Why Are Alcohol Use Disorder Meds Underprescribed in British Columbia?

    Public health insurance in British Columbia covers some treatments for alcohol use disorder (AUD), but not others. Medications (MAUD) like like naltrexone and acamprosate are considered first-line options, but as few as one in four people with moderate to severe AUD are accessing them.

    Using administrative health data from 2015 to 2019, researchers at the BC Centre on Substance Use and the University of British Columbia tracked MAUD access at community pharmacies. The study, published July 24 in Addiction, is the among the first to analyze long-term treatment retention for AUD.

    The researchers found that AUD was most prevalent among men over 45, but that younger women were the demographic most likely to access MAUD, especially those living in urban centers where the concentration of services is higher than in rural areas. Though provincial health guidelines recommend utilizing MAUD for a minimum of three months, under 5 percent of patients ended up doing so.

    Coauthor Dr. Seonaid Nolan, an addiction medicine physician at St. Paul’s Hospital in Vancouver, said the main barrier is that most health care providers don’t receive any formal addiction medicine training—whether related to alcohol or any other substance.

    “Because of that, they don’t incorporate the screening, diagnosis or management of substance use disorders into their clinical practice,” Nolan told Filter. “It’s a medical education problem.”

    Our interview has been edited for length and clarity.

    “There isn’t an established treatment system.”

    Brishti Basu: Why are so few people with moderate or severe AUD accessing medication, despite it being a recommended first line approach?

    Dr. Seonaid Nolan: Historically, training in addiction medicine has not been integrated into medical education. As a result, there really isn’t a lot of widespread understanding around how to effectively screen for, not just AUD, but all substance use disorder (SUD).

    Because [providers] didn’t receive a lot of training, there’s a level of discomfort … with prescribing these medications. The family physician, for example, doesn’t entirely know what to do in terms of generating a treatment plan. Even among primary care providers, there isn’t an established treatment system [where they can] refer their patients for assessment, if they do identify someone with AUD.

    It would be neglectful, I think, for any health care provider to not have an understanding of how to treat basic medical conditions like diabetes or high blood pressure. My overall goal would be to see SUD at that level where there is an expectation amongst frontline clinicians that they’ve had some degree of exposure and training. And that they incorporate screening, diagnosis and management into their day-to-day clinical practice. 

    I think a lot of it does come down to the medical education curriculum that’s provided to trainees and ensuring that they have the basic skills. The provincial and federal government, the onus on them is to help fund and make training programs available and incorporated into the curriculum.

    And there’s the historical attitude around [alcohol] use being a “lifestyle choice” rather than a chronic [addiction] when compared to, for example, opioids or stimulants. Because alcohol is legal. There is sort of a cultural norm.

    “This is part of the intricacies of treating SUD: There’s no one-size-fits-all approach.”

    What are some of the reasons an eligible patient might not want MAUD?

    The two that we generally use, naltrexone and acamprosate, are actually fairly well tolerated. Both can provide some mild gastrointestinal side effects … perhaps mild nausea, a bit of a headache, some loose stools, but generally both medications are not associated with any sort of significant side effects.

    If someone has a problem with their liver function, naltrexone is not the best medication and we would consider acamprosate. Conversely, if they had kidney troubles we likely would not prescribe acamprosate but would prefer naltrexone instead.

    Naltrexone is once a day, whereas acamprosate is three times a day. For some people, remembering to take medication even once a day can be a challenge. 

    Some people aren’t interested in medications at all, and that’s just personal choice. They’re really keen on things like counseling and 12-step programs, or other sort of non-faith based group programs. Or cognitive behavioral therapy, or motivational interviewing.

    This is part of the intricacies of treating SUD: There’s no one-size-fits-all approach. It really comes down to developing an individualized, tailored management plan. 

    Psychosocial treatment modalities combined with medication have been more effective than just providing medication or psychosocial interventions on their own. Generally we try and offer anything and everything to patients, but the challenge comes down to accessibility of those programs. 

    “It’s impossible to treat SUD without also addressing the other social determinants of health.”

    What are the common barriers? Whether based in bureaucracy or stigma, or both.

    Cognitive behavioral therapy, for example, often isn’t covered through the health care system. That, combined with the underprescribing of medications, has really provided a setting where people with AUD find it quite challenging to access [services].

    It’s impossible to treat someone’s SUD without also addressing the other social determinants of health. If someone is unstably housed, bouncing from shelter to shelter or living on the streets, [medication isn’t necessarily] their first priority. And that’s totally understandable.

    Housing and addiction treatment reside within different ministries in the provincial government. It’s challenging [because] there’s a level of coordination … that’s needed between those ministries.

    We’ve certainly seen an increase in the number of people saying they used alcohol to cope with the pandemic.

    The number of MAUD prescriptions did increase between 2015 to 2019. Does that indicate that the health care system is diagnosing AUD more efficiently? Providers are becoming more informed? Both?

    It may be a combination of both. I don’t know that there would be reason to believe that the prevalence of AUD in the general population has significantly increased during the study time period. I think it probably more relates to the increase in the number of prescribers who are educated and trained in addiction medicine, and the expansion of access to specialty services. Particularly in the urban areas of BC.

    There is some limitation around the health-admin data pertaining to medication use, because … though someone may pick their medication up from the pharmacy, that doesn’t, in fact, mean that they’re taking their medication.

    In my clinical practice, we’ve been providing more prescriptions to help people with their acute withdrawal, but also with their long-term recovery goals. We’ve certainly seen an increase in the number of people who come to [the] clinic stating that throughout the pandemic … alcohol [has been] a coping strategy for a lot of the anxiety and the stress that accompanies those difficult few years.



    Image via United States Department of Veterans Affairs/iStock/RapidEye

    • Brishti reports on health care, drug policy, mental health, policing, race, sexual violence and the intersections between them. She was a finalist for several prestigious national and provincial awards for her work as a Capital Daily staff reporter. Her freelance reporting has been published in publications such as VICE, the Tyee, the Narwhal, National Geographic and BBC Future. She’s based in Victoria, Canada.

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