Canada gets new guidelines on diagnosing and treating high-risk drinking

At half a bottle of wine a day, Lynn thought of herself as a "casual drinker." The 53-year-old Vancouver resident owns a small business where socializing with alcohol is common.

When she began experiencing symptoms of depression, she chalked it up to social isolation during the COVID-19 pandemic. She got a prescription for antidepressants, but after a few months she saw no sign of improvement.

She did, however, find herself craving alcohol more often.

"I was drinking faster, I was drinking more," she recalled. "I was getting up to go to the liquor store to start my day." (CBC News agreed not to use Lynn's last name because she feared the stigma associated with alcohol use disorder would hurt her business.)

Two papers published in CMAJ Monday underscore the dangers that high-risk alcohol use can pose to people like Lynn. The first explains that high-risk drinking often goes unrecognized and offers guidelines for treating it. And the second shows that certain kinds of antidepressants can drive some alcohol users to drink more.

High-risk drinking often goes unnoticed

Lynn's initial daily intake of half a bottle of wine would make her a high-risk drinker, according to Canada's guidelines on alcohol and health, updated in January. The fact that she considered it "casual" could be a sign of how prevalent this level of drinking has become: more than 50 per cent of people aged 15 and up in Canada drink more than recommended, according to the new guidance released Monday.

(No amount of alcohol is currently considered safe in Canada. To avoid serious health consequences, we're advised to have no more than two drinks a week.)

WATCH | More than 2 drinks per week risky:

New alcohol guidance warns more than 2 drinks per week risky

9 months ago

Duration 3:13

Featured VideoCanada's new alcohol guidance warns that consuming more than two alcoholic drinks per week raises the risk of developing certain cancers, including breast and colorectal, and more than seven drinks a week also increases your risk of heart disease and stroke.

The new findings also show that high-risk drinking often goes unrecognized and untreated, as does alcohol use disorder (AUD) — defined as ongoing use and difficulty controlling drinking, even in the face of consequences.

"On the order of 95 to 99 per cent do not get effective medications for the treatment of craving of alcohol, or medications that can help prevent a relapse to alcohol," said Dr. Evan Wood, co-author of the guidelines released Monday and Canada Research Chair in Addiction Medicine at the University of British Columbia.

The guidelines were developed by a committee of experts and those with lived experience. They're the first national guidelines for high-risk drinking ever published in Canada.

They make 15 recommendations for family physicians, nurse practitioners and other health-care providers, ranging from how to ask about a patient's alcohol use, to how to manage withdrawal symptoms and treat AUD over the long term.

Dr. Tim Naimi, director of the Canadian Institute for Substance Use Research at the University of Victoria and a primary care physician, said we're all on different trajectories when it comes to drinking, but few are asked about it by their family doctors, if they have one.

"There are lots of people who sort of drink to the point of impairment on a pretty regular basis who may not qualify for an alcohol use disorder," said Naimi, who was not involved with the guidelines. "But they're contributing to domestic violence, to injuries, [experiencing] stomach problems."

In 2017 alone, alcohol was linked to 18,000 deaths and cost Canadian health systems $5.4 billion.

Alcohol and SSRIs can be dangerous mix

When Lynn went to her family physician about her depression, she was prescribed a common antidepressant that's in a group of drugs called selective serotonin reuptake inhibitors, or SSRIs. Over six months, her mood didn't improve. But her drinking rapidly escalated.

The feeling of suddenly craving hard liquor scared Lynn. She entered a detox program with Wood, who recommended she taper off her antidepressants. As she did, her AUD symptoms improved.

While Lynn knew alcohol could interfere with medications, she said, she didn't know SSRIs could make alcohol dependency worse.

"I was relating it to stress, anxiety, the pandemic," Lynn said of her increased drinking. "Everything but the SSRIs."

The second paper published in CMAJ on Monday uses a case study to illustrate how "SSRIs may not be effective for depressive symptoms in people with concurrent AUD, and may worsen alcohol use in some."

Psychiatrist David Menkes of Hamilton, New Zealand, has treated and studied interactions between alcohol and medications for 20 years. He says SSRIs prescribed for low mood, anxiety or insomnia can aggravate AUD in some people like Lynn, leading to more cravings and an overwhelming compulsion to drink.

"A lot of these people who don't have their substance use problems assessed or treated often get antidepressants," Menkes said. "The horrible irony … is that it usually doesn't help and it sometimes makes things worse."

The new paper says it is reasonable for doctors to continue SSRIs in people with AUD whose depressive symptoms improve without their drinking increasing. It also recommends documenting a patient's starting point for using substances, including alcohol.

Doctors stress that no one should stop use of SSRIs suddenly.

Lynn took a hard look at her alcohol use once people around her pointed out that she was no longer herself.

After entering detox treatment with Wood, she says, she turned her life around, drawing closer to her husband and improving her career.

Lynn no longer takes any medications. She's been abstinent from alcohol for nearly a year.

Her advice to those watching a loved one struggle with alcohol, or struggling themselves: "Don't be scared to take that first step."