Introduction

This chapter has been specifically prepared to support candidates preparing for the Pharmacy Examining Board of Canada (PEBC) exams. It is designed to be a comprehensive resource applicable to both the Evaluating Examination (EE) and the Multiple Choice Question (MCQ) components of the PEBC.

This chapter aims to equip pharmacy candidates with the necessary knowledge and understanding required to assess, manage, and treat these conditions effectively in a clinical setting, as aligned with the objectives of the PEBC.

Alcohol-Related Disorders Overview

Alcohol-Related Disorders are common conditions that significantly impact health, productivity, and social interactions. These disorders are often linked to issues such as domestic violence, impaired driving, and other social consequences. This section focuses on at-risk drinking, alcohol use disorder, and alcohol withdrawal, providing detailed guidance on these topics, while excluding other alcohol-related conditions such as intoxication and unspecified alcohol-induced disorders.

Alcohol-Related Disorders are common conditions affecting health, productivity, and social interactions, such as domestic violence and impaired driving. This section emphasizes at-risk drinking, alcohol use disorder, and alcohol withdrawal, while excluding other alcohol-related issues like intoxication.

At-risk drinking occurs when alcohol consumption surpasses recommended limits but does not qualify as alcohol use disorder. According to Canada's Low-Risk Alcohol Drinking Guidelines:

• Women: 10 drinks per week, or 2 per day

• Men: 15 drinks per week, or 3 per day

Complications of Alcohol Use Disorder

1. Poor nutrition (e.g., thiamine deficiency)

2. Liver disease

3. Bleeding disorders

4. Neuropathy, tremor, and seizures

5. Psychiatric disorders like depression

6. Increased risk of cancers (e.g., liver, breast)

Therapy Objectives

1. Ensure Safety: Evaluate ability to care for dependents, and assess risks like driving while impaired.

2. Alter Alcohol Patterns: Focus on abstinence or reducing consumption according to patient goals.

3. Treat Medical/Psychiatric Issues: Address complications or comorbidities.

4. Alcohol Withdrawal: Manage symptoms using pharmacologic and non-pharmacologic treatments.

5. Prevent Relapse: Integrate support systems to prevent recurrence.

Diagnostic Criteria: Alcohol Use Disorder

To diagnose Alcohol Use Disorder, consider the severity:

• Mild: 2-3 symptoms

• Moderate: 4-5 symptoms

• Severe: 6 or more symptoms

Symptoms (within 12 months):

• Drinking larger amounts or longer than intended

• Failed attempts to reduce drinking

• Time spent drinking or recovering

• Cravings or urges to drink

• Continued use despite social or interpersonal problems

• Tolerance and withdrawal symptoms

Diagnostic Criteria: Alcohol Withdrawal

Alcohol Withdrawal is diagnosed based on cessation of alcohol use that has been prolonged and heavy. Symptoms develop within hours to days, including:

• Autonomic hyperactivity (e.g., pulse >100 bpm)

• Tremors, anxiety, seizures

• Nausea, hallucinations

Patient Evaluation and Screening

1. History and Physical Examination: Include the use of alcohol and other substances (e.g., opioids). Screen for comorbid medical and psychiatric conditions.

2. Screening Tools:

• One-question screen: "How many times in the past year have you had X or more drinks in a day?" (X = 5 for men, 4 for women).

• If positive, use the Alcohol Use Disorder Identification Test (AUDIT).

• CIWA-Ar is used for assessing alcohol withdrawal severity.

3. Laboratory Tests: CBC, liver/renal function, electrolytes, and magnesium.

4. Toxicology: Test for substances, including ethanol.

Therapeutic Options

Non-Pharmacologic Treatments:

1. Motivational Interviewing: Use this approach to encourage the patient’s openness and readiness for change. Table 2 below outlines the stages of change, with a motivational interviewing approach at each stage.

2. Psychosocial Interventions: Cognitive-behavioral therapy (CBT), group therapy (e.g., Alcoholics Anonymous), and relapse-prevention strategies. Psychoeducation and motivational interviewing have proven effective in primary care settings, especially for at-risk drinkers.

Pharmacologic Treatments:

1. Naltrexone: An opioid antagonist that reduces the euphoria of alcohol, effective in lowering cravings. It is contraindicated in opioid users and patients with liver dysfunction. Recommended for those aiming to reduce rather than completely abstain from alcohol.

2. Acamprosate: Modulates GABA and glutamate and helps maintain abstinence. It’s the drug of choice for those with liver impairment, although it requires dose adjustments in renal impairment.

3. Disulfiram: A second-line option causing unpleasant reactions when alcohol is consumed. Use in those with a long history of alcohol use disorder and under supervision, particularly in the absence of hepatic dysfunction.

4. Anticonvulsants: Drugs like topiramate and gabapentin have been investigated, with mixed results.

Alcohol Withdrawal Management

1. Benzodiazepines (e.g., diazepam, lorazepam) are the mainstay of treatment, with dosing guided by CIWA-Ar scores. They reduce the hyperactivity of GABA, helping manage withdrawal symptoms.

2. Thiamine: Administer 200 mg/day to prevent Wernicke-Korsakoff Syndrome.

3. Phenobarbital: Reserved for cases of resistant withdrawal, often requiring critical care.

| Table 3: Pharmacologic Management of Alcohol Withdrawal |

Special Considerations

Pregnancy and Breastfeeding:

• Alcohol consumption during pregnancy raises the risk of fetal alcohol spectrum disorder. Withdrawal should be managed in an inpatient setting. The safety of acamprosate, naltrexone, and disulfiram during pregnancy is not well established. Use caution, especially during breastfeeding.

Older Adults:

• Older patients have a higher risk of complications and more severe withdrawal. Lorazepam is preferred over diazepam in older individuals due to its safer metabolic profile. Special attention is required when prescribing medications due to increased risks of adverse reactions.

Therapeutic Tips:

• The primary care setting is ideal for managing alcohol-related disorders, as it ensures continuity and support.

• A combination of pharmacologic and non-pharmacologic interventions is preferred for long-term success.

Algorithm