Substance Use Guidelines:
Alcohol Introduction
September 2023
• Alcohol is a well-known, easily accessible, and legal depressant of the central nervous system.
• The prevalence of Alcohol Use Disorder (AUD) is approximately 40% among people experiencing homelessness (PEH), compared to 10.6% in the general population. i, ii, iii
• Alcohol Use Disorder has been shown to be a risk factor for experiencing homelessness, and many patients identify the stressors of homelessness as causing or exacerbating their AUD. iv
• Experiencing homelessness creates significant barriers to treatment. Patients may have a more limited social network to draw on for support, and treatment may be a secondary priority to addressing basic needs. v
• The presence of AUD did not hinder attainment of stable housing compared with PEH without AUD, and attainment of housing was correlated with increased accessing of treatment for AUD. vi
• Of the 140,000 people who die each year from excessive alcohol use, their lives were shortened by an average of 26 years. vii
• Genetics account for about 50% of the risk of developing alcohol use disorder. viii
• Causes of death from alcohol use includes motor vehicle accidents, poisonings, suicides, as well as increased rates of liver disease, cancer, and heart di sease.vii
Key Terms and Definitions
• Alcohol Use Disorder: A medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. ix
• Alcohol Withdrawal Syndrome: Symptoms that occur when a person stops using alcohol after a period of heavy drinking. Symptoms of alcohol withdrawal can vary widely in severity. In severe cases, the condition can be life-threatening. This can manifest as tremors, confusion, hallucinations, and seizures, and if severe and untreated, can be fatal.
• Trauma-informed care (TIC): A patient-centered approach to care that recognizes the impacts of trauma and actively works to prevent re-traumatization and promote recovery. The principles of TIC are grounded in establishing a trusting relationship and a safe physical and psychological space in which to address needs.
• Harm reduction: A philosophical approach to care that establishes individual agency and selfdetermination as central to all efforts toward well -being. Harm reduction approaches call for the non-judgmental, non-coercive provision of services and resources to people who use substances to assist them in reducing harms related to their substance use or other health behaviors. Harm reduction-based care is collaborative, provides education on available interventions, and centers the goals of the individual in care planning.
Clinical Considerations
Physical Health Impacts
• Patients in the early stages of alcohol -related problems may have few or subtle clinical findings. There are dose-related health effects associated with the consumption of alcohol and there are numerous factors that cause wide variability of progression of illness. Quantity, frequency, gender, genetics, and periods of sobriety all play a role in how alcohol consumption and progression of alcohol-related negative health effects will impact an individual.
• Alcohol use disorders often go undiagnosed; the rate of screening for alcohol consumption in health care settings remains lower than 50%. x Among adults with an AUD, only 6.7% received treatment in the past year. Thus, it is recommended to implement universal screening for alcohol use for individuals 18 years of age and older. xi
Screening Tools
There are a number of alcohol screening tools. Here are some of the most commonly used tools: CAGE Questionnaire, The AUDIT Questionnaire, the SBIRT, and the TWEAK Assessment Tool.
• In the early stages of alcohol -related health challenges, the physical examination provides little evidence to suggest excessive drinking. Patients who have chronic, heavy alcohol use may initially have mildly elevated blood pressure but few other abnormal physical findings. Later, patients may develop significant and obvious signs of alcohol overuse, including gastrointestinal findings such as an enlarged liver; cutaneous findings such as spider angioma, varicosities, and jaundice; neurologic signs such as tremor, ataxia, or neuropathies; and cardiac arrhythmias.
• Abnormal laboratory findings: C ertain chemical markers are indicative but not diagnostic of alcoholuse disorders. Among liver function tests, the glutamyl transferase (GGT) level is usually the first to become elevated, followed by the aspartate aminotransferase (AST) level, which is often twice the level of alanine aminotransferase (ALT). The complete blood cell count may display a number of abnormalities.
• Approximately 70% of individuals with AUD are heavy smokers (more than 20 cigarettes per day), compared with 10% of the general population. xii
• Health impacts for women are routinely seen at lower volumes of alcohol consumption over shorter durations. xiii
• Patients with AUD should be tested for immunity for Hepatitis A and B and vaccinated if nonimmune. Patients should be screened for Hepatitis C, and if positive, referred for treatment. Active AUD is not a contraindication to HCV treatment, and given the i ncreased risk of cirrhosis, treatment of HCV should be of higher priority in these patients. Patients with active AUD or in the first 1- 3 months of recovery should be offered supplementation of thiamine, folic acid, and a multivitamin.
Behavioral Health Impacts
• Nearly all individuals with an alcohol use disorder have a comorbid psychiatric disorder, most commonly anxiety, mood disorders, ADHD, antisocial personality disorders, or co-occurring substance use disorders. xiv
• PTSD was associated with a threefold increase in risk of developing AUD. xv
• Also, in individuals with PTSD and AUD, there is a strong correlation with adverse childhood experiences including abuse and neglect. This is essential in understanding driving factors for AUD and acknowledging that when a person is cutting back or pursuing sobriety, it may be a time when their PTSD or underlying mood disorder may be significantly triggered. This warrants a holistic
trauma-informed approach of co-managing both the S ubstance Use Disorder and underlying mental illness.
Use of Alcohol and Experiences of Homelessness
• Given the high prevalence of AUD among PEH of 40%, screening, diagnosis, and treatment of alcohol use disorder should be a priority for those working with PEH.
• People with AUD experiencing homelessness drink alcohol for a variety of reasons. Reasons include psychological coping, community, enjoyment, and avoidance of withdrawal symptoms. xvi
• Patients experiencing homelessness have lower retention in treatment for alcohol use disorder; this has been shown to improve when housing is bundled with treatment. xvii
• Shelters and medical respite programs may restrict use of alcohol to varying degrees, leading to patients either binging outside of the building, or declining shelter and experiencing increased risks of hypothermia and other injuries.
• Scenarios to consider that are specific to PEH with AUD are preparing for outpatient procedures and/or day surgeries. Many individuals with AUD may not have a goal of abstinence or sobriety but are engaged in their clinical care and may need support for procedures like a colonoscopy or endoscopy due to alcohol-related conditions. Clinicians should take a harm reduction approach to these scenarios and have open dialogue with their patients about the options they have to successfully complete these procedures. Options include 1) Supporting the patient cut ting down on their alcohol intake prior to a procedure with medications to decrease cravings and or managing withdrawal symptoms. 2) Offering an inpatient or outpatient detox prior to the procedure. 3) Providing care coordination with the specialist about the patient’s AUD and discussing ways to successfully complete a procedure and tolerate anesthesia while a person may have consumed alcohol the day of the procedure.
Models of Care Delivery
• Leveraging an interdisciplinary model is vital for supporting people with AUD due to the high prevalence of tri-morbid conditions of chronic health issues, mental illness, and substance use. Service providers should work to improve care coordination and communication between providers, including referrals to behavioral health and specialty care when appropriate.
• Medical outreach and Street Medicine models of care are particularly important for providing care and services for PEH who have AUD and are sleeping outdoors. Many people who need support with alcohol use, including substance use treatment and other primary health services may not be able or comfortable accessing care in more traditional settings, especially if that means waiting for long periods of time and potentially experiencing withdrawal symptoms. Meeting a person where they are and offering medical support — along with necessities like clothes, food, and water — is essential.
• Medical respite may be a vital resource for supporting someone who is experiencing a variety of alcohol-related complications including acute cirrhosis, end-stage liver disease, and/or support managing alcohol withdrawal. Medical respite may be helpful in supporting a person detoxing to prepare for a procedure. Additionally, post-hospitalization care and stabilization while supporting ongoing sobriety can help a person’s health following an acute alcohol -related medical event like a GI bleed or decompensated cirrhosis.
Harm Reduction Strategies
• While programs to treat AUD have historically focused on abstinence, harm reduction models have been validated to help patients with AUD decrease their alcohol use. Such programs do not require abstinence, and support patients in setting and meeting their own goals.
• Studies have found increased functional improvement and improved physical health from offering harm reduction programs paired with medication for AUD.xvi
• Harm reduction strategies for people with AUD experiencing homelessness include both medical and non-medical interventions. Examples include: “Wet” shelters, housing first models, and managed alcohol programs (MAPs)
o Wet shelters provide low-barrier shelter and do not require sobriety to access. These types of shelters often have tailored programming and support for individuals who are currently intoxicated. xviii
o Housing First is a type of permanent supportive housing with an approach that is guided by the belief that people need necessities like food and a place to live before attending to anything less critical, such as getting a job, budgeting properly, or addressing substance use issues. xix
o Sobering Centers offer short-term stabilization to individuals intoxicated in public as an alternative to hospital-based support or justice involvement. The Sobering Center model of care offers a dignified, person-centered approach to individuals and focuses on mitigating the physical and interpersonal harms of public intoxication such as injury, environmental exposure, and victimization. It also offers a non-stigmatizing setting for engaging with individuals using alcohol use and health goals.
o Managed Alcohol Programs: Provision of managed alcohol may be appropriate for individuals with severe Alcohol Use Disorder or those who engage in high-risk drinking, who have not been retained on treatment for AUD or who are not interested or able to stop or reduce drinking and who are at risk of serious harm due to inability to safely obtain alcohol. This provision of alcohol prevents the cycle of intoxication and withdrawal and research shows that it leads to an overall reduction in alcohol consumption, decreased use of emergency services, and improved quality of life. xx
• Due to pathophysiology of AUD in combination with the wide availability of alcohol, social acceptance, and the fact that alcohol is a legal substance, many individuals with AUD experience cycles of alcohol use, intermittent detox, sobriety, and relapse. It is imperative for clinical staff to provide non-judgmental care and support the individual’s health and substance use goals. With a significant dose-related effect of alcohol, even cutting back can make a significant difference in a person's health and symptom burden. Therefore, helping patients understand that their use can occur across a harm reduction spectrum can be very affirming.
• Sobering Centers have been
Treatment and Supportive Services
Treatment options include decreasing, modifying, and stopping alcohol use. It is essential to develop a plan based on the individual’s goals around their use and take into consideration the supports they have to adhere to treatment protocols.
Treatment of Alcohol Withdrawal Syndrome
• Treatment for individuals experiencing alcohol withdrawal syndrome (AWS), often called detox, is typically conducted in an inpatient setting such as medical and psychiatric hospitals, as well as residential treatment programs. However, inpatient settings can serve as a barrier to accessing care, especially if a person has had prior traumatic experiences in an inpatient setting. Outpatient treatment may be an option for certain individuals. Patients should be assessed for ability to understand and adhere to treatment, history of seizures or delirium tremens, and ability to have regular contact with the treatment team to help understand if a person could potentially be supported through detox in an outpatient setting.
• There are special considerations for PEH where the benefits outweigh risks of outpatient withdrawal management. Due to challenges in communication, assess if the person has an active phone with minutes available. Holding medications like benzodiazepines on their person can put them at high risk of assault due to theft, placing them in an unsafe and precarious situation. Consider seeing this person daily for routine assessment, medication distribution, and close communication. This can occur in a clinic setting or having a street medicine team going to the person on a daily basis.
Assess for the following factors associated with increased patient risk for complicated withdrawal:
• History of alcohol withdrawal delirium or alcohol withdrawal seizure
• Numerous prior withdrawal episodes in the patient's lifetime
• Comorbid medical or surgical illness (especially traumatic brain injury)
• Increased age (>65)
• Long duration of heavy and regular alcohol consumption
• The primary medications for AWS are longacting benzodiazepines, especially chlordiazepoxide and diazepam, although lorazepam is preferred in patients for whom there is concern for significant liver disease. xxi Gabapentin, while not a benzodiazepine, has also shown good results in the outpatient setting. Phenobarbital is being used increasingly in hospitalized patients but is not currently recommended in the outpatient setting. Clonidine and Labetalol can be used as adjunct treatments for patients with elevated heart rate or blood pressure but are not recommended for primary treatment. xxii
• Seizure(s) during the current withdrawal episode
• Marked autonomic hyperactivity on presentation
• Physiological dependence on GABAergic agents such as benzodiazepines or barbiturates
*Consider these risks when assessing if a person can safely be managed in an outpatient setting.
• The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale is a validated 10item assessment tool that can be used to quantify the severity of alcohol withdrawal syndrome, and to monitor and medicate patients going through withdrawal.xxiv
Outpatient pharmacologic management of alcohol withdrawal xxiii
CIWA Score <10: Gabapentin
• Day 1: 300 mg orally every 6 hours (1200 mg total daily dose)
• Day 2: 300 mg orally every 8 hours (900 mg total daily dose)
• Day 3: 300 mg orally every 12 hours (600 mg total daily dose)
• Day 4: 300 mg once at night (300 mg total daily dose)
• Additional 300mg tablets can be given for symptom trigged dosing
CIWA Score 10-15 Diazepam or Chlordiazepoxide
Diazepam (Valium) Taper:
• Day 1: 10 mg orally every 6 hours (40 mg total daily dose)
• Day 2: 10 mg orally every 8 hours (30 mg total daily dose)
• Day 3: 10 mg orally every 12 hours (20 mg total daily dose)
• Day 4: 10 mg once at night (10 mg total daily dose)
• Additional 10mg tablets can be given for symptom trigged dosing
Chlordiazepoxide (Librium) Taper:
• Day 1: 50 mg orally every 6 hours (200 mg total daily dose)
• Day 2: 50 mg orally every 8 hours (150 mg total daily dose)
• Day 3: 50 mg orally every 12 hours (100 mg total daily dose)
• Day 4: 50 mg once at night (50 mg total daily dose)
CIWA >15 should be referred for inpatient treatment
Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA) xxiv
Pharmacologic Treatment Options for AUD
Treatment for Alcohol Use Disorder does not require that a person be abstinent from alcohol or other illicit drugs in order to engage in treatment. In addition, individuals may choose to modify their alcohol use while continuing to use other substances.
• Medications for AUD are an important avenue for providers to assist patients who would like to decrease or stop drinking alcohol.
o Naltrexone: A medication that is either given orally (naltrexone) or intramuscularly (vivitrol) that works by reducing the cravings for and reward from alcohol consumption. Individuals do not need to stop drinking before starting naltrexone. Naltrexone is an opioid antagonist, and it cannot be taken together with other opioid agonist medication.
o Acamprosate: An oral medication that is taken to reduce the cravings of alcohol. It is not required that individuals stop using before taking acamprosate although it is typically used to maintain abstinence.
o Gabapentin: An oral medication that can be used for both mild to moderate alcohol withdrawal syndrome as well as for treatment of alcohol use disorder (off-label). For AUD,
dosing is generally 400 mg PO TID. Patients should be cautioned about mixing alcohol and gabapentin due to compounding sedating effects.
o Disulfiram: An oral medication, popularly known under the trade name Antabuse works by preventing metabolism of ethanol’s toxic metabolite acetaldehyde, causing symptoms of nausea, vomiting, flushing, tachycardia, and hypotension. This medication requires daily adherence. If a person drinks alcohol while taking this medication the reaction can cause significant suffering and can be severe enough to necessitate hospitalization, so we recommend against using this as a treatment option for PEH. xxv
Behavioral Treatment Options
• Self-help and recovery-oriented support: Many individuals will seek the support of peers who are also in recovery as part of or their only form of treatment. This may be in the form of peer support groups/meetings, recovery housing, and/or peer mentors/sponsors.
• 12-Step Programs for Addiction are peer-based mutual help programs to support recovery from substance use and other behavioral addictive habits. xxvi Alcoholics Anonymous (AA) is a fellowship model whose goal is to support people’s efforts to achieve and maintain sobriety.
• Cognitive-Behavior Therapy (CBT): The aim of CBT is to teach patients, by roleplay and rehearsal, to recognize and cope with high-risk situations for relapse, and to recognize and cope with craving. CBT has been shown to be effective for AUD alone and even more effective in combination with medication. xxvii
Additional Resources
• US Pharmacist: Treatment of Alcohol Withdrawal Syndrome
• American Family Physician: Outpatient Management of Alcohol Withdrawal Syndrome
• SAMHSA: Finding Quality treatment for Substance Use Disorder
• California Health Care Foundation: Alcohol Management Program Pilots
• California Health Care Foundation: Sobering Centers Explained: And Environmental Scan in California
• Sobering Centers: The National Sobering Collaborative
• The Canadian Managed Alcohol Program Study: Operational Guidance for Implementation of Managed Alcohol for Vulnerable Populations
References
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