institutions that should be really directing where resources go in the healthcare system, if you start pulling at the threads of that, then where are you going to refer people? It could totally derail you if somebody suddenly wants to have this conversation. Yeah, just the way your clinic is working. So we need to build the resources in the community, but we also need to train doctors to have these conversations because whether it's the example you gave, breast cancer as a risk, or infections as a risk, it's estimated that about 200 health conditions are secondary to heavy alcohol use. So if we're only looking down river and trying to help people that have fallen in and not going upstream and trying to deal with some of the underlying things, then obviously we miss a big opportunity for health promotion and avoiding downstream consequences.
Dr. Blair Bigham:
I feel like the obstacles that perpetuate those downstream consequences are probably pretty well-known. We probably don't need to rhyme all of those off. But what are some of the low-hanging fruit or the easy ways people can overcome some of those obstacles? What's a quick tip that an ER doc, or a family doc, or a surgeon who's running a very busy clinic can use to start to improve our recognition of alcohol use disorder?
Dr. Evan Wood:
I ask all my patients about alcohol use, and I've seen physicians do that and just say, "Hey, I don't want you to make you feel uncomfortable. This is just something I ask all my patients about, and I'm wondering how much alcohol you use. Is that something you're comfortable speaking about?" And then you're really sort of allowing someone to say, "You know what? That's not why I'm here. I really need help with X, Y, or Z," and then you can park it for another time. But yeah, that's really what the guideline encourages is just trying to make it safe for people to talk about alcohol, and I think everyone can develop their own individual skills for how they do that.
Dr. Blair Bigham:
Okay. So you've had this conversation. You've gone through either a screening tool or just had a good old chat, and then gotten into your DSM criteria. And let's say we've now identified somebody with alcohol use disorder. Let's move into the treatments here. What does the guidelines recommend when it comes to treating people? Because you made a pretty compelling argument that it is grossly undertreated. Was I reading that 5% of people who have it are treated for it?
Dr. Evan Wood:
Yeah, it depends how you define treatment, and it depends what jurisdiction you're looking at. In the US, there was a nice paper recently published in the Annals of Internal Medicine that looked at people with actual Medicaid coverage to pay for their medications. And for those that had been hospitalized for an alcohol use disorder, about 99% did not receive treatment.
Dr. Blair Bigham:
Oh, wow.
Dr. Evan Wood:
Yeah. In different Canadian jurisdictions, there's a nice paper, I think, from Manitoba that showed about 1% of people who had a severe alcohol use disorder received evidence-based pharmacotherapy. And in British Columbia, we have had a guideline for a number of years now. But I think the latest data, which is out of date now, I'm sure it's improved a little bit, but it showed about 5% of people who were showing up in registries with a diagnosis of alcohol use disorder and received a pharmacotherapy.
Dr. Mojola Omole:
Why? If someone comes in with high cholesterol, just give them a statin. I don't, but some other people give them a statin, right? If I have a patient I'm discharging that had high blood pressure, I'll be like, "You can start this and follow up with your family doctor." Why are people with alcohol use disorder not getting treatment?
Dr. Evan Wood
I think, again, there are structural factors. So just to maybe put it in perspective, I work at Vancouver Coastal Health's big withdrawal management facility, the publicly funded withdrawal management facility for the biggest health authority all the way up to Bella on the coast, Richmond, East/Northwest Vancouver. And the program is in the city's old animal shelter, and I often use that as a metaphor for the lack of funding for the addiction system of care. We have people who will wait weeks to get into the program and sort of get broken the bad news that we actually offer withdrawal management. We don't offer treatment. So we'll offer four or five days of withdrawal management, and for people who are marginally housed and desperate for treatment and recovery, they'll still get discharged to homeless shelters. So we're talking about just a total lack of a system. You couldn't fix the system and kind of tinker with it and improve it.
Then there are structural issues around lack of healthcare provider education. So when it comes to things like statins, medical students will do a cardiology block and they'll learn about lipids and lipid-lowering agents and when they should be used, whereas there's almost no addiction medicine education in medical school. Some of the things that are sadly big influences upon prescribing behavior in the healthcare system in Canada, including pharmaceutical industry influences, these medications are generic.
Dr. Mojola Omole:
Oh, wow.
Dr. Evan Wood:
There's no real sort of influence there that's taking divisions of family practice to nice meals and educational talks, and the things that historically have led to routine, reflexive approaches to prescribing.
Dr. Blair Bigham:
Well, let's go to the med school 101 here. What are the recommended pharmacotherapies for this?
Dr. Evan Wood:
Yeah, so there's a number of on-label, Health Canada-approved medications, and there's medications that have been investigated that are off-label. And I think the most important thing for clinicians to take home about the alcohol use disorder pharmacotherapies is if we were to use lipid-lowering, or let's say blood pressure control as an analogy, they don't really work like that. In so far as the clinical trials of people with alcohol use disorder often measure a number of different phenotypes, like craving. And they also look at patient goals. So some patients will want to cut down on their drinking and they'll be, "I just want it to be like it was before, where I could have a couple glasses of wine and not continue on and get blackout drunk." Other patients will say, "I know it's poison for me. I never ever want to drink again."
And so the two first-line medications recommended in the guideline, the first is naltrexone. It's an opioid antagonist and it really, probably works best for people who have a craving phenotype and who want to cut down on their drinking. Whereas the other medication is acamprosate where if you look at the sort of forest plots in the meta-analyses of acamprosate, it looks like it doesn't really help people reduce heavy drinking. But on the flip side, when you look at duration of abstinence, it can really help people stay in abstinence. So those are probably the big two, and those are the ones that have been examined in these registry studies and showing how low the uptake has been.
Disulfiram, or antabuse, is the one that I think we hear about in medical school. That one tends to create a toxic reaction when people drink alcohol. That medication is very much a niche medication because people who want to drink will just stop taking the medication, and so in clinical trials, it's not particularly useful. But in circumstances, let's say with a husband and wife scenario, where the husband is, "This is your last chance. We're not going to put up with any more drinking," you commit to taking your antabuse every morning and the wife will supervise that under this hypothetical scenario, then it can be effective in those circumstances. And then there's a couple of off-label medications, particularly gabapentin and topiramate are probably the big two, that have been studied in enough clinical trials that there are meta-analyses that have looked at the impacts of those, and they probably provide some benefit as well.
Dr. Mojola Omole:
In your guideline, you say that treatments that patients are frequently prescribed, which are not these, don't work. What are some examples of these that patients are often prescribed that don’t actually work for the alcohol use disorder?
Dr. Evan Wood:
Yeah, so individuals with alcohol use disorder so commonly have consequences, whether it's the high blood pressure, or insomnia would be a classic one, or if your social relationships are fracturing because of your alcohol use, or even the physiologic effects of alcohol, you can have low mood. Or alcohol withdrawal symptoms classically are adrenergic, so people get anxious. You're in the grocery store lineup and you have a panic attack and you go and speak to your doctor about it. And much like statins, are reflexively prescribed without hesitation. SSRI antidepressants in particular are almost ubiquitous among people with alcohol use disorder. People that come in with alcohol use disorder to Vancouver Detox, if they're not on an SSRI, it's always a bit of a head scratcher. And very commonly, they'll be on trazodone to help them sleep. And if they're still struggling, then, again, a very low threshold to use an off-label, antipsychotic, most commonly quetiapine, but sometimes aripiprazole or others. And so sometimes, we'll see people on this sort of triple combination therapy of SSRI, trazodone, and an antipsychotic.
And when the guideline committee came together, there was this very strong feeling that, "Hey, what about all these other things that people are being prescribed?" and it's a hugely interesting story from an evidence-based medicine perspective because actually there's very large case series initially showing people having worsening alcohol use disorder symptoms with SSRIs. There's preclinical data where you can reliably show that if you give an SSRI versus placebo to lab animals, they'll drink more. And lo and behold, there's double-blind, placebo-controlled trials that have consistently shown that a proportion of patients will have dramatically-increased alcohol use in the SSRI condition compared to placebo.
Dr. Mojola Omole:
Why is that? This is mind-blowing. What's the mechanism? Sorry, I'm just ...
Dr. Evan Wood:
Some studies have measured craving and implied that SSRIs increase craving. I think that the jury is out on that in terms of what the actual mechanism is, but we know that these are powerful drugs that are intended to ... You can be in relatively poor social circumstances, or you have financial anxiety or bad relationships or both. And those things don't have to change, but your depression can improve with the use of these drugs, so that's the promise. So we know that they can have very profound impacts, and one of those impacts is changing people's decision making around pursuit of rewards, and even a serotonin transporter gene has been implicated. It's actually been shown over and over again that there's a serotonin transporter gene that has been implicated. I think three randomized trials have shown that. And there's also, actually, a lot of concern around publication bias in this area, and the big NIH-sponsored trial that was intended to answer this question and looked at that serotonin transporter gene was never published.
But if you contact the investigators, they did present it as a poster at a conference, and it actually showed the highest rate of alcohol use was among individuals who, at the start of the trial, were hoping to be abstinent and also got prescribed an SSRI. So it's just a super, super interesting story in the history of evidence-based medicine that somehow didn't see the light of day when it came to your average prescriber.
Dr. Blair Bigham:
I want to spend a minute on this. I mean, it's so counterintuitive to me because people always say that they're self-medicating with alcohol. So you think, "Oh, they're sad so they're drinking alcohol, and so maybe if I prescribe them an antidepressant, they won't be sad anymore. They won't drink alcohol." I don't know. That's just a pathway that was in my head. But I guess that's just totally not supported by the evidence.
Dr. Evan Wood:
Yeah, and I think historically, till I saw the evidence around trazodone, which showed a dramatically-increased, higher use of alcohol, both on the medication and six months after the medication was stopped. And SSRI studies have shown that as well, that in comparison to placebo ... because some of these studies have a treatment window and then they stop and then they follow people for six months ... they've shown that the elevation in drinking, in what people call type B alcoholics or very high risk heavy alcohol users, can continue for six months after the medication has been stopped.
Dr. Blair Bigham:
Oh, okay.
Dr. Evan Wood:
So that sort of hope that if we target the insomnia, because a person's saying they're drinking because they can't sleep. Or they've got such a low mood, they might even be suicidal. But the meta-analyses ... and I don't think I made this point clear enough, which I think is the most important point ... suggests no benefit in mood symptoms with SSRIs if you have an alcohol use disorder. So you're not going to get the benefit that you're aiming for, and then you might get the side effect of increased drinking in some patients. Not everybody, of course,
Dr. Mojola Omole:
It feels as if our understanding of alcohol use disorder, similar to what Blair was talking about, has always been that it is a symptom of something. Drinking alcohol is a symptom of all of the mental health issues. But this is really making it clear that alcohol use disorder is literally like having high blood pressure. I'm basically reiterating your work, but I'm just trying to make it clear in my head that alcohol use disorder is a disease process on its own.
Dr. Evan Wood:
Yeah. And don't get me wrong, there's genetic predisposition to alcohol use disorder. We estimate about 50% of the burden of disease with addictive disorders is genetic, but 50% is environmental. And so if you have a history of trauma, or if you're in a horrible situation where, at the end of the day, the decision to be able to drink heavily is better than staying sober, don't get me wrong. And certainly, there's lots of mental health issues that may predispose to alcohol use disorder, like PTSD, and then there's all sorts of mental health consequences that come with heavy alcohol. The challenge is in that, I think, the wrong turn we've taken as a healthcare system is this notion that people with alcohol use disorder can have fleeting visits with prescribers and get a bunch of polypharmacy, and that's going to be our approach to helping people. Again, I think of cardiology environments, if people are being admitted to cardiology environments and everyone was rounding on the patients and people were on a bunch of medications that, in meta-analyses, were shown to be of no benefit, you would see some sort of changes.
And then if there was medications that actually had been implicated in increasing heart attacks, there'd be smoke coming out of the top of prescribers' heads.n Whereas in the mental health and substance use world, it hasn't been subjected to that same type of scrutiny and there's a huge hesitation to take people off of medications. You ask people, "Who prescribed it?" "Oh, I got a consult from a specialist four years ago and my GPs just continued it." "And what about this antipsychotic?" "Oh. Well, I ended up in the emergency department with a seizure, and so they started it there." People are just super distressed and there just hasn't been that kind of evidence-based medicine approach to prescribing.
Yeah, it's very complex and I don't want to simplify it. But to your question, alcohol use disorder prevalence is predicted, in many respects, by availability and cultural norms. And use of alcohol in society has a lot to do with things like the price and taxation of alcohol, and outlet density and things like that. So it's a complex milia of forces that lead to alcohol use disorder, but it is a standalone disorder that, whether you have a concurrent disorder or not, we should be providing evidence-based treatment for it.
Dr. Blair Bigham:
Right. Evan, this is fascinating. In addition to family docs needing to be looking out for this triple therapy, or people on SSRIs, trazodone, antipsychotics, do you have another top takeaway that you'd like to leave people with?
Dr. Evan Wood:
I think the top takeaways would be just the fact that this is a very common concern in Canada. We don't do well. And hopefully, Canada's guidance on alcohol and health will help address some of those bigger issues. Then, issue A would be the under-prescribing of evidence-based treatments that have really impressive number needed to treat in terms of their comparison to statins. The number needed to treat for naltrexone is about 12, whereas for preventing heart attacks ...
Dr. Blair Bigham:
Wow.
Dr. Evan Wood:
Yeah. And same for acamprosate for keeping people in abstinence, the number needed to treat is about 12, which is pretty great in comparison to a lot of medications we prescribe. And then there's the polypharmacy issue, to be a lot more careful with what we prescribe and watching for those adverse effects that can happen. And then I think the third one is just an acknowledgement that we do need to build this system from the ground up. Because busy family physicians, when they see somebody who's actually like, "Yeah, I'm really having trouble with alcohol. I need help," under normal circumstances for a prevalent medical condition, you'd be able to turn and say, "Okay. Well, this is who I refer to. This is the outpatient resource. These are the things that support me as a primary care provider," and that system still needs to be built. So the entire committee acknowledges that, that we're at the ground floor of trying to build an effective system around health promotion around alcohol use. And then what this guideline is really looking at, people who are struggling with alcohol use disorder, how they can get effective care and support.
Dr. Blair Bigham:
Well, it was a ton of work. It's a comprehensive guideline. Thank you so much for spending time to help explain it for us.
Dr. Evan Wood:
Yeah, my pleasure. Thanks so much for your interest.
Dr. Blair Bigham:
Dr. Evan Wood is the lead author of the “Canadian guideline for the clinical management of high risk drinking and alcohol use disorder, published in CMAJ. He's an addiction medicine physician and Canada Research Chair at UBC.
Dr. Blair Bigham:
All right, Jola, there is a lot of information to digest there. What is your key takeaway from that discussion?
Dr. Mojola Omole:
I think my top takeaway from this was that actually the agnostic view about it doesn't really matter what you use to diagnose alcohol use disorder, and also the fact that there actually really seems to be compelling evidence in terms of treatment.
Dr. Blair Bigham:
Yeah, I was kind of glad to hear Evan say, ask whatever question you want, as long as you have the conversation, because it is so dramatically underdiagnosed. I mean, it is such a hard conversation to start for every patient and every provider. You're just going to find your own groove to kind of open that door. And it sounds like with Evan's experience, it, kind of, is up to us just to at least make sure we open that door and get started.
Dr. Mojola Omole:
And also, I think the other thing that was really fascinating for me is just the fact that SSRIs, which is commonly prescribed for everybody but that it makes alcohol use disorder worse. And so for me, that was actually a bit of an eye opener in terms of, like, okay, this is something to kind of remember. Yeah, go ahead.
Dr. Blair Bigham:
And I'm still wrestling sort of with that concurrent disorders idea of how you balance depression and alcohol use and how one might promote the other, but very interesting that SSRIs are now advised against.
Dr. Mojola Omole:
Yeah. And I think for me, I always viewed alcohol use as a symptom of a larger problem, and I view it actually, as I'm processing right now, I view it differently the way I view an opiate addiction or any other forms of addiction. That's a primary concern. I always viewed alcohol as a symptom of another issue, whether you're depressed or I know there's association with alcohol use disorder and PTSD, but I always thought of it as, like, as a symptom, not necessarily the main problem,
Dr. Blair Bigham: As a standalone diagnosis.
Yeah.
Dr. Mojola Omole:
So, this was really fascinating to view it that way. And, his example, like, if your blood pressure is up, you give you medication for that. So us, almost, like, destigmatizing alcohol use disorder with the way that this was written was really important to me and about how my approach to my patients will be too.
Dr. Blair Bigham:
Yeah. I also found the treatment to be, sort of, I don't know, I don't know when the last time I prescribed naltrexone is, but I feel like in the ER I meet plenty of people who I could at least have that conversation with. I mean, I do prescribe bupropion or Champix for people who are like, oh, I'm ready to quit smoking, as an ER doc. But I don't have that conversation around naltrexone. And now I'm just kind of reflecting on why that might be.
Dr. Mojola Omole:
100%. And I think that, for me, just destigmatizing alcohol use disorder was really important.
Dr. Blair Bigham:
Yeah. In the ER, we have all these rapid access addictions clinics that have started up in a lot of hospitals. I think it's kind of taken the pressure off of emerg docs. I think we're kind of like, oh, go talk to the RAAM clinic about that. Or, we've, sort of, offloaded that from emergency medicine. But I wonder what the actual attendance rate of those self referrals or physician referrals to an addictions clinic is. Maybe they're more comfortable talking about it with somebody who they already have a clinical relationship with. Or maybe you just seize that moment where they're there for their, I don't know, hangnail or influenza or whatever it was that brought them into the Emergency department to say, ‘do you want to talk about your drinking? It seems to have contributed to the reason you came to the ER today.’
Dr. Mojola Omole:
Yeah, I think that's a very elegant way of saying it.
Dr. Blair Bigham:
That's it for this week on the CMAJ podcast. Thank you so much for joining Jola and I. Big shout-out to Neil, our producer at Podcraft Productions, and our editor at CMAJ, Catherine Varner. Don't forget to like or share our podcast wherever it is you download your audio or communicate with your colleagues and friends. We would love to get the message out there and have more people join us here on the CMAJ podcast. I'm Blair Bigham.
Dr. Mojola Omole:
And I'm Mojole Omole. Until next time, be well.