PRIMARY CARE MANAGEMENT OF ALCOHOL USE DISORDER IN RURAL, REMOTE, AND NORTHERN SETTINGS by Scott Burrell BScN, University of Victoria, 2009 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIRMENTS FOR THE DEGREE OF MASTERS OF SCIENCE IN NURSING – FAMILY NURSE PRACTITIONER UNIVERSITY OF NORTHERN BRITISH COLUMBIA January 2018 © Scott Burrell, 2017 ii ABSTRACT Alcohol consumption is a leading cause of substance-related morbidity and mortality globally. In Canada, there are established Guidelines for Low-Risk Drinking, which are designed to reduce the risk of disease, injury, or death by outlining recommended maximum volumes of, and frequency for, alcohol consumption (Butt, Beirness, Gliksman, Paradis, & Stockwell, 2011). Exceeding the recommended limits places individuals at risk of developing alcohol use disorder (AUD), and subsequently increases the likelihood of alcohol-related adverse health outcomes. In rural, remote, and northern British Columbia (BC), there are significant rates of AUD and alcohol-related morbidity and mortality. In these geographic areas, the responsibility for recognition and treatment of patients with AUD usually resides with the primary care provider. Primary care management of patients with AUD in BC is supported by evidence-based treatment guidelines; however, these guidelines suggest that certain patients may benefit from referral to specialist AUD services, which may be a barrier to treatment in this geographic context. In rural, remote, and northern BC, primary care providers often experience significant barriers to referral of patients outside of the home community, suggesting that the guidelines may be discordant with the realities of AUD treatment in these areas. In order to improve AUD treatment, participation and success within patients’ home communities, an integrative review was conducted to assess the optimum primary care treatment modalities within rural, remote, and northern settings. The findings from this integrative review suggest that there are some modifications to current primary care practice, which could benefit patients with AUD in rural, remote, and northern BC. In order to enhance treatment options for future patients with AUD, recommendations for primary care practice, nurse practitioner education, and further research are proposed. iii TABLE OF CONTENTS Abstract ii Table of Contents iii List of Tables vi List of Figures vii Acknowledgement viii Introduction 1 Chapter One Background Alcohol Use Disorder and Diagnostic Criteria Health Effects Short-Term Health Effects Long-Term Health Effects Fetal Alcohol Spectrum Disorder Financial Costs Alcohol in Canada Who Develops Alcohol Use Disorder? British Columbia Aboriginal Populations in British Columbia Genetics or the Environment Pathophysiology of Alcohol Use Disorder Positive Reinforcement Neurotransmitters and Positive Reinforcement Hypothalmus-pituitary-adrenal Axis and Positive Reinforcement Negative Reinforcement Neurotransmitters and Negative Reinforcement Hypothalmus –pituitary-adrenal Axis and Negative Reinforcement Current Canadian Guidelines for Alcohol Use Disorder Screening and Assessment for Alcohol Use Disorder Counseling for Alcohol Use Disorder Brief Intervention Prescribing Medications for Alcohol Use Disorder Disulfiram Acamprosate Naltrexone Connect to Ancillary and Specialist Services Residential Programs Abstinence with Residential Programs 5 7 9 9 10 12 13 14 15 16 17 18 19 20 21 22 23 23 24 25 27 29 30 32 32 34 35 37 37 38 iv Residential Programs in British Columbia 39 Outpatient Day Programs 40 Abstinence with Outpatient Day Programs 40 Outpatient Day Programs in British Columbia 40 Medical Detoxification 41 Medical Detoxification in British Columbia 42 Addictions Medicine Specialists 42 Addictions Medicine Specialist in British Columbia 43 Support Groups 44 Alcoholics Anonymous 44 Alcoholics Anonymous in British Columbia 45 Health Belief Model 45 Perceived Susceptibility 46 Perceived Severity 46 Perceived Benefit 47 Perceived Barriers 47 Cues to Action 47 Self-efficacy 48 Other Variables 48 Chapter Two Methods Search Strategy Initial Literature Searches Focused Search Analysis of Selected Literature 50 51 52 53 54 Chapter Three Findings Comorbidities Rural Versus Urban Alcohol Use Disorder Screening Primary Care Management of Alcohol Use Disorder Benefits of Primary Care Management Barriers to Primary Care Management Specialist Management of Alcohol Use Disorder Benefits of Specialist Management Barriers to Specialist Management Interventions Applicable to Primary Care Pharmacotherapy Benefits of Pharmacotherapy Barriers to Pharmacotherapy Brief Intervention Benefits of Brief Interventions Barriers to Brief interventions 57 58 62 65 67 67 71 72 72 73 75 75 76 78 80 81 85 Chapter Four Discussion The Health Belief Model and it Applies to the Common Themes 86 86 v Common Themes Drawn from the Literature Regarding the Role of Primary Care Providers in Rural, Remote, and Northern BC Theme One: Screening for Alcohol Use Disorder Theme Two: Brief Intervention Theme Three: Electronically Delivered Counseling Theme Four: Pharmacotherapy Theme Five: Universal Trauma-informed Practice Recommendations for Nurse Practitioner Education Regarding Alcohol Use Disorder Gaps in Current Research Pertaining to Alcohol Use Disorder in Rural, Remote, and Northern Canadian Communities Chapter Five Conclusion 88 89 93 96 99 101 103 109 112 References 115 Appendix 127 vi LIST OF TABLES Table 1 DSM-5 Diagnostic Criteria for AUD 8 Table 2 DSM-5 Diagnostic Criteria for Alcohol Withdrawal 8 Table 3 Recommended Guidelines for Low-Risk Drinking 26 Table 4 MeSH and Keyword Search Terms 53 Table 5 Search Inclusion and Exclusion Criteria 54 vii LIST OF FIGURES Figure 1 Health Belief Model 49 Figure 2 Disposition of Articles 56 viii ACKNOWLEDGMENTS Foremost, I would like to acknowledge my wife Heather’s unwavering love and support. During the course of this project you gave birth to our son, Stanley, and nurtured him with grace and poise, all while supporting my academic commitments. Without you this project would not have been possible. I would also like to express my deepest thanks to my University of Northern British Columbia (UNBC) supervisors Catharine Schiller RN, BScN, MSc, JD, PhD(c) and Dr. Tracey Day DNP NP(F). You were both there for me when I needed you. Your commitment to the success of your students is truly inspiring. Thank you both very much for your endless patience and all of your hard work. 1 INTRODUCTION Alcohol use disorder (AUD) is ubiquitous throughout many parts of the world. In 2012, alcohol consumption accounted for 3.3 million deaths globally and 5.9 percent of all deaths worldwide (World Health Organization, 2014). In comparison, during 2014 there were an estimated 207,400 drug-related deaths globally (excluding alcohol) (United Nations Office on Drugs and Crime, 2016). These numbers demonstrate that the mortality risk posed by alcohol is significantly greater than all other drugs combined. In addition, there is also a significant risk of morbidity associated with excessive alcohol consumption; it has been linked to over 200 injury and disease processes (World Health Organization, 2015). Furthermore, because of the risk of violence and injuries related to intoxication, such as those associated with impaired driving, the health risks associated with alcohol use often extend beyond the individual consumer. Canadians are not exempt from the deleterious effects of excessive alcohol consumption. During 2013, 18.9% of Canadians chronically exceeded the recommended safe amount of alcohol consumption as stated in the Guidelines for Low-Risk Drinking (Butt et al., 2011; Statistics Canada, 2014). Consequently, nearly one in five Canadians are directly at risk of adverse health effects related to alcohol consumption. The impetus for this integrative review stemmed from my personal experiences working as an emergency department registered nurse (RN). During my career as a RN, I worked in emergency departments in the Lower Mainland of British Columbia (BC), and as far north as Whitehorse, Yukon. Regardless of the emergency department’s location, I observed a seemingly endless stream of patients who were either acutely intoxicated with alcohol, or who met the Diagnostic and Statistical Manual of Metal Disorders-V (DSM-V) 2 criteria for AUD (American Psychiatric Association, 2013). During my time working in northern emergency departments, I perceived that alcohol-related health and social dysfunction was disproportionally more prevalent then I had noted in my urban Lower Mainland experience. These acute care experiences lead me to consider how patients with AUD are managed in the primary care setting and whether there are any challenges specifically related to AUD treatment in the north. The resultant research question for this integrative review is: in rural, remote, and northern primary care settings, what is the optimum treatment for adults with AUD? The research question considers primary care settings in general, irrespective of whether the provider is a physician or a nurse practitioner. However, this particular integrative review does address the question from a nurse practitioner’s perspective because the review is a key component of my University of Northern British Columbia Masters of Science Nursing-Family Nurse Practitioner (MScNFNP) degree. To narrow the focus of the research question, a geographical target area was chosen. Northern BC was selected because it exemplifies all of the requisite components of the research question and is the location where my nurse practitioner education was provided. This region is a large, northern geographical area that is sparsely populated and that has a significant prevalence of AUD (British Columbia Ministry of Health, 2013; University of Victoria, 2017a). Since primary care providers are the mainstay of rural health care service provision in BC, such providers are responsible for the majority of AUD screening, diagnosis, and treatment implementation (Slaunwhite & Macdonald, 2015). Furthermore, alcohol-specific services, such as inpatient detoxification units, residential treatment programs, and addictions medicine specialists, are only available in a select few locations in 3 Northern BC (Canada Drug Rehab Addiction Services Directory, 2017; McEachern et al., 2016; Northern Health Authority, n.d.; Slaunwhite & Macdonald, 2015). This combination of attributes makes Northern BC an ideal location to examine rural, remote, and northern primary care treatment of AUD. To begin the integrative review process, I conducted a preliminary literature search to gather relevant articles. This literature search produced a number of articles that addressed key aspects of the research question, but none that addressed it completely. As a result, literature from a variety of sources, both domestic and international, was synthesized to help answer the research question as fully as possible. This literature review is comprised of four chapters, which will systematically address my research question. Chapter One, Background, provides a foundational understanding of AUD, AUD in BC, the current status quo of primary care treatment of AUD within Northern BC, and the Health Belief Model (HBM). Chapter Two, Methods, details the preliminary literature search, the focused search with the application of inclusion and exclusion criteria, and the methodological plan that provided for a comprehensive analysis of the selected literature. A visual representation of the disposition of all articles produced by the literature search is included within this chapter. In Chapter Three, Findings, common themes within the selected articles are identified through the use of a literature review matrix (see Appendix). The literature review matrix provided a standardized format through which the selected articles were evaluated for study attributes, strengths and weaknesses. In Chapter Four, Discussion, the common themes identified within the literature review matrix have been synthesized and applied in the context of rural, remote and northern primary care. The HBM is utilized in this chapter to support the discussion and to 4 substantiate any suggested changes to the current primary care model of AUD treatment. Since the role of nurse practitioners in rural, remote, and northern BC is currently expanding, ideas to enhance nurse practitioner education in the area of AUD are discussed. Lastly, gaps within the current body of evidence are highlighted with the intent of providing stronger evidence for the various AUD treatment modalities within a rural, remote, and northern primary care setting. Chapter Five, Conclusion, revisits the impetus for this integrative review, briefly summarizes the key findings, and closes by highlighting the importance of the nurse practitioner role within the context of rural, remote, and northern AUD treatment. 5 CHAPTER ONE: BACKGROUND Alcohol enjoys a unique social status in Canadian culture that other psychoactive drugs do not. Toasts with alcohol are made at weddings, wakes, and other special occasions, and social gatherings are often centered on “having a drink” with friends and family. The social status of alcohol is fostered by its nearly ubiquitous availability in all regions in Canada (National Alcohol Strategy Working Group, 2007). Subsequently, alcohol is the most utilized psychoactive drug in Canada and is consumed by 80% of the population; this is fourtimes the number of people who use tobacco (Public Health Agency of Canada, 2016). However, not all Canadians who drink alcohol do so in sufficient quantities or with sufficient frequently to increase their risk of health problems. Drinking alcohol in large quantities or for a long duration of time is associated with significant health risks (Alderazi & Brett, 2007; Molina, Gardner, Souza-Smith, & Whitaker, 2014; Public Health Agency of Canada, 2016; Schuckit, 2009). These health risks can be the result of either acute intoxication, which instigates risk taking behaviour, or chronic consumption, which can lead to diseases in nearly every bodily system (Molina et al., 2014). In addition to the significant health risk associated with problematic alcohol consumption, there are also social and financial ramifications that affect the lives of many Canadians. It is estimated that in British Columbia (BC), there are 350,000 individuals who consume problematic amounts of alcohol consistent with AUD (British Columbia Ministry of Health, 2013). These individuals suffer more ill health and consume disproportionally more health care resources that those who abstain from, or consume small amounts of alcohol (Public Health Agency of Canada, 2016). A recent longitudinal study in BC reported that over a 10-year period, approximately 200,000 problematic drinkers were responsible for 6 nearly 700,000 health care visits. The majority of these visits (65%) took place in the primary care setting, with the remainder occurring in emergency departments or in hospitals (Slaunwhite & Macdonald, 2016). Clearly, assessing and treating AUD and its associated the health implications is an import component of primary care practice. Appropriate recognition and treatment has the potential to make a positive difference in the lives of individuals, families, and communities. This chapter will provide background information and context for the research question: in rural, remote, and northern primary care settings, what is the optimum treatment for adults with AUD? A description of AUD, its diagnostic criteria, its negative health effects, and its financial costs to Canadians will be provided. A review of pertinent Canadian statistics for prevalence of AUD will be presented, with a particular emphasis on northern British Columbia (BC). Northern BC was selected as a focus for this integrative review because the population can be classified as rural, remote, and northern, and there is sufficient research available to examine this population in depth. Further, a discussion regarding AUD’s etiology and its associated pathophysiological mechanisms will be presented in detail. An examination of the current Canadian and BC Guidelines will follow, with particular emphasis on variations between the guidelines. The final section of the background will discuss the Health Belief Model (HBM). The HBM is a behavioural change model that has been used since the 1950s (Champion & Skinner, 2008). The HBM helps to predict how likely an individual is to address a potential health problem. This integrative review is focused on improving AUD treatment for individuals who live in rural, remote, or northern communities, and as such, the HBM will be used to help guide treatment recommendations in hopes of successful remission of AUD. 7 Alcohol Use Disorder and Diagnostic Criteria AUD is a pattern of drinking behaviours that impair an individual’s ability to achieve goals and place the individual’s health at risk both in the short- and long-term. Health impacts are extensive but include: psychosis, risk for unintentional trauma, suicide, hypertension, pancreatitis, liver cirrhosis, and multiple types of cancer (Public Health Agency of Canada, 2016). AUD is a Diagnostic and Statistical Manual of Mental Disorders5 (DSM-5) diagnosis with rigid diagnostic criteria (American Psychiatric Association, 2013). It is a novel term that replaced the terms alcohol abuse and alcohol dependence found in the DSM-4 (American Psychiatric Association, 1998). AUD encompasses all of the previous diagnostic criteria for both alcohol abuse and alcohol dependence, with an additional criterion for cravings. However, it should be noted that some of the literature included in this review may still utilize the antiquated terminology because it was published prior to the release of the DSM-5. AUD is defined as, “a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following [diagnostic criteria], occurring within a 12-month period” (American Psychological Association, 2013, p. 490). Please refer to Table 1 for the list of diagnostic criteria for AUD. A key component of the AUD diagnostic criteria is the presence of withdrawal symptoms, such as tremors and anxiety, when drinking is reduced or stopped. Table 2 provides the diagnostic criteria for alcohol withdrawal. The presence of withdrawal symptoms is an important component for the diagnosis of AUD because they not only indicate more severe disease, but also pose a risk to the individual’s safety. The severity of AUD is graded in relation to the number of criteria present from Table 1. Mild AUD requires two or three criteria, moderate AUD 8 requires four or five criteria, and severe AUD requires six or more criteria (American Psychiatric Association, 2013). Table 1 DSM-5 Diagnostic Criteria for AUD 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either of the following: • A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. • A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: • The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B the criteria set for alcohol withdrawal [see Table 2]. • Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms. (American Psychiatric Association, 2013, pp. 490–491) Table 2 DSM-5 Diagnostic Criteria for Alcohol Withdrawal A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after the cessation (or reduction in) alcohol use described in Criterion A: • Autonomic hypersensitivity (e.g. sweating or pulse rate greater than 100bpm). • Increased hand tremor. • Insomnia. • Nausea or vomiting. • Transient visual, tactile, or auditory hallucinations or illusions. • Psychomotor agitation. • Anxiety. • Generalized tonic-colonic seizures. 9 C. The signs or symptoms of Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs and symptoms are not attributed to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. (American Psychiatric Association, 2013, pp. 499–500) Health Effects Alcohol use has potential health implications in the setting of both short- and longterm consumption. In the short-term, health impacts are positively correlated with the degree of impairment, and are dose-dependent on a single occasion. Whereas, for long-term consumption patterns, health impacts are associated with end organ damage over time and the development of dependence (Butt et al., 2011) Long-term alcohol exposure is positively correlated with the volume and duration of alcohol consumption (Butt et al., 2011; World Health Organization, 2014). To best facilitate early recognition and treatment, it is imperative that primary care providers remain vigilant for both the short- and long-term adverse effects of alcohol consumption because patients may present with either in the clinical setting. Specific details associated with short- and long-term consumption will be discussed more below. Short-Term Health Effects Short-term health effects are primarily linked to cognitive and psychomotor impairment, precipitating harm to the individual drinker as well as others. Homeostatic suppression due to the sedating effects of alcohol poses a risk for hypoventilation, aspiration, hypothermia, and death (Public Health Agency of Canada, 2016). Lay-people often refer to this state as “alcohol poisoning,” which, if left untreated, can result in permanent brain damage or even death. Violent acts against self and others, including up to 30% of all 10 suicides in Canada, are also associated with alcohol intoxication (Public Health Agency of Canada, 2016; World Health Organization, 2014). However, driving while intoxicated by alcohol is likely the most publicly recognized short-term health risk. In BC, 35% of motor vehicle incident-related fatalities are attributed to impairment, primarily with alcohol (British Columbia Coroners Service, 2015). Other vehicle passengers, pedestrians, bicyclists, and other road users are also at significant risk of fatal harm from impaired drivers. Although mortality rates have improved since the 1980s, impaired driving continues to be a significant health risk today (Public Health Agency of Canada, 2016). Non-fatal injuries also represent a substantial concern in BC. In 2007 there were 2990 impaired driving related injuries in BC, representing a significant amount of morbidity, human suffering, health care resource consumption, and lost wages (BC Injury Research and Prevention Unit, 2017). Long-Term Health Effects Long-term health effects tend to be more difficult to directly attribute to the consumption of alcohol, and instead, researchers must rely on epidemiology for correlation. Epidemiological studies have helped to causally link a number of health conditions to longterm alcohol consumption. These conditions include neurological, psychiatric, gastrointestinal, cardiovascular, and neoplastic diseases, which have high rates of morbidity and mortality (Public Health Agency of Canada, 2016). Many of the alcohol-associated conditions are quite severe, demonstrating the importance of proactive treatment in the primary care setting. Neurological and psychiatric conditions, including epilepsy, withdrawal seizures, anxiety, and depression, are all causally linked to long-term alcohol use (World Health 11 Organization, 2014). A change in an individual’s neurological and psychiatric capacity alters their ability to function in society, maintain employment, and to meet personal or family obligations. This alteration means that alcohol consumption affects not only the drinker, but also the greater community and support systems around them. Gastrointestinal disorders, most prominently liver cirrhosis, pancreatitis, and gastric ulcers are also causally linked to long-term alcohol use (Canadian Centre on Substance Abuse, 2014; Public Health Agency of Canada, 2016; World Health Organization, 2014). Morbidity and mortality are significant, especially for liver disease that has progressed to the point of decompensated cirrhosis (Martin, DiMartini, Feng, Brown, & Fallon, 2014). Hospitalization is usually required, and without liver transplantation, life expectancies are short (Martin et al., 2014). Cardiovascular diseases, such as stroke, myocardial infarction, and hypertension are also linked to long-term alcohol exposure (Public Health Agency of Canada, 2016; World Health Organization, 2014). These conditions are noted in patients who chronically exceed the Guidelines for Low-Risk Drinking (Table 3), and they represent significant sources of morbidity and mortality. However, there is some controversy regarding the cardiovascular effects of alcohol consumption. Some research suggests that low-dose alcohol can actually be cardioprotective and help to reduce the incidence of myocardial infarction, and stroke (Roerecke & Rehm, 2012). Cardioprotection is found in some, but not all epidemiological studies, and there is insufficient evidence to justify advocacy for prescriptive drinking (Roerecke & Rehm, 2012). Other significant health effects that show positive associations with long-term alcohol use include cancers of the mouth, throat, liver, breast, and digestive tract, as well as diabetes 12 and infectious diseases (Canadian Centre on Substance Abuse, 2014; Public Health Agency of Canada, 2016; World Health Organization, 2014). Patients suffering from any one of the health effects listed above tend to have a lower quality of life and will likely require greater amounts of health care services, with a large portion requiring specialist care. Overall, the social and systemic burdens of long-term drinking behaviours are severe. Addressing these health effects and their root causes needs to be a top priority for the public and for primary care providers alike. Fetal Alcohol Spectrum Disorder Pregnant women are a population of particular concern because of alcohol’s deleterious effects on unborn fetuses. Maternal consumption of alcohol places the fetus at high-risk for a spectrum of physical, emotional, behavioural, and neurological derangements, referred to as Fetal Alcohol Spectrum Disorder (FASD) (Cook et al., 2016; Public Health Agency of Canada, 2010). Although there is no known absolute volume of maternal alcohol consumption that precludes teratogenic effects in the fetus, larger volumes and greater frequency have been found to increase the risk to the fetus (Canadian Centre on Substance Abuse, 2014; May & Gossage, 2011; Public Health Agency of Canada, 2016; World Health Organization, 2014). Depending on the severity of FASD, children may have lifelong disabilities and may require more societal and familial resources throughout their lives (Public Health Agency of Canada, 2010). In the general Canadian population, approximately 14% of fetuses are exposed to alcohol, with some populations reaching exposure rates of 60% (Popova, Lange, Burd, & Rehm, 2015). Maternal alcohol ingestion does not necessarily result in FASD, as demonstrated by the Canadian FASD prevalence of approximately 1%, although certain 13 rural, remote, and northern communities FASD has been reported up to 20% (Popova et al., 2015). There is a significant challenge in breaking the cycle for the next generation (Popova et al., 2015). The prevalence of FASD, especially in some of these communities, places a significant burden on families, communities, and the health care system. FASD prevalence is a key indicator that expectant mothers need to be a top priority when considering treatment for alcohol consumption. Financial Costs In Canada, alcohol is legally sold through provincial and territorial controlled distribution systems (Thomas, 2012). This means that the money raised through taxation and costs incurred, through health care and other indirect expenses, moves in and out of the same governmental coffers. The last detailed breakdown of the financial burden of alcohol in Canada was for the year 2003 (Rehm et al., 2006). At that time, the nation-wide total cost attributed to alcohol consumption was 14.6 billion dollars (Rehm et al., 2006). Although direct health care costs were the largest single expenditure at 3.3 billion dollars, law enforcement costs were a close second at 3.1 billion dollars (Thomas, 2012). By far, the largest cost associated with AUD in Canada is lost productivity at work, accounting for 7.1 billion dollars (Thomas, 2012). Causes of lost productivity include: long-term disability, short-term disability, and premature death (Thomas, 2012). Additional costs associated with alcohol included traffic accident damage, fire damage, administrative costs, prevention and research, and losses associated with workplace damage (Public Health Agency of Canada, 2016). Alcohol sales do generate tax revenue in Canada; however, the revenue generated is not enough to offset the associated costs (Public Health Agency of Canada, 2016; Thomas, 14 2012). The significant costs associated with alcohol consumption could be partially mitigated with appropriate treatment of AUD, thereby saving Canadians billions of dollars. Financial analysis provides objective evidence for the short- and long-term harms associated with alcohol use. However, the analysis is limited in its scope, and may be grossly underestimated, because it does not take into account the downstream costs of lost productivity for individuals, families, and communities. Alcohol in Canada Except for caffeine, alcohol is the most commonly used psychoactive substance in Canada (Public Health Agency of Canada, 2016). The Canada Centre on Substance Abuse (2014) reports that 70% of people aged 15 to 24, and 80% of people aged 25 and older used alcohol in the past year. These statistics are not directly indicative of AUD, but they clearly demonstrate the ubiquitousness of alcohol use in the Canadian culture. The prevalence of alcohol consumption in Canada may be partially attributed to its ease of access. All jurisdictions in Canada maintain governmental control over the sale of wholesale alcohol, which means that prices are uniformly set within each province or territory (Thomas, 2012). This means that a given bottle of alcohol costs the same in a port city as it does in a rural, remote, or northern community. This price-fixing makes alcohol seem relatively less expensive when compared to other essential food and drink commodities because, unlike those, alcohol prices are unaffected by transport costs (National Alcohol Strategy Working Group, 2007; Thomas, 2012). Governmental control over alcohol sales was originally instituted in order to limit the physical availability of alcohol, and to ensure that social responsibilities were not subordinated by financial pressure; however, in today’s 15 society this price-fixing facilitates relatively easier access for those in rural, remote, and northern communities (National Alcohol Strategy Working Group, 2007). Alcohol holds a prominent status in the social fabric of Canadian culture, likely contributing to Canadians consuming more alcohol than is considered safe or at least without deleterious effect (Public Health Agency of Canada, 2016). Alcohol is often consumed in celebration or at social gatherings, and there is often an expectation among peers that social events will involve drinking alcohol. In Canada, drinking alcohol is viewed as being generally acceptable, which promotes consumption and can lead to people feeling as though they are obligated to drink (Public Health Agency of Canada, 2016). The social consumption of alcohol is not considered a health risk; however, when alcohol is pervasive in Canadian culture, it further normalizes drinking and can promote transition into unhealthy and longerterm drinking behaviours. Ultimately, this results in negative health outcomes and increased pressures on the Canadian health care system. Who Develops Alcohol Use Disorder? Individuals who develop AUD may do so for a multitude of reasons. In Canada, the rate of alcohol consumption varies based on sex, age, and geographical location (Statistics Canada, 2016b). In 2013, 18.9% of Canadians over the age of 12 were considered heavy drinkers because they exceeded the amounts defined in the Guidelines for Low-Risk Drinking (Table 3) at least once per month over the preceding year (Statistics Canada, 2014). Nearly one in five Canadians in this age category expose themselves to increased health and safety risks due to alcohol consumption. Among heavy drinkers, the majority were between 18 and 54 years of age and there were twice as many males as females (Statistics Canada, 2014, 2016b). This indicates that AUD in Canada typically affects relatively young and 16 predominantly male individuals. Since young males access health care more infrequently than other demographic categories, identification of AUD and their subsequent treatment may occur later in the disease process than for other individuals (Navarro, Shakeshaft, Doran, & Petrie, 2011). The prevalence of heavy drinking in Canada is concerning for both its short- and long-term health implications. Moreover, rural, remote, and northern populations display elevated rates of heavy drinking and risky drinking behaviours than the general Canadian population, placing them at greater risk for poor health outcomes. In Canada, Aboriginal peoples comprise a significant percentage of the rural, remote and northern populations and appear to suffer disproportionately heavier drinking than their non-aboriginal counterparts (Statistics Canada, 2016a). Subsequently, Aboriginal peoples are placed at increased risk for negative health outcomes associated with heavy drinking. British Columbia The prevalence of heavy drinking is 16.1% in BC, making it one of the few provinces below the Canadian median of 18.9% (Statistics Canada, 2016b). In 2014, the median per capita consumption in BC was 8.95L of absolute alcohol consumption per year (1 liter of alcohol equals 85 standard drinks), which is below the recommended amounts set out in the Guidelines for Low-Risk Drinking (Table 3) (Butt et al., 2011; University of Victoria, 2017a). Within BC, there are regional variations in alcohol consumption that demonstrate differences between the mostly urban Lower Mainland and the remainder of the province. The lowest per capita consumption of alcohol in BC that year was in the Southern Vancouver Coastal Health and Fraser Health Authorities, measuring 8.5L and 6.52L per capita 17 respectively (University of Victoria, 2017a). These two Health Authorities account for more than 60% of the total BC population and only a small portion of the geographical area of the province (Foster, Keller, McKee, & Ostry, 2011). The rural, remote, and northern populations in BC drank the most, with the Northern Vancouver Coastal Health Authority drinking the most at 15.6L per capita (University of Victoria, 2017a). This is well above the Guidelines for Low-Risk Drinking (Butt et al., 2011). The Interior and Northern Health Authorities each respectively drank 12.25L and 11.18L per capita, which is at, and even just above, the Low-Risk Drinking threshold (University of Victoria, 2017a). When considering alcohol-related harm in BC, the statistics demonstrate that rural, remote, and northern populations are at greater risk. Hospitalizations linked to alcohol in the Northern and Interior Health Authorities were 732 and 798 per 100,000 people respectively; whereas, they were 366 and 393 per 100,000 people in the more urban Fraser Health and Vancouver Coastal Health Authorities (University of Victoria, 2017b). Mortality rates linked to alcohol were similarly elevated away from the urban areas of the Lower Mainland. In the Interior and the Northern Health Authorities, deaths were 43 and 34 per 100,000 people respectively while, in the Fraser Health and Vancouver Coastal Health Authorities, rates were both 19 per 100,000 people (University of Victoria, 2017b). There is no reported reason for the increased incidence of mortality in these regions; however, mortality rates are important because they demonstrate the ultimate objective harm associated with drinking, and portray the seriousness of AUD-related harm. Aboriginal Populations in British Columbia Aboriginal peoples – First Nations, Inuit, and Métis – comprise approximately 5% of the total population of BC (Foster et al., 2011). Of the total Aboriginal population, the 18 majority live outside of the Lower Mainland, and approximately one third live in the northwestern portion of the province (Foster et al., 2011). When surveyed, Aboriginal populations were found to have a greater prevalence of heavy drinking than non-Aboriginal Canadians (Statistics Canada, 2015). An estimated 35% of off-reserve Aboriginal people exceeded the Guidelines for Low-Risk Drinking at least once per month in the 12 month period preceding the survey (Statistics Canada, 2015). This number far exceeds the 18.9% total Canadian median, which highlights the prevalence of AUD in the rural, remote, and northern communities. On-reserve Aboriginals reported weekly heavy drinking rates of 16% (Public Health Agency of Canada, 2011). This number appears significant but, unfortunately, there is not an equivalent measurement between on- and off- reserve alcohol drinking, limiting the possibility of a direct comparison. However, 82.6% of on-reserve Aboriginal respondents rated alcohol use as the primary wellness challenge for their communities, followed by housing and then employment (Canadian Centre on Substance Abuse, 2017). Considering that the vast majority of on-reserve Aboriginal people consider alcohol use to be the primary problem in their communities, it is clearly a topic worthy of further consideration. Genetics or the Environment Understanding the circumstances that precipitate the development of AUD will help researchers cultivate new and more appropriate treatment modalities. Both genetic and environmental factors have been linked to the development of AUD, but neither have shown definitive, independent causation (Van Der Zwaluw & Engels, 2009). Twin studies have demonstrated a 58% heritability rate for developing the AUD phenotype, indicating that genetics alone does not explain AUD’s etiology. There is likely an interaction between 19 genetics and environment that provides a more comprehensive etiological understanding (Van Der Zwaluw & Engels, 2009). The WHO concurs that there is no single dominant risk factor that guarantees an individual will develop AUD, but rather, that an accumulation of risk factors increases the likelihood of developing AUD (Schmidt, Mäkelä, Jürgen, & Room, 2010). Among environmental exposures, lower socioeconomic status, exposure to alcohol prior to 15 years of age, familial history of AUD, and regulatory control of alcohol are leading risk factors for the development of AUD (World Health Organization, 2014). None of these risk factors are necessarily pathognomonic for AUD; however, the chance of developing AUD increases with each additional environmental risk factors (Schmidt et al., 2010). Moreover, genetics may also play a role in susceptibility to AUD because there may be genetic predispositions that increase the individual’s susceptibility to their environment (Van Der Zwaluw & Engels, 2009). For example, lower socioeconomic status is inversely correlated with the potential of AUD development, but not all people of low socioeconomic status will develop AUD (World Health Organization, 2014). Although both genetics and environmental circumstances play significant roles in the development of AUD, in most cases it is the combination of risk factors that ultimately determines their susceptibility. Pathophysiology of Alcohol Use Disorder In order to provide comprehensive care for patients with AUD, it is important for the primary care provider to have an understanding of the pertinent pathophysiological processes involved. A greater understanding of the pathophysiology will assist the primary care provider in selecting an appropriate treatment modality. An additional reason to review the pathophysiology of AUD is because patients with AUD are exposed to higher rates of 20 marginalization by some health care providers, and patients may be inappropriately dismissed when seeking treatment (Allan, 2010; Slaunwhite & Macdonald, 2015). This marginalization can act as a barrier to care and can cause missed opportunities for change. Understanding and appreciating the pathophysiology legitimizes AUD for health care providers, and fosters empathy for patients seeking care. Like many addiction processes, AUD is thought to be the result of complex interactions between a person’s genetic predisposition and the environment that is unique to that individual’s life (Schuckit, 2009; Wackernah, Minnick, & Clapp, 2014). These interactions result in biological adaptations, primarily in the neurological and endocrine systems, which reinforce drinking behaviours and can ultimately result in the development of AUD. Reinforcement is a term used in addiction literature to describe the formation of behaviours in relation to the individual’s previous experiences (Gilpin & Koob, 2008). Reinforcement can be either positive or negative; meaning, the behaviour is motivated by a pleasing experience or by the avoidance of an adverse experience. The biological mechanisms for AUD will be discussed below in terms of positive and negative reinforcement. Positive Reinforcement Positive reinforcement plays a critical role in the development of AUD because it creates the desire to seek out the rewarding feelings associated with alcohol ingestion. The positive reinforcing features associated with acute alcohol ingestion are feelings of euphoria, intoxication, generalized neuronal inhibition, sedation, and muscle relaxation (Gilpin & Koob, 2008; Schuckit, 2009; Wackernah et al., 2014). With chronic alcohol exposure, alcohol tolerance is developed; therefore, progressively larger doses of alcohol are needed to 21 produce the same functional, metabolic, and positive reinforcing effects (Gilpin & Koob, 2008). These effects are achieved through a variety of neurotransmitters including dopamine, serotonin, endogenous opioids, ϒ-aminobutyric acid (GABA), and glutamate, as well as through modulation of the hypothalamus-pituitary-adrenal (HPA) axis. Neurotransmitters and positive reinforcement. In the central nervous system, dopamine is considered to be one of the primary neurotransmitters associated with reward. Acute exposure to alcohol creates a sense of euphoria by indirectly stimulating dopaminergic release from the ventral tegmental area into the nucleus accumbens, which is part of the mesolimbic system (Gilpin & Koob, 2008; Schuckit, 2009; Stephens & Wand, 2012). This dopaminergic activity is likely mediated through alternate neurotransmitter pathways including serotonin, endogenous opioids, GABA, and N-methyl-D-aspartate (NMDA) (Gilpin & Koob, 2008). Serotonin is associated with positive reinforcement primarily by promoting sedation (Marcinkiewcz, 2015). Although serotonin is less strongly associated with reward than dopamine, increased concentrations of serotonin are observed in the presence of alcohol, indicating some mediation of the reward pathways (Marcinkiewcz, 2015). Acute exposure to alcohol also stimulates the central and peripheral release of endogenous opioids, such as endorphins, enkephalins, and dynorphins (Gilpin & Koob, 2008; Wackernah et al., 2014). These opioids are associated with reward and independently stimulate the release of dopamine (Schuckit, 2009). The combination of endogenous opioids and dopamine significantly contribute to the euphoric effects of alcohol and are thought to be part of the main stimuli for individuals to seek out alcohol (Gilpin & Koob, 2008). 22 Alcohol also acts on GABA receptors, which are considered the primary inhibitory neurotransmitters in the central nervous system (Gilpin & Koob, 2008). Alcohol increases GABA release from pre-synaptic neurons and increases sensitivity to GABA stimulation in post-synaptic neurons (Gilpin & Koob, 2008). GABAminergic activity contributes to sedation, muscle relaxation, and intoxication, which are all positive reinforcement traits. Conversely, alcohol has an inhibitory effect on glutamate, which is the primary excitatory neurotransmitter in the central nervous system (Gilpin & Koob, 2008). Within the glutamate system, the NMDA receptor is particularly affected by the acute ingestion of alcohol, and when suppressed, contributes to generalized neuronal inhibition and positive reward (Gilpin & Koob, 2008; Wackernah et al., 2014). Hypothalamus-pituitary-adrenal axis and positive reinforcement. The HPA axis is one of the primary metabolic pathways in the body and it plays a key role in the stress response (Rachdaoui & Sarkar, 2013). Hormones communicate between the hypothalamus, the pituitary gland, and the adrenal glands in response to stressors. Corticotropin-releasing hormone (CRH) is secreted by the hypothalamus, causing the pituitary to secrete adrenocorticotropic hormone (ACTH), which triggers the adrenal gland to release glucocorticoids – primarily cortisol (Molina et al., 2014; Rachdaoui & Sarkar, 2013). Cortisol is chiefly responsible for restoration of homeostasis during a stress response (Molina et al., 2014; Rachdaoui & Sarkar, 2013). Cortisol is also required for the function of cognitive processes including learning, memory, and decision making (Stephens & Wand, 2012). Alcohol ingestion causes a dose-dependent activation of the HPA axis, which correspondingly increases cortisol levels (Rachdaoui & Sarkar, 2013). In addition to 23 modulation of the stress response and facilitation of cognitive processes, it is postulated that cortisol stimulates dopaminergic activity and contributes to positive reinforcement (Stephens & Wand, 2012). Negative Reinforcement Negative reinforcement is an important component of the transition from low-risk drinking to AUD. As tolerance to alcohol builds, motivation to drink can change from seeking out positive reinforcement to avoiding negative reinforcement. Negative reinforcement is associated with the avoidance of withdrawal symptoms including tremors, sweating, anxiety, and dysphoria (American Psychiatric Association, 2013; Gilpin & Koob, 2008). With increased tolerance to alcohol, changes are noted in the dopamine, serotonin, GABA, and glutamate neurotransmitter systems, as well as the in the HPA axis. These systems become reliant on the presence of alcohol for normal homeostatic function and they become dysfunctional in the absence of alcohol, precipitating negative symptoms. Neurotransmitters and negative reinforcement. As discussed above, dopamine is the neurotransmitter primarily responsible for reward in the central nervous system. Long-term indirect stimulation causes the release of dopamine to become dependent on the ingestion of alcohol (Gilpin & Koob, 2008). Without the presence of alcohol, a relatively hypodopaminergic state is created, causing dysphoria and withdrawal symptoms (Table 2) (Gilpin & Koob, 2008). Individuals who experience adverse symptoms are motivated to reestablish normal dopamine levels through alcohol consumption, leading to relapse and further health risks (Stephens & Wand, 2012). The mechanism for dopamine modulation is by up-regulation of NMDA receptors and decreased function of GABA receptors, likely through down-regulation (Koob, 2011; Wackernah et al., 2014). Since these two 24 neurotransmitters are respectively responsible for neuronal excitation and inhibition, the balance is shifted towards a state of hyperexcitability (Wackernah et al., 2014). This is acutely manifested as tremors, anxiety, nausea, and dysphoria during alcohol withdrawal (Wackernah et al., 2014). With chronic exposure to alcohol, serotonin function is also modulated. Overall, serotonin is down-regulated in the central nervous system, meaning that serotonergic activity becomes reliant on the presence of alcohol for normal functioning (Marcinkiewcz, 2015). Decreased sensitivity to serotonin leads to increased alcohol-seeking behaviours and promotes relapse (Marcinkiewcz, 2015). However, serotonin function is up-regulated in the amygdala, the area of the brain associated with habit formation, and is correlated with anxniogenesis during withdrawal (Marcinkiewcz, 2015; Stephens & Wand, 2012). GABA dysfunction and glutamate up-regulation are also thought to contribute to both the anxiety associated with withdrawal and with the alcohol cravings (Gilpin & Koob, 2008; Wackernah et al., 2014). Hypothalamus-pituitary-adrenal axis and negative reinforcement. With long-term alcohol use and tolerance, adaptations can be observed in the HPA axis. The HPA axis becomes blunted, leading to decreased CRF, ACTH, and cortisol levels (Molina et al., 2014). This results in diminished homeostatic responses to both physical and psychological stressors (Molina et al., 2014; Rachdaoui & Sarkar, 2013; Stephens & Wand, 2012). The resulting relative cortisol deficiency negatively affects the dopamine reward system and impairs the stress response, which leads to feelings of dysphoria and cognitive impairment (Stephens & Wand, 2012). This negative reinforcement is postulated to be one of the reasons that people with AUD often relapse soon after stopping drinking. 25 Current Canadian Guidelines for Alcohol Use Disorder Practice guidelines are designed to support health care providers by providing evidence-based recommendations for assessment, diagnosis, and treatment for a variety of health conditions. Guidelines condense a large body of evidence into usable recommendations for practice. Guidelines are also useful to inform policy makers as well as those members of the public who wish to educate themselves on a particular issue. Specific to the assessment and/or treatment of individuals with AUD, there are three pertinent guidelines included in this integrative review. They are the Canadian Centre for Substance Abuse’s Guidelines for Low-Risk Drinking (Butt et al., 2011), the BC Guidelines for Problem Drinking (British Columbia Ministry of Health, 2013), and the Canadian Family Physician Guidelines (Canadian Guidelines) (Spithoff & Kahan, 2015b, 2015c). In light of the significant health impact associated with drinking alcohol, the Canadian Centre on Substance Abuse created the Guidelines for Low-Risk Drinking (Table 3) (Butt et al., 2011). The intent was to mitigate short- and long-term harms and to reduce the prevalence of alcohol tolerance (Butt et al., 2011). This guideline can be used by health care practitioners, policy makers, and to inform the creation of subsequent clinical guidelines. The Guidelines for Low-Risk drinking are pertinent to both the BC and Canadian Guidelines, and aid primary care practitioners in the assessment of patients who drink alcohol. 26 Table 3 Recommended Guidelines for Low-Risk Drinking Guideline 1 When operating any kind of vehicle, tools or machinery; Do not drink in these using medications or other drugs that interact with alcohol; situations: engaging in sports or other potentially dangerous physical activities; working; making important decisions; if pregnant or planning to be pregnant; before breastfeeding; while responsible for the care or supervision of others; if suffering from serious physical illness, mental illness or alcohol dependence. Guideline 2 Women Men 0–2 standard drinks* per day 0–3 standard drinks* per day If you drink, reduce longNo more than 15 standard term health risks by staying No more than 10 standard drinks per week within these average levels: drinks per week Always have some non-drinking days per week to minimize tolerance and habit formation. Do not increase drinking to the upper limits as health benefits are greatest at up to one drink per day. Do not exceed the daily limits specified in Guideline 3. Guideline 3 Risk of injury increases with each additional drink in many If you drink, reduce shortsituations. For both health and safety reasons, it is important term risks by choosing safe not to drink more than: situations and restricting • Three standard drinks* in one day for a woman your alcohol intake: • Four standard drinks* in one day for a man Drinking at these upper levels should only happen occasionally and always be consistent with the weekly limits specified in Guideline 2. It is especially important on these occasions to drink with meals and not on an empty stomach; to have no more than two standard drinks in any three-hour period; to alternate with caffeine-free, non-alcoholic drinks; and to avoid risky situations and activities. Individuals with reduced tolerance, whether due to low bodyweight, being under the age of 25 or over 65 years old, are advised to never exceed Guideline 2 upper levels. Guideline 4 The safest option during pregnancy or when planning to When pregnant or planning become pregnant is to not drink alcohol at all. Alcohol in to be pregnant: the mother's bloodstream can harm the developing fetus. While the risk from light consumption during pregnancy appears very low, there is no threshold of alcohol use in pregnancy that has been definitively proven to be safe. Guideline 5 Alcohol can harm healthy physical and mental development Alcohol and young people: of children and adolescents. Uptake of drinking by youth should be delayed at least until the late teens and be consistent with local legal drinking age laws. Once a decision to start drinking is made, drinking should occur in a safe environment, under parental guidance and at low levels (i.e., one or two standard drinks* once or twice per week). 27 From legal drinking age to 24 years, it is recommended women never exceed two drinks per day and men never exceed three drinks in one day. Note. * A "standard drink" is equal to a 341 ml (12 oz.) bottle of 5% strength beer, cider or cooler; a 142 ml (5 oz.) glass of 12% strength wine; or a 43 ml (1.5 oz.) shot of 40% strength spirits (NB: 1 Canadian standard drink = 17.05 ml or 13.45 g of ethanol). 2 Copyright (c) Canadian Centre on Substance Abuse. All rights reserved. Reproduced with permission from the Canadian Centre on Substance Abuse. The BC Guideline (2013) includes recommendations for screening, assessment, counseling, office-based alcohol withdrawal, and prescription medication for alcohol dependence. This guideline is user-friendly but despite being released in the same year as the change was made to the novel term of AUD, it employs the antiquated terms of alcohol abuse and alcohol dependence. The most recent Canadian guideline for AUD treatment in the primary care setting is a non-systematic review series published in the Journal of the Canadian Family Physician (Spithoff & Kahan, 2015b, 2015c). Spithoff and Kahan (2015b, 2015c) recommend a similar process to the British Columbia Ministry of Health guideline; screening and assessment, counseling, prescription of medication, and connection to auxiliary or specialized services. Each category of these two guidelines will be reviewed with pertinent comparisons and contrasts. Screening and Assessment for Alcohol Use Disorder Diagnosing AUD in the primary care setting is a universal challenge experienced by primary care providers. There is a finite amount of time available per patient, and providers have to balance the patients’ priorities with a multitude of health maintenance demands. The Canadian recommendation is for at least yearly screening of all primary care patients regardless of demographics, whereas the BC Guideline suggests screening for those 19 years of age and older if there is clinical suspicion of at-risk drinking or AUD (Spithoff & Kahan, 28 2015b). Relevant clinical suspicions in this context would include patients who present with medical, psychological, and/or psychosocial problems potentially linked to alcohol use (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015b). The consensus in the literature is that consistent annual screening for alcohol problems is more successful than targeted screening only (National Institute on Alcohol Abuse, 2005; Navarro et al., 2011; Solberg, Maciosek, & Edwards, 2008; Spithoff & Kahan, 2015b). Meta-analysis shows that without universal screening, primary care providers’ diagnostic sensitivity for AUD detection is 41.7% (Mitchell, Meader, Bird, & Rizzo, 2012). Primary care screening rates are reported to be between 2% and 50%, which indicates that more diagnoses of AUD could be made by increasing screening rates (Bendtsen et al., 2015; Enoch & Goldman, 2002; Johnson & Seale, 2015). Primary care screening for unhealthy drinking consists of a step-wise questioning process. Initially patients should be screened using a validated single question (Spithoff & Kahan, 2015b). The most validated question for screening is: how many times in the past year have you had four or more drinks (women), or five or more drinks (men) in a single day (Smith, Schmidt, Allensworth-Davies, & Saitz, 2009; Spithoff & Kahan, 2015b)? This single question is 82% sensitive and 79% specific for indicating unhealthy drinking (Smith et al., 2009). If this question is positive, the provider should move on to the 10-question Alcohol Use Disorders Identification Test (AUDIT), 3-question AUDIT test, or the cut-downannoyed-guilt-eye-opener (CAGE) questionnaire (Spithoff & Kahan, 2015b). The AUDIT-10 is 92% sensitive and 94% specific, the AUDIT-3 is 86% sensitive and 72% specific, and the CAGE is 71% sensitive and 90% specific (Schorling, 2005; Spithoff & Kahan, 2015b). If the screening questions are positive, the provider should refer to the DSM-V diagnostic criteria 29 and proceed to more detail questioning. The BC Guideline provides example questions that follow the DSM-IV diagnostic criteria and thus would be particularly helpful for primary care providers, although there are no questions pertaining to cravings for alcohol as this was not added until the DSM-V (American Psychiatric Association, 1998; British Columbia Ministry of Health, 2013) Screening and assessment tests for AUD are heavily reliant on the patient to report the truth of their situation. Patients who are motivated to evade providers’ questions will likely be successful and thereby remove themselves from the possibility of effective treatment. As a result, the effectiveness of the screening tools relies solely on the individual’s honesty with self-reporting. Counseling for Alcohol Use Disorder Once a diagnosis of AUD has been made according to the DSM-V diagnostic criteria, the patient should be informed of the diagnosis and offered counseling sessions with frequent follow-up appointments (American Psychiatric Association, 2013; Spithoff & Kahan, 2015c). The BC Guideline recommends that primary care providers use the brief intervention counseling technique for all patients with alcohol abuse or alcohol dependence (British Columbia Ministry of Health, 2013). Brief interventions involve short, goal-directed counseling techniques that can be delivered easily in a primary care setting. Among counseling techniques that are applicable to the primary care setting, brief interventions demonstrate the greatest efficacy and are well supported by the literature (Kaner et al., 2007; Navarro et al., 2011; O’Donnell et al., 2014). Although the Canadian Guidelines refer to “brief counseling” instead of brief intervention, the technique described is consistent with the 30 brief intervention technique (Barry, 2012; Spithoff & Kahan, 2015c). A more detailed discussion on the brief intervention technique will follow. Brief intervention. Brief intervention is a counseling technique that utilizes concepts and techniques across a variety of theoretical bases in order to facilitate behavioural changes (Barry, 2012). In the setting of alcohol use, the principal theoretical basis for brief interventions originates from behavioural self-control literature (Barry, 2012). Behavioural self-control theory recognizes the substance user as the foundation for change within the counseling process (Barry, 2012), meaning that the patient learns to recognize their drinking behaviours through a series of steps, and then develops self-efficacy to overcome those behaviours. Brief interventions are designed to take between five and 25 minutes to perform, with most lasting between five and 15 minutes in the primary care setting (Barry, 2012; Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005). Brief interventions are meant to be performed over a number of successive visits, increasing patient engagement and offering ongoing opportunities for positive reinforcement. Frequent follow-up with the primary care provider is essential with the brief intervention technique and is recommended at least every 14 days (British Columbia Ministry of Health, 2013). This appointment frequency provides time to highlight the patient’s successes and to recognize triggers that may cause continued drinking. Frequent follow-up also facilitates the assessment and treatment of comorbid diseases, such as depression, that may contribute to the patient’s urge to drink. Generally, there are eight sequential steps that comprise a brief intervention for alcohol use: 1. The patient establishes a goal, either a number of drinks per day or abstinence; 31 2. The patient starts to self-monitor the number of drinks and the setting in which the consumption occurs; 3. The patient starts to modify the rate of alcohol consumption; 4. The patient develops the ability to refuse alcohol when it is offered; 5. The patient creates a positive reward system for achieving their goals; 6. The patient determines the circumstances that instigate overdrinking; 7. The patient learns self-efficacy instead of using alcohol to cope; and 8. The patient learns methods to prevent relapse. (Barry, 2012) In the primary care setting, brief interventions show significant reductions in alcohol consumption (Bertholet et al., 2005; O’Donnell et al., 2014). One meta-analysis demonstrated a weighted mean average reduction of 38g of ethanol per week (95% CI, -51 to -25g/week) – equating to approximately four drinks less per week than the control group (Bertholet et al., 2005). This meta-analysis did not find any statistical difference between men and women; however, a recent systematic review suggested that the women and youth have been understudied in regards to brief intervention for alcohol use (Bertholet et al., 2005; Kaner et al., 2007; O’Donnell et al., 2014). Additionally, there is a lack of evidence for efficacy of brief intervention in patients with more severe AUD (Saitz, 2010). Both the Canadian and BC Guidelines suggest utilizing the brief intervention technique for all patients, regardless of sex. Unlike sex, greater severity of AUD is recognized in both of the guidelines and is an indication for prescription medications and referral to specialist services. There are no statistics available for prevalence of brief intervention usage for AUD in BC. However, the general utilization of brief interventions in primary care is thought to be between 10% and 50% (Kaner, Lock, McAvoy, Heather, & Gilvarry, 1999; Navarro et al., 32 2011). This indicates that brief interventions may be underutilized in the primary care setting, and that there may be a gap in the current treatment of AUD by primary care providers. Prescribing Medications for Alcohol Use Disorder For patients who have been diagnosed with moderate or severe AUD, both the BC and Canadian Guidelines suggest that providers consider instituting pharmacotherapy in addition to patient counseling (Spithoff & Kahan, 2015c). Three medications are currently approved for the treatment of AUD in Canada – disulfiram, naltrexone, and acamprosate (Spithoff & Kahan, 2015c). A description of these medications, their indications, and their contraindications will follow. There is no optimal pharmacotherapy treatment duration; however, all three medications are suggested for a minimum of six months to one year, and for those who respond positively, treatment can be extended to two years (British Columbia Ministry of Health, 2013). Despite pharmacotherapy being included in both guidelines for AUD, it appears that actual utilization remains quite minimal (Crowley, 2015). A large meta-analysis suggested that only 33% of patients with AUD receive any type of treatment, and less than 10% of patients receive pharmacological treatment (Jonas et al., 2014). Disulfiram. Disulfiram is the oldest medication approved for the treatment of AUD and is relatively well known among both health care providers and patients. It is an aversive agent that inhibits the metabolism of alcohol, producing nausea, vomiting, flushing, tachycardia, and hypotension (Wackernah et al., 2014). After alcohol is ingested, it is metabolized into acetaldehyde by the enzyme alcohol dehydrogenase (ADH); acetaldehyde is then oxidized by the hepatic enzyme aldehyde dehydrogenase (ALDH) (Molina et al., 2014). 33 Disulfiram irreversibly inhibits the ALDH enzyme, leading to a accumulation of acetaldehyde, which results in the negative physiological affects listed above (Wackernah et al., 2014). Despite disulfiram’s relative familiarity, there is minimal evidence demonstrating that it significantly reduces drinking (Jonas et al., 2014; Jørgensen, Pedersen, & Tønnesen, 2011). In a recent meta-analysis, disulfiram failed to show overall reductions in alcohol consumption (Jonas et al., 2014). This is unfortunate because disulfiram is the most widely known medication for AUD and its lack of efficacy may deter patients and prescribers from initiating pharmacotherapy. However, a systematic review of disulfiram’s efficacy has found some evidence that supervised ingestion does reduce alcohol consumption until relapse, indicating that there may be a subgroup of individuals who may benefit from this drug (Jørgensen et al., 2011). Patients with a spouse, family member, pharmacists, or primary care provider that would be willing to supervise ingestion may find more benefit than Jonas et al. (2014) reports. Contraindications for disulfiram include usage in patients receiving metronidazole, antihypertensives, preparations that contain alcohol – e.g., cough syrup or mouthwash, and in patients with severe cardiovascular or cerebrovascular disease (Teter & Sherwood, 2016). To ensure patient safety, the primary care provider must provide counseling regarding these contraindications and for the need to abstain from all alcohol during treatment (British Columbia Ministry of Health, 2013). Since disulfiram is contraindicated with alcohol ingestion, patients are required to have already withdrawn from alcohol, which further reduces the patient population who may be eligible for its use. 34 Disulfiram is relatively inexpensive in BC; depending on the dosage, it costs between $0.30 and $0.80 per pill (Province of British Columbia, 2017). The provincial pharmaceutical plan, BC Fair PharmaCare, does list disulfiram as a regular benefit medication in the formulary, indicating that it will be covered without special authority according to the patient’s previous year’s taxable income (Province of British Columbia, 2017). Given the minimal financial burden associated with disulfiram, it may be an option for patients who have supervised ingestion available. Acamprosate. Acamprosate is structurally similar to the glutamate and GABA neurotransmitters discussed in the pathophysiology section above (Wackernah et al., 2014). Acamprosate antagonizes glutamate, which reduces the excess glutaminergic activity associated with the up-regulation of glutamate receptors (Wackernah et al., 2014). While using acamprosate, the feelings of chronic alcohol withdrawal and the associated urge to drink are both diminished (Wackernah et al., 2014). In meta-analysis, acamprosate was only statistically significant in reducing the return to any drinking, with a risk difference of -0.09 (95% CI, -0.14 to -0.04) and number needed to treat (NNT) of 12 (95% CI, 8 to 26) (Jonas et al., 2014). No significance was found for returning to heavy drinking (Jonas et al., 2014). Acamprosate is only approved for use in patients who have already withdrawn from alcohol, limiting the eligible patient population (British Columbia Ministry of Health, 2013; Jonas et al., 2014). Acamprosate is relatively well tolerated with side effects of anxiety, diarrhea, and vomiting being reported more often than with placebo (Jonas et al., 2014). Contraindication for acamprosate include hypersensitivity, pregnancy, and severe renal dysfunction, although a reduced dose can be used with moderate renal function (British Columbia Ministry of 35 Health, 2013; Spithoff & Kahan, 2015c). Given acamprosate’s relative tolerability and limited number of contraindications, it should be considered as a first-line pharmacotherapeutic option for patients with AUD. Acamprosate tablets are relatively inexpensive in BC, costing $0.80 per pill, and special authority coverage is available under the BC PharmaCare for a three month supply (British Columbia Ministry of Health, 2017b; Province of British Columbia, 2017). To receive special authority coverage, the patient is required to have been abstinent from alcohol for four days or to have contraindications to naltrexone, and they must receive concurrent counseling services (British Columbia Ministry of Health, 2017b). One drawback to acamprosate is that it requires three times per day dosing, which may be an additional barrier for patients who have difficulty with memory of scheduling. Naltrexone. Naltrexone is a competitive opioid antagonist that disrupts the positive reward associated with drinking alcohol (Jonas et al., 2014; Wackernah et al., 2014). By blocking the alcohol-related stimulation of the endogenous opioid systems, naltrexone reduces cravings for alcohol and the euphoria felt after consumption (Wackernah et al., 2014). In meta-analysis, the risk difference for return to heavy drinking was -0.09 (95% CI, 0.14 to -0.04) with a NNT of 12 (95% CI, 8 to 26) (Jonas et al., 2014). Return to any drinking was less significant with a risk difference of -0.05 (95% CI, -0.10 to -0.002) and a NNT of 20 (95% CI, 11 to 500) (Jonas et al., 2014). Naltrexone shows similar efficacy to acamprosate and is likewise considered a first-line pharmacotherapeutic agent. Overall side effects to naltrexone are minimal, although it is slightly less well tolerated than acamprosate (Jonas et al., 2014). Common side effects include dizziness, nausea, vomiting, headache, insomnia, and nervousness, with a number needed to harm 36 (NNH) of 48 to cause trial drop out (Jonas et al., 2014; Teter & Sherwood, 2016). Hepatotoxicity has been noted with naltrexone necessitating serum liver transaminase measurements at baseline, then periodically throughout treatment (Teter & Sherwood, 2016). Naltrexone is subsequently contraindicated with hypersensitivity, liver failure (British Columbia Ministry of Health, 2013). Naltrexone is further contraindicated with opioid therapy because of the risk of precipitated opioid withdrawal (British Columbia Ministry of Health, 2013). For those who have used opioids but are able to stop, there is a mandatory seven day opioid abstinence period before the first dose of naltrexone can be administered (Teter & Sherwood, 2016). An additional opioid consideration with naltrexone is the potential requirement for emergency opioid therapy. Patients should wear a medical alert bracelet indicating naltrexone therapy because, in the event of an emergency, they will require otherwise-toxic doses of opioids before any effect will be felt (Teter & Sherwood, 2016). Furthermore, long-term opioid antagonist therapy can result in opioid hypersensitive if the antagonist is stopped, thus increasing the risk of accidental opioid overdose (Teter & Sherwood, 2016). Naltrexone costs $5.26 per pill in BC, which is a significant barrier for self-paying patients (Province of British Columbia, 2017). However, naltrexone is covered for three months under the BC PharmaCare special authority program with a requirement for concurrent behavioural intervention therapy (British Columbia Ministry of Health, 2017c). For those who have the financial means or additional medication coverage, naltrexone may be a good option to assist in the treatment of AUD. 37 Connect to Ancillary and Specialist Services A key component of the Canadian Guideline is to “connect” patients with services outside of primary care (Spithoff & Kahan, 2015c). The services specifically mentioned in the Canadian Guideline are: residential programs, outpatient day programs, addictions medicine specialists, addictions counselors, and support groups (Spithoff & Kahan, 2015c). Interestingly, the BC Guidelines only mention coordinating care with a specialist if the patient has consented; however, it does not elaborate further on what type of specialist service, or which patients, should be referred (British Columbia Ministry of Health, 2013). Included below is a discussion about each of the above-mentioned services in addition to medical detoxification. Although neither the BC nor the Canadian guideline discuss medical detoxification, I will briefly review this service and its availability in northern BC because abstinence is a requirement for most alcohol treatment programs. Furthermore, the accessibility of specialist services in northern BC will be examined and, where available, the general rates of remission associated with these services will be included. Residential programs. Residential programs, sometimes referred to as inpatient programs, are facility-based extended-stay rehabilitation services. They require the patient to live in a facility for a pre-determined amount of time, usually a minimum of 28 days (Gifford, 2016). There are a wide variety of theoretical models that create the foundation for each program; however, a common theme among all residential programs is that alcohol rehabilitation is the primary focus of daily life (Gifford, 2016). Programs that are based in a therapeutic community model can be up to 24 months in length (Perryman & Dingle, 2015). The treatment services available in day and residential programs can be quite similar, with 38 both offering group therapy, individual therapy, and educational sessions; however, residential programs generally include 24-hour supervision, meals, and accommodation (Canada Drug Rehab Addiction Services Directory, 2017; Martin & Rehm, 2012). Martin and Rehm (2012) suggest that, although empirical evidence is weak, residential programs may be most appropriate for patients with severe AUD, concurrent psychopathology, and low social stability and social continence. Decision making support is conspicuously absent from both the BC and the Canadian Guidelines for primary care providers regarding residential treatment for patients with AUD. Abstinence with residential programs. The short- and long-term abstinence rates associated with residential programs are difficult to accurately study (Finney, Hahn, & Moos, 1996; Perryman & Dingle, 2015). Programs are heterogeneous in theoretical foundations, duration of stay, and patient demographics, limiting the generalizability of success rates (Finney et al., 1996; Perryman & Dingle, 2015). The Canadian Guideline suggests that 33% of day or residential treatment program graduates are abstinent at the one year mark (Spithoff & Kahan, 2015c) However, the article cited in the guideline is a review of multiple studies with broadly heterogenic interventions, limiting my ability to find causation from the day or residential programs alone (Miller, Walters, & Bennett, 2001; Spithoff & Kahan, 2015c). A somewhat consistent theme in the literature is that dropout rates are high among residential program attendants, but again, the effect this has on the overall success is unclear (Perryman & Dingle, 2015). The high dropout rate supports Spithoff and Kahan’s (2015a) assertion that primary care management can be as successful as referral to specialist care. 39 Residential programs in British Columbia. Residential programs are often designed for certain demographics. They may admit patients based on abstinence, gender, age, or ethnicity, and may or may not allow children to join their mothers (Canada Drug Rehab Addiction Services Directory, 2017). In BC, all but one program in Kelowna requires abstinence prior to admission, indicating that many patients will require medical detoxification (Canada Drug Rehab Addiction Services Directory, 2017). Outside of demographic restriction, the waitlist may also impair access to residential programs in BC. Programs that are publicly funded by the BC Ministry of Health often have wait lists that are many weeks in duration, which can be a barrier for some patients. In BC’s Northern Health Authority, there are only two municipalities that have residential programs available to the general public, Fort St. John and Prince George (Canada Drug Rehab Addiction Services Directory, 2017). Funding is provided through the BC Ministry of Health for patients who are eligible for income or disability assistance (Ministry of Social Development and Social Innovation, 2017). For patients who are considered the “working poor” or “lower middle class,” financial constraints may be a significant barrier to treatment. People of Aboriginal descent have separate funding and can receive financial coverage to attend any residential program in BC through the First Nations and Inuit Health Branch (FNIHB) (Health Canada, 2016b). A complete and current list of inpatient residential treatment programs can be found at the Canadian Alcohol & Drug Rehabilitation Centres & Programs’ (2017) website. In BC, people of Aboriginal descent have access to residential programs that provide culture-specific care. There are four of these programs in the Northern Health Authority, located in Vanderhoof, Kitwanga, Haisla (Kitimat), and Dawson Creek (Health Canada, 40 2016b). Funding is provided by the FNIHB and is not generally a barrier to accessing treatment (Health Canada, 2016b). Outpatient day programs. Outpatient day programs are as diverse in theoretical underpinnings as residential programs (Martin & Rehm, 2012). Outpatient day programs allow patients to continue to live at their own home while maintaining close contact with the treatment program (Gifford, 2016). The advantage of these programs is that they allow patients to better protect their privacy because there is not a long absence from work, family, or educational commitments (Gifford, 2016). From a systemic point of view, outpatient day programs are less expensive to provide than the more intensive residential programs (Martin & Rehm, 2012). The main challenge associated with this type of program is that patients are not removed from their normal environment, necessitating self-imposed abstinence, which can be major barrier for some patients (Gifford, 2016). Abstinence with outpatient day programs. Rates of remission associated with outpatient day programs are difficult to obtain because of significant between-program heterogeneity. There is not enough generalizable empirical data to make assertions regarding remission rates; however, outpatient day programs have been found to be comparable in effect to residential programs (Martin & Rehm, 2012; Raistrick, Heather, & Godfrey, 2006). In contrast to residential programs, patients recommended for outpatient day programs should have less severe AUD, lower-risk social factors (living arrangements, criminal involvement, and other drug involvement), limited concurrent psychopathology, and shorter duration of AUD (Martin & Rehm, 2012; Raistrick et al., 2006). Outpatient day programs in British Columbia. In BC, many smaller municipalities have outpatient day programs available, including many municipalities in the 41 Northern Health Authority (Canada Drug Rehab Addiction Services Directory, 2017). A complete and current list of these programs can be found at the Canadian Alcohol & Drug Rehabilitation Centres & Programs’ (2017) website. Patient access to outpatient day programs is generally easier than residential programs because there are a multitude of sites across BC. Additionally, these programs are publicly funded under the Medical Services Plan of BC and administered by the five Health Authorities and the Provincial Health Services Authority (British Columbia Ministry of Health, 2017d). Public funding removes the financial barrier for those not on income or disability assistance, and may promote outpatient day programs as a treatment choice for primary care providers. Medical detoxification. Medical detoxification, commonly referred to as ‘detox’, is medically supervised withdrawal from alcohol. The use of medications, usually benzodiazepines, and patient monitoring helps to alleviate some of the symptoms and risks associated with alcohol withdrawal (British Columbia Ministry of Health, 2013). Medical detoxification can be performed in a residential treatment program, in the outpatient setting, and in an inpatient or hospital setting (Canada Drug Rehab Addiction Services Directory, 2017). Patients can also withdraw from alcohol without medical care, but this is then not classified as medical detoxification. The BC Guidelines suggest that most patients with AUD can be safely withdrawn from alcohol in the outpatient setting (British Columbia Ministry of Health, 2013). Medication dosing schedules are easily accessible for primary care providers in both the United States and Canada (British Columbia Ministry of Health, 2013; Muncie, Yasinian, & Oge, 2013). The contraindications to outpatient medical detoxification are numerous and include: acute illness, previous withdrawal seizures or delirium, failed attempts at outpatient 42 withdrawal, unstable comorbidities (cardiovascular disease or diabetes), comorbid psychiatric illness, concurrent sedative dependence, liver compromise, pregnancy, failure to respond after one to two days of medications, advanced withdrawal state, and absence of support network (British Columbia Ministry of Health, 2013; Muncie et al., 2013). In the presence of any of these conditions inpatient medical detoxification is suggested. Medical detoxification in British Columbia. Medical detoxification in BC has varied availability depending on location. There are numerous detoxification units in the southern half of the province, but less in the north. In the Northern Health Authority, there is a regional adult withdrawal management unit in Prince George that services most of northern BC (Northern Health Authority, n.d.). This unit has 14 beds, six acute, six non-acute, and two transitional (Northern Health Authority, n.d.). There is also a five-bed medical detoxification unit in Quesnel (Canada Drug Rehab Addiction Services Directory, 2017). These two units service the entire northern portion of BC. Barriers to accessing these treatment services include the significant coverage areas, the expense of travel to and from the facility, and bed availability. A complete and current list of medical detoxification units can be found at the Canadian Alcohol & Drug Rehabilitation Centres & Programs’ (2017) Addictions medicine specialists. Addictions medicine specialist are physicians who have completed specialty training and are certified under the American Board of Addiction Medicine (ABAM), or are psychiatrists who are certified under the American Board of Psychiatry and Neurology (ABPN) (American Society of Addiction Medicine, 2017). There is no equivalent Canadian certification in addictions medicine available from the Royal College of Physicians and Surgeons of Canada, or the College of Family Physicians of Canada, meaning that Canadian physicians are required to complete the American board 43 exams (College of Family Physicians of Canada, 2017; McEachern et al., 2016; Royal College of Physicians and Surgeons of Canada, 2014). Addiction medicine specialists deliver medical care for those with a variety of addictions including tobacco, prescription medication, illicit drugs, and alcohol (American Society of Addiction Medicine, 2017). The goal of addictions medicine is to address an unmet need in addictions treatment, especially with medically complex patients (McEachern et al., 2016; Wood, Samet, & Volkow, 2013). Similar to the other treatment options discussed above, deciding which patients should be referred to addictions medicine is a challenge. The Canadian Guidelines suggest that patients who are highly complex, such as those with comorbidities, or patient who have failed to respond to primary care management should be referred to addictions medicine (Spithoff & Kahan, 2015c). This is intuitive to many primary care providers; however, accessing addictions medicine services may be particularly challenging to access for many patients in rural, remote, and northern communities (McEachern et al., 2016). Addictions medicine specialists in British Columbia. In BC, the highest concentration of certified addictions medicine specialists is in the Lower Mainland (McEachern et al., 2016). A recent study calculated the provider availability index (PAI) for addictions medicine in BC (McEachern et al., 2016). PAI is a ratio of how many providers there are per 1000 people affected with a given health concern. During this study, the Northern Health Authority and the Island Health Authority both had zero addictions medicine specialists per 1000 people affected with AUD, although the authors do state that they could only measure those who were ABAM-certified (McEachern et al., 2016). Using the ABAM certification only may underestimate those actually practicing in the field of addictions medicine (McEachern et al., 2016). For instance, Dr. Gerrard Prigmore is the 44 Medical Lead for Addiction and Harm Reduction in the Northern Health Authority, and his practice was not found in the McEachern et al. (2016) study (British Columbia Ministry of Health, 2017a). However, even with this potential for underestimation, addictions medicine specialists are clearly a limited resource in the Northern Health Authority and are likely inaccessible to most patients. Another possible approach to gain access to addiction medicine specialist in BC is through the Rapid Access Consultative Expertise (RACE) telephone line (RACE, n.d.). The RACE line provides consultative only specialist advice Monday to Friday during business hours. This service may be beneficial for primary care providers who have a specific health care question regarding a patient with AUD, but is limited in availability after hours, and does not have the capacity to receive referrals or assume care of patients. Support groups. Support groups are a diverse collection of group gatherings that have the common theme of supporting individuals to overcome addiction. Groups can be faithbased, community-based, or subscribed to the 12-step program philosophy. Some programs are professionally lead but the majority are peer-lead (Spithoff & Kahan, 2015c). Support groups are easy to access, inexpensive and readily available. Alcoholics Anonymous (AA) is perhaps the most well-known support group for AUD. It is a global organization and is available in many locations and languages (Alcoholics Anonymous, 2017). Alcoholics Anonymous. AA is a non-professional lead, spiritual-based support group (Alcoholics Anonymous, 2017). There are no restrictions on participation, such as age, gender, or race, which removes many barriers to access for individual seeking treatment (Alcoholics Anonymous, 2017). A recent Cochrane Review of AA and other 12-step programs found equivocal effect when compared to other interventions, namely motivational 45 enhancement therapy, cognitive behavioural therapy, relapse prevention therapy (Ferri, Amato, & Davoli, 2006). Additionally, the authors did not find a difference in effect linked to severity of AUD (Ferri et al., 2006). These findings have been contested by some, citing inappropriate interpretation of the data, but overall, the results for these programs seem mixed (Kaskutas, 2008). For primary care providers, recommendation of participation in AA should be primarily based on patient preference. Alcoholics Anonymous in British Columbia. In large centers, AA meeting are usually held daily, while rural communities may have meetings less frequently (although they are still usually held multiple times per week). In the Northern Health Authority, there are meetings accessible in most of the rural areas, including in many small towns and villages (BC/Yukon area 79, 2017). One negative aspect to AA is the lack of confidentiality, which may represent a significant barrier to its utilization (Coleman, 2005). Individuals who live in small communities may experience disproportionately less confidentiality because, by nature of living in a small community, there is reduced anonymity. Health Belief Model The Health Belief Model (HBM) originated in the 1950s in an attempt to explain why people may choose not to participate in programs that can detect or prevent disease (Champion & Skinner, 2008). The HBM has evolved minimally since its conception and its key constructs remain relatively intact (Champion & Skinner, 2008). These key constructs include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (Champion & Skinner, 2008). By examining each component of the HBM, researchers and clinicians can illuminate the complex reasons why a person may or may not engage in a given health behaviour. Health behaviours such as 46 smoking cessation, breast self-exams, mammography, condom use, and pertinently, entry into alcohol use treatment, all lend themselves well to application of the HBM. The key constructs of the HBM will be discussed below. Please see Figure 1 for a depiction of the HBM. Perceived Susceptibility Perceived susceptibility refers to an individual’s perceived risk of contracting or developing a certain health condition (Champion & Skinner, 2008). In this integrative review, this refers to how likely a patient is to develop AUD. Perceived susceptibility may vary among different populations; for instance, young male patients generally consume more alcohol and visit their primary care provider less than other populations and therefore young males perceive themselves as less susceptible to alcohol-related harms (Navarro et al., 2011). Patients must consider themselves to be susceptible to a health condition before they will participate in a health behaviour designed to mitigate risk of that condition (Champion & Skinner, 2008). Perceived Severity Perceived severity refers to the clinical consequences of contracting or developing a health condition or to the repercussions from leaving a known condition untreated (Champion & Skinner, 2008). In the case of AUD, consequences refer to sequelae such as liver cirrhosis, gastritis, cardiovascular disease, and many other potential adverse health effects. Perceived severity can also refer to social consequences, such as losing family or employment, both of which are pertinent to AUD (Champion & Skinner, 2008). Perceived severity and perceived susceptibility can be combined into the single term ‘perceived threat’, 47 which provides a more complete description of how a person may assess the possibility of harm from a given health condition (Champion & Skinner, 2008). Perceived Benefit Perceived benefit refers to a person’s beliefs regarding the benefit of a given health behaviour (Champion & Skinner, 2008). Despite being susceptible to a severe health condition, the individual needs to believe there is benefit to changing before they are likely to undertake a health behaviour. For example, if patients with AUD do not perceive that they will benefit from treatment, they are unlikely to seek out treatment options. Perceived Barriers Perceived barriers are obstructions that a person believes will prevent them from participating in a given health behaviour (Champion & Skinner, 2008). For rural, remote, or northern patients with AUD, perceived financial constraints, geographical isolation, or social stigma may be seen as barriers to seeking help. Perceived barriers are considered to be the most significant single aspect of the Health Belief Model (Champion & Skinner, 2008). Meaning, that if an individual perceived a significant barrier to participating in a health behaviour, they are unlikely to overcome the barrier regardless of the perceived threat and perceived benefit. Cues to Action Cues to action are a non-descript group of motivating factors that are not defined within the perceived benefits (Champion & Skinner, 2008). Cues to action can include a bodily event or environmental event that triggers the need for change. For patients with AUD, a cue to action could include a family member mentioning their drinking, the 48 development of tremors when abstaining from alcohol, or a driving while intoxicated charge. These events may cue the patient to take action and seek out treatment. Self-efficacy Self-efficacy is the self-belief that an individual is capable of completing a given health behaviour to produce a desired outcome (American Psychological Association, 2017). In patients with AUD, self-efficacy could refer to their belief that they can decrease their drinking or that they can remain abstinent. Without self-efficacy, they are unlikely to attempt to address their AUD. Other Variables Other variables that affect the likelihood of an individual undertaking a health behaviour are listed in Figure 1 as “Modifiable Factors.” These variables include the social, economic, psychological, and demographic components of their life. Individuals can be influenced by these variables in both their perceptions of health and disease, as discussed above, and in the decision to participate in a health behaviour. 49 Figure 1 Health Belief Model From Health behavior and health education: Theory, research, and practice (4th ed.) (p. 49), by V. L. Champion, & C. S. Skinner, 2008, San Francisco, CA: Jossey-Bass. 2 Copyright (c) by Wiley Publishing. Reproduced with permission. 50 CHAPTER TWO: METHODS An integrative literature review is a specific research methodology that synthesizes previous literature for the purpose of addressing a new or unique research question (Torraco, 2005). Inclusion of both experimental and non-experimental evidence reinforces conclusions drawn from within the integrative review, and encourages the application of findings to evidence-based practice. Furthermore, integrative reviews have the potential to influence theory development and policy makers alike (Whittemore & Knafl, 2005). An integrative literature review was conducted to address the research question: “In the setting of rural, remote, and northern primary care, what is the most appropriate treatment for adults with alcohol use disorder?” This question was explored in detail because AUD is quite prevalent in northern BC and its associated sequelae pose significant health risks to the individual drinker and to the general public (Public Health Agency of Canada, 2016; University of Victoria, 2017a, 2017b). Furthermore, individuals with AUD who live in rural, remote, and northern areas suffer disproportionately greater barriers when attempting to access treatment, especially for services that require referral outside of their home community. The goal of this integrative review is to utilize current research to guide primary care treatment of AUD in rural, remote, and northern regions. An additional aim is to illuminate areas of weaknesses in the current body of evidence that may benefit from further research. The literature selection and analysis took place in multiple stages. A preliminary literature search was conducted, followed by a focused search with the application of inclusion and exclusion criteria, and finally a comprehensive analysis of the selected literature was executed. Each of these stages will be addressed in detail below. 51 Search Strategy To begin the literature search, the research question listed above was converted into the population-intervention-outcome (PIO) question format. The general concepts were ruralremote-northern, primary care, AUD, and treatment. Once in the PIO format, search terminology was developed through the use of a concept map. The outcome component - treatment - appears to be intrinsic within the literature. Meaning, that articles written about AUD generally focused either on epidemiology or on treatment. Both of these outcomes are applicable to this integrative review; therefore, the search terminology concentrated on the population and the intervention aspects of the PIO question. Initially, all population and intervention components were included in the database searches, but this lead to very few results. In particular, the search terms ‘north” and “northern” limited the results. These two terms limited search results to less than 20 articles in most databases, and the results did not equate well with what is considered northern in a Canadian context. In Canada, northern is synonymous with rural and remote, but also suggests an aspect of harshness, such as long and cold winters. The search results did not reflect the essence of the Canadian meaning of northern; for example, results included “Northern Africa,” or “North America” in the titles but were not applicable to the research question. Consequently, the northern terminology was removed from the searches. The concept of “primary care” also significantly reduced the number of search results. However, since primary care is a crucial concept within the integrative review, searches were performed both including this concept and excluding it. The two sets of results 52 were screened separately using a focused search, which is described in the focused search heading below. Initial Literature Searches The initial literature searches were conducted in five databases: CINAHL (EBSCOhost), PsychINFO (EBSCOhost), MEDLINE (Ovid), PubMed, and Cochrane Database of Systematic Reviews ([CDSR] Ovid). These databases were accessed electronically through the University of Northern British Columbia library. These five databases were chosen because they are well-known academic databases that include peerreviewed literature from multiple disciplines. To ensure a complete representation of AUD in rural, remote, and northern settings, and given that AUD is a topic that has been researched by a range of social and health care professions, it was imperative to search a variety of databases. With the exception of the CDSR, PsychINFO, and CINAHL databases, Medical Subject Headings (MeSH) were exclusively used. Keyword searches with truncation were added to the CINAHL and the PsychINFO searches to elicit additional results. CDSR does not utilize MeSH in its archival algorithm so keyword searches with truncation were used. When available, the MeSH search terms were exploded to include all subheadings. Exploding the MeSH term facilitated a more comprehensive search because it reduced the risk of omitting pertinent articles archived within a subheading that might have otherwise been missed. Reference lists of the selected articles were also searched for additional literature pertinent to the research question. These articles were retrieved from the Google Scholar database. Please refer to Table 4 for the specific search terms that were used. 53 Table 4 MeSH and Keyword Search Terms CINAHL PsychINFO MEDLINE PubMed CDSR (EBSCOhost) (EBSCOhost) (Ovid) • Rural Health • Rural • Rural Health • Rural Health • “Rural” Personnel Environments • Rural • Rural Nursing • “Remote” • Rural Health • “Rural” Population • Rural • “Isolat*” Centers • “Remote” • Hospitals, Population Rural • Hospitals • “Isolat*” • Rural Health Rural Services • Rural Nursing • Rural • Rural Health • Hospitals, Populations services Rural • Rural Health Services • Rural Health Nursing • Rural Areas • Rural Health • “Rural” • “Remote” • “Isolat*” • Alcohol• Alcoholism • Alcohol• Alcohol• “Alcohol adj3 Related Related Related Drink*” • Alcohol Disorders + Disorders + Disorders + Rehabilitation • “Alcohol adj3 Rehabilitation • Alcoholics Diet Therapy Rehabilitation Abuse” + Drug + Drug + Therapy Anonymous • “Alcohol adj3 Therapy + Therapy + Disorder” • Detoxificatio Therapy Rehabilitation n • “Alcohol adj3 + Therapy • Alcohol Depend*” • Alcohol Rehabilitation Abuse Programs • Primary • Primary • Primary • Primary • “Primary adj2 Health Care Health Care Health Care Health Care Care” Note. Search terms within each box were combined with OR. “” indicate a keyword search. * indicates truncation. Adj followed by a number indicates the number of words that can appear between the search terms. + indicates subheadings within a MeSH. Focused Search In total, the above searches produced 1099 articles. To narrow these results to only the most relevant articles, titles and abstracts were screened using inclusion and exclusion criteria (see Table 5). Given the relatively broad research question, minimal inclusion and exclusion criteria were applied to try and preserve pertinent articles. No specific criteria 54 related to year of publication were applied because AUD has been researched for a long period of time and it was anticipated that some of the older literature might still be relevant to the research question. Similarly, no geographical criteria were included because countries such as Australia, the United States, and England have comparable health care systems to Canada, and may have produced relevant research to this integrative review. Study design criteria were also avoided because, although the research question does lend itself well to quantitative research, it was felt that qualitative studies had the potential to enrich the integrative literature review with the experience of both the patient and the health care provider. Please see Table 5 for the inclusion and exclusion criteria. The detailed disposition of the articles from the preliminary searches can be found in Figure 2. Table 5 Search Inclusion and Exclusion Criteria Inclusion Exclusion Reason Adult (18 years Youth (younger than 18 I chose to exclude younger populations and older) years) because AUD is less common in children and adolescents. Published in Published in any language Limited resources to translate articles given English other than English time restraints and scope of the capstone project. Specific to Concurrent disorders and Focuses on alcohol and avoids concurrent alcohol use other substance use disorders (e.g. cocaine use, opioid use). disorder. issues. Peer-reviewed Non-peer reviewed Limits results to academic journals. Avoids research articles articles non-scientific articles. Analysis of Selected Literature The final step in the integrative review process was to complete a comprehensive analysis of the selected literature. A literature review matrix was created as the primary tool to analyze the articles and elicit themes between and among them. The headings within the literature review matrix were chosen based on recognized appraisal tools found on the Critical Appraisal Skills Programme’s (2013) website. The matrix headings include a 55 description of the study, study design, strengths, limitations, important findings, and utility, all of which are integral parts of an integrative literature review. An additional tool used to analyze the literature results was the Johns Hopkins Research Evidence Appraisal Tool (Johns Hopkins University, n.d.). This tool provides rigid criteria for grading all types of evidence from levels one to three, with level one being the highest level of evidence. The Johns Hopkins Research Appraisal Tool was chosen as an additional analysis method because of the significant study design heterogeneity included in the integrative review. The literature analysis resulted in a number of common themes being elucidated. These findings will be discussed in detail in the Findings chapter, with further analysis to follow in the Discussion chapter. 56 Figure 2 Disposition of Articles 57 CHAPTER THREE: FINDINGS An integrative review was conducted to examine the treatment options available to primary care practitioners within rural, remote, and northern settings, with the aim of increasing treatment success and to highlight those areas that could be improved. To guide this analysis, the following research question was posed: in rural, remote, and northern primary care settings, what is the optimum treatment for adults with AUD? A literature search returned 18 pertinent articles for inclusion in the integrative review. To examine each of these selected articles in detail, a literature review matrix was constructed. This literature review matrix provided a uniform format through which each of the articles was scrutinized. Six themes were elucidated from the selected literature. These themes were: (a) comorbidities; (b) rural versus urban AUD; (c) screening for AUD; (d) primary care management of AUD; (e) specialist management of AUD; and (f) interventions applicable to primary care. Within each of these six themes, a critical review of the 18 included articles, including literature gaps, is provided below. The Johns Hopkins Evidence Appraisal Tool (n.d.) will be referenced throughout this chapter as “evidence level” one, two, or three. Evidence level one is considered to be the most robust, while evidence level three is the least robust (Johns Hopkins University, n.d.). A detailed review of all 18 articles is presented within the literature review matrix found in the Appendix. None of the articles included in the review addressed the research question directly; however, the articles included in the integrative review did tackle various elements of the research question and provided opportunity for further synthesis within the Discussion chapter. 58 Comorbidities Comorbidities are commonly found in patients suffering from AUD and can include disease of almost all bodily systems; these various diseases can pose a significant threat to an individual’s health and well-being. In the literature sample included in this review, the most commonly cited comorbidities associated with AUD were mental health problems and emotional trauma. From this point forward in the review, emotional trauma will be referred to simply as trauma. Four articles specifically stated that mental health, trauma, and AUD were commonly found in coexistence; however, none of these articles assessed this relationship as a primary focus (Allan, 2010; Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015b, 2015c). Slaunwhite and Macdonald (2015) examined the experience of “isolated” primary care physicians (n = 67) in BC who treated people with alcohol-attributed disease processes. The authors utilized an evidence level three, qualitative cross-sectional survey design. In this article, the term ‘isolated’ is used synonymously with the terms ‘rural, remote, and northern’ that are used within this integrative review. The authors utilized the Rural Coordination Centre (RCC) of BC’s (2017) scoring system to quantify rurality, remoteness, and isolation of physician practices. The RCC’s system is the mechanism by which physicians in BC receive additional funds for engaging in rural practice. This system was an appropriate method to ensure that only physicians from the desired rural, remote, and isolated backgrounds received the survey. The physicians in the study population had an average of 15.8 years of experience in the primary care setting, which fostered confidence in the validity of their reports. Another strength of this study was the use of an inductive theoretical model to guide data analysis, which allowed taxonomies and themes to be derived from the survey. 59 The primary weakness within this study was the low response rate (22% of eligible physicians in BC), which significantly limited its generalizability. However, given the sample population the authors studied, it did provide some insight into the real-world challenges of AUD treatment in rural, remote, and northern BC. The authors found that mental health was reported as the most common alcohol-related harm, and that causation was indicated in both directions (Slaunwhite & Macdonald, 2015). In other words, those with AUD were more prone to developing mental health disorders, and those with mental health disorders were more prone to developing AUD (Slaunwhite & Macdonald, 2015). No analysis was provided regarding the types of mental health issues involved or their respective prevalence rates. Trauma services were specifically mentioned as a gap in services available within rural, remote, and northern BC, specifically for First Nations peoples impacted by residential school system, assimilation, and historical trauma (Slaunwhite & Macdonald, 2015). This concern was highlighted by only 10% (n = 4) of the surveyed physicians; however, it remains important to this integrative review since trauma is a frequent reality in rural, remote, and northern patients who develop AUD (Slaunwhite & Macdonald, 2015). Spithoff and Kahan (2015b, 2015c) provided a two-part series of non-systematic literature reviews that resulted in clinical recommendations for primary care providers. Part one of the series addressed screening and assessment of AUD (Spithoff & Kahan, 2015b) whereas part two of the series addressed counseling, prescription medication, and connections to specialist for patients with AUD (Spithoff & Kahan, 2015c). The authors also cited mental health and trauma as common comorbidities among patients with AUD. These findings were evidenced with a somewhat dated (2002) Canadian Best Practice Guideline on 60 concurrent substance use and mental health, and a retrospective cross-sectional survey of adult patients’ who had experienced adverse childhood events (trauma), in order to better understand their current substance abuse practices (Spithoff & Kahan, 2015b, 2015c). The retrospective study suggested that those children who experienced one or more adverse childhood events were at a two- to four-fold risk for developing AUD as an adult, indicating a strong causal relationship (Spithoff & Kahan, 2015c). Accordingly, Spithoff and Kahan (2015b, 2015c) suggested that concurrent mental health treatment and trauma informed services were an integral component of AUD management. Spithoff and Kahan (2015b, 2015c) highlighted the importance of mental health and trauma services but they did not account for the limited availability of these services in rural, remote, and northern locations. Instead, the authors suggested that the primary care provider should assess and treat for mental health and trauma as required. This strategy may undervalue the impact that mental health and trauma have on patients with AUD because, although the authors suggested that primary care providers had the capacity to take on this role fully, it is clear from their own articles that AUD, mental health, and trauma remain significant comorbid concerns in patients with AUD (Spithoff & Kahan, 2015b, 2015c). Both of these non-systematic review articles were evidence level three, with their recommendations supported by a number of randomized controlled trials, systematic reviews, and meta-analyses (Spithoff & Kahan, 2015b, 2015c). The major limitation associated with these articles was that there was no explanation of their literature search or analysis techniques. Allan (2010) utilized a qualitative, social action research design to assess the challenges of implementing drug, alcohol, and mental health treatment programs in rural 61 Australia. This evidence level three study utilized in-depth, semi-structured interviews of a variety of health care workers to elucidate themes and develop strategies to overcome the barriers identified. Although the aim of the study was not to address the characteristics of patients with AUD, a common theme noted by the authors was that AUD patients were “more likely than not” (Allan, 2010, p. 315) to suffer from comorbid mental health problems or trauma. Strengths of this study included a moderate sample size (n=47) and computerized data analysis. Although manual-coding techniques would have been possible in this study, each interview lasted up to 90 minutes, suggesting that computerized data analysis was likely a more appropriate method to allow thorough and rigorous coding. However, it is difficult to exclude bias from this study because some of the subjects were actually employees of the agency conducting the study. The power differential between employee and employer is likely to have influenced the study participants’ responses, which limited the validity of this study. Although none of the studies listed above were designed to assess comorbidities as a primary outcome, Slaunwhite and Macdonald (2015), Spithoff and Kahan (2015b, 2015c), and Allan (2010) all suggested that mental health and trauma were common comorbidities in patients with AUD. In rural, remote, and northern BC, AUD is common and it follows that mental health and trauma are likely to be common as well (University of Victoria, 2017a). For primary care providers in rural, remote, and northern settings, consideration should be given to patients’ comorbid mental health and trauma histories because this may affect their ability to participate in, or access AUD treatment, especially if referral outside of the community is required. Furthermore, because a significant portion of Aboriginal people live in rural, remote, and northern BC, particular consideration of the trauma suffered in the 62 residential school system is warranted (Foster et al., 2011). This historical trauma continues to affect the health of Aboriginal peoples today and is considered a causal factor in the prevalence of AUD in this population (Spithoff & Kahan, 2015b). Considering that primary care providers are often the only access to health care in many rural, remote, and northern communities, both mental health and trauma remain significant factors in the management of patients with AUD. Furthermore, Slaunwhite and Macdonald (2015) found that primary care providers in these environments do not feel fully equipped to care for individuals with comorbid mental health and trauma, and therefore, these providers would likely benefit from further training, support, and/or resources. Rural Versus Urban Alcohol Use Disorder In BC, AUD is more prevalent in rural, remote, and northern regions (University of Victoria, 2017a). Additionally, alcohol-related mortality is more common in these areas of BC (University of Victoria, 2017b). The relationship between rurality and AUD is discussed below. Malek-Ahmadi and Degiorgio’s (2015) evidence level three study examined rural and urban residents of Nebraska who had previously been arrested for exceeding the legal alcohol limit while driving a vehicle while intoxicated. The authors defined rural residency by using the Rural-Urban Continuum Codes from the United States Department of Agriculture Economic Research Service ([USDAERS], 2017). The USDAERS categorized counties in nine separate population-based levels. The urban-rural separation is at a population of 2,500 within the county (USDAERS, 2017). Given that county sizes in the US vary widely, a direct comparison cannot be made to the rural, remote, and northern population in this integrative review; however, this rural definition is congruent with the 63 essence of the study population in this integrative review. This was a large (n=11,066) study with robust statistical analyses. The researchers utilized the validated Driver Risk Inventory II (DRI-II) to determine if there were significant differences between the urban and rural DWI offender. The DRI-II consists of six separate self-reported scales. The Cronbach’s alpha method was utilized to confirm internal consistency of the scales, and Cohen’s d was used to calculate effect size. Pertinent to this review were the 23-question alcohol survey (α=0.94), the 25-question driver risk scale (α=0.88), and a 21-question truthfulness scale (α=0.89). The truthfulness scale was used to identify participants who may have under-reported their drinking behaviours. Logistical regression in both the unadjusted and the adjusted (for age, education, gender, ethnicity, blood-alcohol at time of arrest, and number of prior alcohol related arrests) analyses indicated participants with medium (OR 1.43; CI 95% 1.20, 1.71; p < 0.001), problematic (OR 1.43; CI 95% 1.19, 1.72; p < 0.001), or severe (OR 1.38; CI 95% 1.14, 1.67; p = 0.001) alcohol use were significantly more likely to be rural residents (MalekAhmadi & Degiorgio, 2015). The authors reported that, although the results were statistically significant, the magnitude of effect was relatively small (d = 0.11). No differences were found between urban and rural participants for the truthfulness scale or the driver risk scale. In summary, this study demonstrated that, in the central USA state of Nebraska, rural DWI offenders were slightly more likely to have more severe AUD than their urban counterparts. Malek-Ahmadi & Degriorgio’s (2015) findings were consistent with the statistics found in rural, remote, and northern BC (University of Victoria, 2017a, 2017b). The primary limitation of this study was its reliance on self-reporting by the study sample. This method may have exposed the data to recall bias; however, the authors did attempt to limit purposeful deception through the use of the truthfulness scale. 64 The evidence level three observation pilot study by Brennan et al. (2013) examined one model of training remotely-located primary care physicians in screening and the brief intervention technique for AUD. This study aimed to assess the physicians’ perceived role, knowledge, confidence in screening and management of AUD; to assess satisfaction with the training session provided; and to assess the impact of the training session on physician practices. The authors utilized the Australian Institute of Health and Welfare’s (2017) definition of rural and remote, which is summarized as any resident who lives outside of a major city (Brennan et al., 2013). The comparability of this relatively loose definition with the study population of rural, remote, and northern BC is uncertain. The uncertainty is routed in the definition of a “major city,” which open to interpretation, and may vary greatly from Australia to BC. This study was not designed to assess characteristics of rural and urban residents; however, the authors reported that rural Australians consumed greater amounts of alcohol than their urban counterparts, and they experienced more alcohol-related harms such as injury, social problems, mortality, and morbidity. The alcohol consumption data was evidenced by Australian governmental statistics, which showed that up to 10% more of the rural population was placed in the “high-risk” drinking categories (Australian Institute of Health and Welfare, 2005). The assertions regarding alcohol-related harms were evidenced by multiple peer-reviewed journals. The utility of this study for the integrative review may be limited by the authors’ definition of rural, and by the fact that this was not the primary aim of this study. Nonetheless, Brennan et al.’s (2013) findings appear consistent with the statistics from BC, and with Malek-Ahmadi and Degiorgio (2015). A cross-sectional survey of family physicians (n = 40) in Washington State and Idaho State by Ferguson et al. (2003) assessed barriers to AUD treatment by both urban and rural 65 practitioners. This was an evidence level three study that utilized a Likert scale survey instrument to categorize answers as “a barrier” or “not as a barrier”. The sample of physicians was equally split between rural and urban practices. Three categories were elucidated: patient centered barrier, physician centered barrier, and system centered barrier. Overall, the patient centered barrier category, which included patient denial of the problem, and lack of patient motivation to change, was ranked as the greatest barrier (p < .001). Within a subgroup analysis, a greater number of rural than urban physicians ranked distance to treatment as a barrier (40% vs 5%, χ2 = 5.16, p = .02). This supports the idea that for rural, remote, and northern populations, access to specialist care remains a principal barrier. Limiting factors of the study include: a small sample size, a nearly entirely male sample, and a lack of randomization with sample selection. Screening The recommendations for routine screening for AUD in primary care practice settings are inconsistent between the literature reviewed here and the BC and Canadian Guidelines. The BC Guidelines suggest selective screening for patients over 19 years of age who exhibit signs and symptoms that may be attributed to alcohol use, while the Canadian Guidelines suggest that “all” primary care patients should be screened yearly in addition to when there is a clinical suspicion of AUD (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015b). Spithoff and Kahan (2015b) provided supporting literature for their recommendation, including a large meta-analysis of 48 studies, whereas the source of the BC Ministry of Health’s (2013) recommendation is unclear. Given the other screening and health maintenance demands on primary care providers’ time, it was important for this integrative 66 review to examine the selected literature regarding the effectiveness of screening, and how it relates to AUD in rural, remote, and northern populations. An evidence level three study by Navarro et al. (2011) assessed the effectiveness of increased screening and the brief intervention counseling technique for AUD in rural Australia. Navarro et al. (2011) utilized a cross-sectional survey design to gather baseline alcohol consumption, screening, and brief intervention data for 10 rural communities. This data (n=1540) was combined with population data from the Australian Bureau of Statistics to estimate the total number of drinkers in each category within the 10 experimental communities. These numbers were used to populate a decision making tool to project the potential cost savings to the Australian health care system if screening alone, or screening and the brief intervention technique, were used more frequently by rural primary care providers. The authors found that increasing annual screening rates (without any other intervention) to 100% of the patient population was the most cost-effective method for reducing heavy drinking to low-risk levels (Navarro et al., 2011). The authors cite that reduction in alcohol consumption from screening only was between 11.5% and 46%, although the reasons for this reduction remain unclear (Navarro et al., 2011). The incremental cost-effective ratio (ICER) for increasing screening to 100% of the patient population was $197 (Australian dollars) per patient to reduce their drinking to low-risk levels (Navarro et al., 2011). The authors admitted that implementation of universal screening may not be acceptable to all primary care providers, and that these interventions may not work for some populations with high rates of AUD, such as young males, because of a tendency toward more infrequent primary care visits (Navarro et al., 2011). This study did suggest that yearly screening of all rural primary care patients was a cost effective method of 67 increasing recognition of, and remission from AUD. Bias cannot be excluded in the Navarro et al. (2011) study because the authors did not detail randomization techniques, the sample demographics, or the survey tool. A significant methodological weakness in this study was that females and older adults were over-represented in their survey data, indicating that the survey may not have been completed by a representative sample of the 10 experimental communities, thus potentially biasing the results. This article supports the importance of screening for AUD in rural Australia, which is likely also true in rural, remote, and northern BC. However, what remains unclear is whether the cost-benefit analysis the authors provided would be applicable to BC because of the differences between these health care systems. Primary Care Management of Alcohol Use Disorder There are up to 350,000 individuals with some degree of AUD living in BC (British Columbia Ministry of Health, 2013). Those who live in rural, remote, and northern areas of BC have limited access to alcohol treatment beyond what a primary care provider can deliver (British Columbia Ministry of Health, 2017a; Canada Drug Rehab Addiction Services Directory, 2017; Northern Health Authority, n.d.). The care for these individuals typically falls to local primary care providers, who comprise the backbone of rural Canadian health care (Slaunwhite & Macdonald, 2015). This section will discuss findings related to both the benefits of, and barriers to, primary care management of AUD. Benefits of Primary Care Management Of the 18 articles pertaining to the research question, only four directly addressed the benefits of primary care management of AUD (Allan, 2010; Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015c, 2015a). The authors outlined a number of benefits to primary care management that can be grouped into three main themes: accessibility; patient to provider 68 relationships; and prescription medications. The accessibility theme was emphasized with a number of points: minimal wait times; proximity to home community; convenience; and increased opportunities for intervention related to more frequent appointments (Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015a, 2015c). Slaunwhite and Macdonald (2015) added to this by saying that, in rural BC, primary care providers act as the “gate-keepers” to specialist treatment, indicating that the first point of contact with the health care system is through the primary care provider. This highlights the crucial role that primary care providers play in the management of patients with AUD. To support this assertion, the authors referenced a peer-reviewed Australian study that explored the concepts that underpin rural health care. Although this study was not experimental in nature, it did highlight limited access to services beyond a primary care provider as a defining factor or rural health care. While Allan (2010) argued that primary health care workers (primary care providers fall into this broader category) were in the best position to deliver alcohol treatment, it is unclear whether Allan (2010) was referring to physical location or to existing relationships with patients seeking treatment. The patient to provider relationship theme appeared to be an important factor in primary care management of AUD. Pre-existing relationships between the patient and provider foster trust, especially when confronting addictions issues that can be stigmatizing for patients (Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015a, 2015c). An existing relationship also increased success of counseling interventions, patient retention, and longitudinal care, which may be particularly salient when considering rural, remote, and northern populations in BC (Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015a, 2015c). Access to specialist services in such settings tend to be limited, require a long wait, 69 and/or are located outside the patient’s home community; however, a strong relationship with a primary care provider can improve chances of treatment retention and success in the primary care setting (Spithoff & Kahan, 2015a). Spithoff and Kahan (2015a) provided an evidence level three summary article that was meant to highlight some of the limitations of specialist management as well as the benefits of primary care management of AUD. The authors cited a recent single-blinded randomized controlled trial comparing veterans in the United States who were treated in a primary care clinic to those who were under specialist care at an addictions clinic (Spithoff & Kahan, 2015a). The primary care cohorts were more likely to refrain from heavy drinking than those treated in the specialist care setting (OR = 2.16, 95% CI = 1.27 – 3.66) (Oslin et al., 2014). The authors attributed this finding to increased patient engagement with primary care (OR – 6.97, 95% CI = 4.04 – 12.05) and to increased naltrexone use (65.9% of primary care, and 11.5% of specialist treatment) (Oslin et al., 2014). Spithoff and Kahan (2015a, 2015c) suggested that another benefit of primary care management of AUD was the ability to prescribe medications (Spithoff & Kahan, 2015a, 2015c). They reported that many specialist treatment services rely on psychosocial interventions alone whereas a primary care provider can prescribe one of three adjunct medications in combination with psychosocial intervention to assist patients with drinking cessation (Spithoff & Kahan, 2015a, 2015c). There was some evidence to show that medications may improve AUD treatment outcomes; this will be discussed in the pharmacotherapy section below. The evidence level three prospective cohort study by Moos and Moos (2006) examined individuals (n=461) who initiated help-seeking for AUD by contacting an 70 information and referral line or detox center. To determine rates and predictors of AUD remission and relapse, follow-up interviews were completed at one, three, eight, and 16-years after entry into the study. Study retention was high with 90% of participants completing at least two of the four follow-ups, and over half (n = 276) completing the 16-year follow-up (Moos & Moos, 2006). Comparisons were made between participants who had help (professional treatment or supports groups), and those who remitted from alcohol on their own. The authors found that, at the three-year follow-up, 62.4% of those who had help were remitted, compared to 43.4% of the who did not receive help (χ2 < 11.54; p < 0.01) (Moos & Moos, 2006). This indicated that the participants who had help were significantly more likely to stop drinking. Follow-up at the 16-year mark revealed that, of those who remitted without help, 60.5% had relapsed whereas, of those who remitted with help, only 42.9% had relapsed (χ2 < 4.48; p < 0.05) (Moos & Moos, 2006). This adds further support to the importance of treatment of AUD in the more readily available primary care setting rather than through specialist treatment options. Based in the above findings, rural, remote, and northern primary patients with AUD will have a greater chance of successful, long-term remission from AUD if they receive assistance in remitting from alcohol (Moos & Moos, 2006). The primary limitations of the Moos and Moss (2006) study was that study participants were self-selected for treatment. Self-selected study participants demonstrated that they were motivated to change their drinking behaviours prior to the onset of the study. This makes it difficult to know if the benefits found were related to the existing motivation to change or to the help received. Furthermore, the lack of specifics regarding what type of help was received limits the ability to find causation for AA or professional care. Overall, the Moos and Moos (2006) study supports the importance of the primary care provider’s role because those who 71 received help with AUD treatment were more successful in attaining remission, and remaining remitted. In rural, remote, and northern BC, the primary care provider is the main contact for any patient needing help with their AUD. Access to a primary care provider is usually available and, by receiving help with AUD, patients are more likely to succeed in overcoming their AUD. Barriers to Primary Care Management No specific barriers to primary care management of AUD were identified in the literature sample for this integrative review. Although, the Canadian Guidelines suggested that individuals who suffer from severe or complex AUD, or who failed to respond to treatment, should be considered for referral to an addictions medicine specialist (Spithoff & Kahan, 2015c). This recommendation indicates that, although more severe AUD is not a specific barrier to primary care management, there may be some benefit to the patient if a referral is made to specialist care. For certain individuals, there may be medical or psychosocial barriers to office-based management of alcohol withdrawal (British Columbia Ministry of Health, 2013). The BC Guidelines provide a list of contraindications to outpatient withdrawal that may require medically supervised withdrawal in an inpatient setting (British Columbia Ministry of Health, 2013). Some of the contraindications included previous withdrawal seizures; unstable medical conditions, such as coronary artery disease or diabetes mellitus; signs of liver failure; and pregnancy (British Columbia Ministry of Health, 2013). This list of contraindications was minimally supported by one dated non-systematic review article (Myrick & Anton, 1998). The authors cite two even more dated articles from the 1980’s, but they do state that there is a lack of research-based criteria and a “pragmatic” approach should 72 be taken (Myrick & Anton, 1998). There was no other literature found to support or refute these contraindications. In the setting of rural, remote, and northern BC, patient safety is a primary concern when considering office-based alcohol withdrawal, and some cases may necessitate in-patient detoxification despite its relative lack of availability in rural, remote, and northern BC (Northern Health Authority, n.d.). Specialist Management of Alcohol Use Disorder A key part of the Canadian Guidelines, and a briefly mentioned part of the BC Guidelines, was the referral of patients with AUD to specialist services (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015c). Specialist services included: residential treatment programs; outpatient day programs; medical detoxification; addictions medicine specialist; and support groups. The findings related to the benefits of, and the barriers to specialist management of AUD are discussed below. Benefits of Specialist Management The benefits of specialist services were only briefly discussed in both the BC and the Canadian Guidelines (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015c). Both sets of guidelines suggested that patients with complex psychosocial situations, complex medical needs, or contraindications to out-patient alcohol withdrawal should be considered for specialist management (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015c). Both guidelines encouraged specialist psychosocial interventions, such as counseling or support groups, in addition to medical management delivered by the primary care provider (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015c). There is no guidance for primary care providers beyond these general recommendations and it was suggested that the patient should choose the most appealing modality (British Columbia 73 Ministry of Health, 2013). No other literature included in this integrative review addressed the benefits of specialist management of AUD. Barriers to Specialist Management A primary theme that emerged from the literature was that numerous barriers could impede patients from successfully accessing specialist services. Barrier to specialist management were found to be the to be the inverse of the benefits to primary care management. Five articles highlighted these barriers (Allan, 2010; Ferguson et al., 2003; Jonas et al., 2014; Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015a). Spithoff and Kahan (2015a) reported that rates of missed specialist appointments ranged from 30% to 75% for the initial appointment and 15% to 50% for follow-up appointments. The authors cited two recent large, multi-cite studies that directly examined missed specialist appointments in addictions medicine. Reasons for missed appointments included ambivalence towards treatment and a lack of therapeutic alliance with the specialist. Slaunwhite and Macdonald (2015) directly cited the difficulty in accessing specialist services as a significant barrier to treatment of AUD in rural, remote, and northern BC. The authors grouped barriers to specialist treatment into five themes: limited services; wait-lists; travel and cost of treatment; service suitability; and patient willingness. Slaunwhite and Macdonald (2015) reported that a total of 76% of the surveyed physicians who referred patients to treatment (n = 55, or 87.3% of the sample) reported difficulties, especially if travel outside of the patient’s home community was required. The most frequently reported barriers were limited services, wait-lists, and travel and cost of treatment (Slaunwhite & Macdonald, 2015). Pertinently, one participant said, “usually there is a wait for admission [to 74 specialist treatment], during which a patient’s alcohol abuse [sic] problem may relapse” (Slaunwhite & Macdonald, 2015, p. 340). Jonas et al. (2014) agree that limited access may be a significant barrier to obtaining specialist services. This study was a large (n = 151), evidence level one systematic review with meta-analyses of pharmacotherapeutic options for AUD (Jonas et al., 2014). However, the authors only briefly mentioned access to specialist services in the discussion section with no citation for their assertion. Although this study examined the efficacy of pharmacotherapy in-depth, it was not designed to assess barriers to specialized services. Moreover, there was no data analysis provided regarding this statement, thus limiting its utility in this context. Monetary costs associated with access to specialist care, and the cost of the treatment itself, were found to be significant barriers in two articles (Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015a). Travel, lost work, and cost of treatment were highlighted as primary financial barriers to accessing treatment. Slaunwhite and Macdonald (2015) reported that travel and cost of treatment were significant barriers to specialist care in 47.5% of their sample. No specific numbers were provided regarding how many patients were prevented from accessing specialist care in either of these articles. Patient willingness to access specialist services was a barrier identified in four of the included articles (Ferguson et al., 2003; Jonas et al., 2014; Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015a). Ferguson et al. (2003) found that 88% of the survey sample indicated patient denial, and 78% of the survey sample indicated lack of patient motivation, as the most significant barriers to accessing treatment. Interestingly, Slaunwhite and Macdonald (2015) found that only 7.5% of the respondent physicians (n=3) viewed patient willingness as a significant barrier to accessing specialist treatment. The authors stressed that 75 patient willingness “was not viewed in isolation from other factors that negatively impact patient adherence to treatment plans” (Slaunwhite & Macdonald, 2015, p. 341). The reason for the stark contrast between these two studies is unclear, but both had relatively small populations, and they were conducted in different geographical settings. Jonas et al. (2014) also reported that patient willingness may be a barrier to accessing specialist care; however, this article was focused on the efficacy of pharmacotherapy for AUD and there was no analysis or evidence provided. Hence, bias cannot be excluded from this statement. In rural, remote, and northern BC, accessibility of specialist services appears to be a significant barrier experienced most of the time (Slaunwhite & Macdonald, 2015). The literature reviewed above supports the assertion that management of AUD in rural, remote, and northern BC may be heavy reliant on primary care providers. Interventions Applicable to Primary Care The literature included in this integrative review revealed three interventions that are applicable to rural, remote, and northern primary care. These interventions included pharmacotherapy, brief interventions, and tele-health. The pertinent findings related to these three intervention techniques will be discussed below. Pharmacotherapy Three medicines – naltrexone, acamprosate, and disulfiram – are approved for the treatment of AUD in Canada (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015c). The use of pharmacotherapy in AUD treatment appears to be at odds with the current evidence for efficacy (Jonas et al., 2014). There is evidence to support the efficacy of both naltrexone and acamprosate in certain populations but actual utilization may be limited (Jonas et al., 2014). The specific prescription rates of these three medications in BC were 76 unobtainable for this integrative, despite contacting the British Columbia Medical association, the College of Pharmacists of British Columbia, and the Medical Services Plan Of British Columbia. Prescription rates are only available through Population Data BC, and require ethics approval and a research plan submission, which is beyond the scope and timeline of this integrative review. The benefits and barriers to pharmacotherapy in AUD will be discussed below. Benefits of Pharmacotherapy. Jonas et al. (2014) provided a comprehensive systematic review and meta-analysis of pharmacotherapeutic options for AUD. The authors examined 151 articles dating from 1970-2013, and excluded studies with unclear biases from their analyses. Research was graded utilizing the established guidelines from the Agency for Healthcare Research and Quality (Jonas et al., 214). Meta-analyses were conducted on 95 of the included articles. Jonas et al. (2014) found that both oral naltrexone and oral acamprosate significantly reduced drinking. To prevent the return to any drinking, the number needed to treat (NNT) for acamprosate was 12 (95% CI, 8 to 26; risk difference [RD], -0.09; 95% CI, 0.14 to -0.04) and for naltrexone was 20 (95% CI, 11 to 500; RD -0.05; 95% CI, -0.1 to 0.002) (Jonas et al., 2014). Naltrexone was also found to be effective for preventing patients from returning to heavy drinking with a NNT of 12 (95% CI, 8 to 26; RD -0.09; 95% CI, 0.13 to 0.04) (Jonas et al., 2014). Both medicines had relatively limited side effects and both were generally tolerable to patients (Jonas et al., 2014). The authors found no evidence to demonstrate efficacy for disulfiram. The major limitation to the authors’ conclusions was the significant between-study heterogeneity (I2 28% to > 60%). Additionally, the studies included in this review universally employed co-psychosocial interventions along with the pharmacotherapeutic agent. The authors were not able to control for the heterogeneous 77 psychosocial interventions, thereby making it difficult to definitively find causation with the drug alone. Pertinent to this integrative review, the authors suggested that their findings regarding efficacy of naltrexone and acamprosate may be significant to the primary care setting, citing their barriers to accessing specialist services (Jonas et al., 2014). The authors suggest this despite the relative lack of study evidence from the primary care setting in this systematic review. There is conflicting evidence regarding long-acting injectable (depot) naltrexone, which is not currently available in Canada. Jonas et al. (2014) found no evidence that it improved abstinence rates or rates of heavy drinking, but did find some evidence that it reduced the number of heavy drinking days by 4.6% (95% CI, -8.5% to -0.56%). Marienfeld, Iheanacho, Issa, and Rosenheck (2014) conducted a large (n = 101,026) study in the United States Veterans’ Health Administration to identify characteristics of patients who received depot naltrexone. Of the large sample, only 0.24% (n = 240) received depot naltrexone and the majority of those participants had concurrent psychiatric disorders. The authors did not assess the efficacy of this naltrexone modality, but they cited three recent randomized controlled trials that claim significant improvements in the number of heavy drinking days, time to first drink after abstinence, number of drinking days, and abstinence rates (Marienfeld et al., 2014). This was an evidence level three study because it was a crosssectional study without randomization. Only two of the cited trials were included in the Jonas et al. (2014) systematic review and meta-analyses, so there may be some evidence for the efficacy of depot naltrexone but it was unclear how much evidence was actually present. In Australia, an evidence level one randomized controlled trial examined what would happen to prescription rates of naltrexone and acamprosate, and alcohol-related 78 hospitalizations, if rural primary care physicians were mailed feedback letters regarding AUD statistics and general information regarding acamprosate and naltrexone (Navarro, Shakeshaft, Doran, & Petrie, 2012). There were 20 rural communities within the study area that satisfied the inclusion criteria for the study (population of 5,000-20,000, at least 100km away from an urban centre [>100,000 population], and were not involved in any other largescale alcohol-related projects). The communities were paired according to demographics, and one of each pair was randomly allocated (randomization not detailed) to the control group and one to the experimental group. All of the primary care physicians in these communities were mailed the information package. After the intervention, the authors found that, relative to the control group, the experimental group increased prescription rates for acamprosate (0.24; CI 95%, 0.13 to 0.35; p < 0.001), slightly decreased prescriptions of naltrexone (-.012; CI 95%, -0.17 to -0.06; p < 0.001) and decreased alcohol-related hospitalizations per 10,000 population (-0.07; 95% CI 95%, -0.13 to -0.01; p < 0.05) (Navarro et al., 2012). The authors also found ICER for the intervention was $3,243 Australian dollars (including reductions in hospital expenditures). That means that for every extra person prescribed medication for AUD, the overall health care costs were reduced by $3,243 Australian dollars. These findings suggested that increasing rural pharmacotherapeutic utilization could decrease alcoholrelated harm. It also provided a model that may be adaptable to rural, remote, and northern BC populations. Barriers to Pharmacotherapy. Utilization rates of pharmacotherapy for AUD in BC are unclear; however, Jonas et al. (2014) indicated that pharmacotherapy was generally under-utilized to treat AUD. Reasons for medication under-utilization were examined by Mark et al. (2003). This was a small, evidence level three, qualitative study of both 79 physicians who had treated AUD (n = 11) and patients who had been treated for AUD (n = 11). The study aimed to understand attitudes towards naltrexone use for AUD. Both groups identified “lack of knowledge” as the primary reason for under-utilization (Mark et al., 2003). The patient group reported that they were unaware that naltrexone existed and were unaware of its uses. The physician group reported skepticism about the amount of research done on naltrexone and reported a perceived lack of efficacy. Recommendations of how to overcome the barriers identified by the physician and patient focus groups were absent from this study; however, the authors suggested that both physicians and patients must be persuaded not only that naltrexone is effective, but that it is effective enough to offset the costs (Mark et al., 2003). The authors suggested that the financial cost, the risk of medical complications (such as liver injury), and the side effects (such as nausea) are all reasons for the limited use of naltrexone; this is further discussed below. Given the very small sample size, and the fact that the authors only examined naltrexone, generalizability of this study is quite limited. As indicated above, additional barriers to medication use are the actual cost of the medication, intolerable side effects (as described in the Background chapter), and medical comorbidities that are contraindications for pharmacotherapy (as described in the Background chapter). The most cost-prohibitive medication for AUD is naltrexone. Costs are $5.26 per tablet ($158 per month) in BC, and a reported similar cost in the United States (Mark et al., 2003; Province of British Columbia, 2017). Acamprosate only costs $0.80 per tablet but it must be taken three times per day ($72 per month), making it also quite expensive for patients who have to self-pay (Province of British Columbia, 2017). Disulfiram is the least expensive, costing between $0.30 and $0.80 per pill ($9 to $24 per month); 80 however, because of the lack of proven efficacy, it is likely a poor choice in most clinical situations (Province of British Columbia, 2017). In BC, some of the financial constraints for both naltrexone and acamprosate can be alleviated with special authority coverage for the medication; however, coverage only lasts for three months and may not be renewed (British Columbia Ministry of Health, 2017b, 2017c). Similarly, for Aboriginal patients covered under the Non-Insured Health Benefits (NIHB) program, naltrexone is not listed on the drug benefits list, indicating that an application for special coverage would have to be completed (Health Canada, 2016a). Acamprosate is listed on the NIHB drugs list, but does require prior approval (Health Canada, 2016a). The BC Guidelines suggest that patients should expect to use pharmacotherapy (any of the three medications) for six to twelve months at a time, potentially making cost an insurmountable barrier to longer-term naltrexone or acamprosate use (British Columbia Ministry of Health, 2013). In some cases, the use of use of pharmacotherapy may be inhibited by the stigma associated with AUD. Mark et al. (2003) suggested that patients may be embarrassed to retrieve medications for AUD at the pharmacy. The authors also found that, because naltrexone was originally used for opioid use disorder, there may be an additional stigma associated with it (Mark et al., 2003). For patients in rural, remote, and northern BC, the stigma associated with receiving medicine for AUD in a non-anonymous setting may present a significant barrier. Brief Intervention Psychosocial interventions are a mainstay of AUD management (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015b, 2015c). The most commonly utilized psychosocial intervention in the primary care setting is a counseling technique called a ‘brief intervention’ (Kaner et al., 2007; O’Donnell et al., 2014). Brief interventions can be 81 performed in five to fifteen minutes over a series of consecutive appointments. The number of appointments is not specified and can be tailored to the amount of reinforcement and support the patient requires (Kaner et al., 2007; O’Donnell et al., 2014). The goal of the brief intervention technique is for the patient to recognize his/her own drinking behaviours and to develop self-efficacy to overcome them (Barry, 2012). Both the BC and Canadian Guidelines include brief interventions in their recommendations for treating AUD; however, both sets of guidelines advise that patients with severe AUD may not respond to brief interventions alone (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015c). The benefits of, and barriers to utilizing brief interventions in the rural, remote, and northern setting will be discussed below. Benefits of brief interventions. Bertholet et al. (2005) performed a systematic review and meta-analysis examining the reduction of alcohol consumption related to brief interventions in primary care. This was an evidence level one study with robust statistical analyses. After inclusion and exclusion criteria had been applied, 24 articles were included in the review (n = 5639 total subjects) (Bertholet et al., 2005). The authors found the brief intervention counseling technique to be effective for both men and women in that it helped to reduce alcohol consumption for up to 12 months after the intervention (Bertholet et al., 2005). Pooled reductions were 50g of alcohol (95% CI, -65 to -34) per week, which equates to five standard drinks less per week, or a 15% reduction (Bertholet et al., 2005). Minimal between-study heterogeneity was found, and it accounted for one-fourth of the variance (I2 = 25.8%) (Bertholet et al., 2005). The authors concluded that brief interventions demonstrated significant reductions in alcohol consumption, and they recommended widespread use of 82 brief interventions for AUD. Furthermore, there were no negative effects reported when using the brief intervention technique in any of the included studies. The Australian study by Navarro et al. (2011) reported that, at baseline, 0.7% of those who reduce their alcohol consumption to low-risk level, did so because a primary care provider screened them for AUD and performed a brief intervention. The authors found that, if screening was completed with 100% of the patient population, and brief interventions were performed every time AUD was detected, 36% of the risky-drinkers (synonymous with the definition of “heavy-drinkers” used previously in this review) would reduce their consumption to low-risk levels (Navarro et al., 2011). The combination of screening and brief intervention was marginally more expensive than screening alone (ICER $216 Australian dollars versus $197). The increased cost was incurred because of increased time required to perform a brief intervention and increased training costs for primary care providers. The authors qualify these findings by stating that increasing screening and brief intervention ubiquitously to 100% would be difficult (discussed in the Barriers to brief intervention section below). A recent Australian pilot study examined a model for training remotely located general practice physicians in AUD screening and brief intervention techniques (Brennan et al., 2013). This pilot study was a small (n= 8), evidence level three study that provided a specialized clinical psychologist-lead one-hour training session for brief interventions. Preand post- test evaluations were performed by study participants. Respondents reported that, after the training session, their understanding of the brief intervention technique had increased by a moderate (n = 4) or significant (n = 4) degree (Brennan et al., 2013). Six months after the training session, approximately half of the physicians reported modest to 83 moderate increases in actual use of screening and brief intervention in their practices (Brennan et al., 2013). Given the extremely small size of this pilot study, generalizability is limited; however, this study does indicate that, when provided with additional training, primary care providers have the capacity to perform brief interventions in rural locations, develop the confidence to do so, and increase their use of brief intervention strategies. Two articles included in this literature review addressed the potential for electronically-delivered treatment services (Finfgeld-Connett, 2006; Staton-Tindall et al., 2012). Finfgeld-Connett (2006) provided an evidence level three, non-systematic review of multiple web-based treatment programs. The web-based treatment programs utilized motivational interviewing as the foundation for the patient interactions, which is also used in the brief intervention technique discussed above. A primary theme highlighted by the authors was that women accessed web-based treatment programs more often than men (FinfgeldConnett, 2006). The author suggests that women with AUD experience greater stigma then men do, and that the anonymity offered by electronic access may be a reasons for their increased use (Finfgeld-Connett, 2006). Finfgeld-Connett (2006) asserted that the use of home computers facilitated confidentiality and, because of this improved confidentiality, women felt more comfortable to utilize web-based treatment than other more public forms of treatment. Advantages of a web-based format were that geographical location was not a barrier as long as the individual had Internet access; importantly, marginalized populations could use free public Internet access to obtain treatment. The principal barriers to the webbased treatment modality were that English literacy was required, and that confidentiality could be compromised if public Internet access were required. Limitations of this study were that no details for statistical analyses, search methodology, or inclusion or exclusion criteria 84 were provided. Furthermore, this article was published in 2006 which, because of the advancements of technology made since that time, makes it somewhat dated. The second article that addressed electronically-delivered treatment modalities was a preliminary report on a study that examined tele-health-based motivational interviewing for AUD in rural, previously incarcerated individuals in Kentucky, USA (Staton-Tindall et al., 2012). This was an evidence level one study, with a study sample of individuals with very heavy drinking behaviours (average of 15.3 drinks per day). The study sample primarily consisted of ex-inmates who were currently on probation or parole or had recently been released. The researchers used a video conferencing tele-health machine to connect patients with therapists trained in motivational interviewing. Unfortunately, the focus of the preliminary report was not on efficacy of the intervention but rather on profiling the study sample and on describing the feasibility of the intervention. Preliminary results indicated that tele-health-based motivational interviewing may be feasible, with 72.7% of the group completing part of the sessions, and 50% of the group completing all of the sessions (StatonTindall et al., 2012). Limitations of this study were that rurality was not specifically defined in this study and the sample population was almost homogenously Caucasian males. Furthermore, the study participants may have felt compelled to complete the intervention, given their recent incarceration, to appease their parole officers and the judicial system. This may have inflated the completion rates beyond what they otherwise might have been with a different population. Nonetheless, this preliminary report does indicate that tele-health may be a viable alternative for individuals in rural, remote, and northern BC who require specialist services. 85 Barriers to brief interventions. There are a few notable barriers to the utilization of brief interventions by primary care providers. Navarro et al. (2011) highlighted that individual primary care provider styles and preferences may be a barrier to universal implementation of this counseling technique. The authors also suggest that treatment adherence is generally low among individuals with AUD; therefore, the brief intervention technique may be difficult to utilize (Navarro et al., 2011). Additionally, Navarro et al. (2011) emphasized that young males demonstrate disproportionate amounts of AUD, which is consistent with Canadian statistics, but that this population rarely accesses health care (Statistics Canada, 2014). The authors indicate that not seeking health care is a barrier to utilizing brief interventions; however, this would represent a barrier to any kind of treatment, not solely brief interventions. The final barrier to utilizing brief interventions in the treatment of AUD is the logistics of training rural, remote, and northern primary care providers (Brennan et al., 2013). By definition, these primary care providers are dispersed across a large geographical area, increasing the challenges and costs associated with training them. Brennan et al. (2013) suggest this barrier may, at least in part, be alleviated through the use of Internet-based training modalities. Primary care providers could participate in scheduled training sessions from their respective home community’s. This method could alleviate some of the difficulties associated with training rural, remote, and northern primary care providers in the brief intervention technique. 86 CHAPTER FOUR: DISCUSSION In Canada, the scope of practice of nurse practitioners includes autonomously diagnosing and managing client health conditions (Canadian Nurses Association, 2017). In BC, nurse practitioner practice is regulated by the College of Registered Nurses of British Columbia (2017b), which provides standards, limits, and conditions for nurse practitioner scope of practice. All aspects of diagnosis and treatment of AUD fall within the nurse practitioner scope of practice in BC (College of Registered Nurses of British Columbia, 2017b). This includes the diagnosis of AUD using the DSM-V criteria as well as patient counseling, ordering of prescription medications, and consulting and/or referring patients to specialist services. This literature review was tailored to be applicable to all primary care providers, particularly those who work in rural, remote, and northern BC, including both nurse practitioners and physicians. This chapter will include discussions on: the HBM as it applies to the common themes elucidated from the literature; common themes drawn from the literature regarding the role of primary care providers in rural, remote and northern BC; recommendations for nurse practitioner education pertaining to AUD; and gaps in current research pertaining to AUD treatment in rural, remote and northern Canadian communities (specifically BC). The Health Belief Model as it Applies to the Common Themes The HBM is a theoretical model that originated in the 1950’s but remains pertinent to health care today. It endeavours to explain why patients may or may not participate in behaviours that can help detect or treat disease processes and to predict future behaviours (Champion & Skinner, 2008). There are six key constructs within the HBM: perceived 87 susceptibility; perceived severity; perceived benefits; perceived barriers; cues to action; and self-efficacy. Please refer to the Background chapter and Figure 1 for further details regarding the individual constructs. The HBM was selected as the supporting theoretical model in this literature review because it explains why individuals may not address their AUD, and therefore it highlights areas where changes can be implemented to increase treatment uptake and improve patient outcomes. By applying the HBM to the research question “in the setting of rural, remote, and northern BC, what is the optimum treatment for adults with AUD,” the importance of the primary care provider’s role is emphasized because many of the changes that could improve treatment uptake could be completed at the primary care level. Furthermore, when viewed through the six constructs of the HBM, areas of weakness in the current status quo for AUD treatment are underscored. In this integrated literature review, there are five discussion themes regarding the treatment of AUD in rural, remote and northern BC. These themes are: screening for AUD; brief intervention; electronically delivered counseling; pharmacotherapy; and universal trauma-informed practice. The HBM will be applied to the five discussion themes to highlight areas that can be improved for both the patient and primary care provider regarding the recognition and treatment of AUD. When these areas for improvement are elucidated using the HBM, primary care providers will be better positioned to create tangible goals that will help move patients towards treatment for, and eventual recovery from, AUD. When referring to the six constructs of the HBM in the discussion below, the relevant construct will be italicized. The following discussion will outline the ways in which adjustments within each of the five themes can support improved primary care treatment 88 outcomes. Additional discussion will be provided regarding how the constructs of the HBM can be used to achieve treatment success and reinforce the roles of the patient and the primary care provider. Common Themes Drawn from the Literature Regarding the Role of Primary Care Providers in Rural, Remote and Northern BC For rural, remote, and northern BC populations, a primary care provider tends to be the initial (and sometimes only) access point to the health care system (Slaunwhite & Macdonald, 2015). This means that the primary care provider will be responsible for the initial recognition and diagnosis of AUD in patients and will likely be responsible for planning and overseeing the majority of the patient’s treatment regime. Spithoff and Kahan (2015a) argued that primary care providers have the capacity, knowledge, and skills to manage the majority of AUD cases; however, research from rural, remote, and northern BC demonstrates that primary care providers often encounter barriers to effective treatment of patients with AUD (Slaunwhite & Macdonald, 2015). By addressing these barriers, primary care providers could deliver more meaningful and effective treatment for patients with AUD. Considering that, on average, people in rural, remote, and northern BC drink more alcohol than the Guidelines for Low-Risk Drinking suggest, it is essential to examine treatment modalities in order to minimize the prevalence AUD in this specific population (Butt et al., 2011; University of Victoria, 2017a, 2017b). The goal of this chapter is to discuss current evidence for the care of patients with AUD in the context of the barriers faced within rural, remote and northern BC. The following sub-sections will discuss the five pertinent themes from the included literature in 89 relation to: screening for AUD; the brief intervention technique; electronically delivered counseling; pharmacotherapy; and universal trauma-informed practice. Theme One: Screening for Alcohol Use Disorder Due to differing screening recommendations between the BC and Canadian Guidelines, it was important for this integrative review to examine the supporting evidence for each of the screening recommendations and to apply this evidence to the rural, remote, and northern BC setting specifically. The Canadian Guidelines recommend at least annual AUD screening with a validated screening tool for all primary care patients, whereas the BC Guidelines recommend screening with a validation screening tool only in the presence of clinical triggers and red flags (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015b, 2015c). Considering the cumulative time investment required by the primary care provider to screen all patients annually, the benefit of universal screening should be made clear before such a practice is undertaken. Both the BC and Canadian Guidelines suggest using a single question to initially screen for AUD (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015b). The single screening question, “how many times in the past year have you had four or more drinks (women), or five or more drinks (men) in a single day?’ has been found to be 82% sensitive and 79% specific for identifying unhealthy drinking patterns (Smith et al., 2009). If a patient reports that they have exceeded these sex-specific amounts for even a single day on one occasion in the preceding year, the screening question is considered positive and an indepth assessment for AUD should be undertaken by the primary care provider (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015b). 90 In addition to helping to identify AUD, annual screening also addresses two of the key constructs of the HBM: perceived susceptibility and cues to action. The HBM indicates that, prior to a change in behaviour, the person must first recognize that they are susceptible to the disease (Champion & Skinner, 2008). Annual screening promotes perceived susceptibility to AUD, especially if the screening tool is positive. In the case of a positive screening result, there is an opportunity for discussion between the primary care provider and the patient regarding their unhealthy drinking patterns and any potential associated health consequences. Interestingly, Navarro et al. (2011) found that screening alone increased recovery rates for AUD, demonstrating that, by virtue of the act of screening, patients reduced their alcohol consumption without any formal AUD treatment. This indicates that the patient’s perceived susceptibility to AUD had been effectively highlighted through the screening questions. In the Navarro (2011) study, screening for AUD may also have acted as a cue to action, or a “wake-up call”. If patients were previously unaware that their drinking habits were placing their health at risk, the discussion between the primary care provider and the patient regarding the screening results may have acted as a stimulus for change. These findings suggest that universal screening may be an appropriate method for rural, remote, and northern BC primary care providers to increase detection of AUD, and to simultaneously begin the treatment process in some patients. Both the Canadian and the BC Guidelines recommend the single screening question as a reasonably sensitive and efficient method to initially detect cases of AUD (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015b). Additionally, the AUDIT and CAGE screening tools are suggested by both sets of guidelines for adult patients as additional or alternative options for identifying patients at risk for AUD. There was no 91 further guidance provided in either set of guidelines regarding which tool is the most appropriate tool to use in a given situation. For the identification of hazardous or harmful drinking, the 10-question AUDIT score is 92% sensitive and 94% specific whereas the fourquestion CAGE is 71% sensitive and 90% specific (Schorling, 2005; Spithoff & Kahan, 2015b). Spithoff and Kahan (2015b) suggest that this lower sensitivity of the CAGE may mean a failure to detect patients with less severe drinking habits. The higher sensitivity and specificity of the AUDIT score over the CAGE tool makes it appealing to primary care providers as a screening tool but it is also recognized that it requires more time to complete. Some primary care providers may be deterred by the additional time commitment to use the AUDIT score given a tendency toward shorter appointment times and significant pressure to see a large volume of patients. There was no additional evidence found in this integrative review to suggest which screening tool would be best suited for rural, remote, and northern BC in particular. The literature included in this integrative review suggested that, if primary care providers had sufficient time available to complete the AUDIT score, that more patients with AUD could be accurately identified. There was very limited evidence in the articles included in this integrative review to support using clinical suspicion alone to detect AUD. One meta-analysis from the United Kingdom found that primary care providers were only 41.7% sensitive and 93.1% specific for the detection of AUD in situations where a screening tool was not used (Mitchell et al., 2012). The low sensitivity of clinical suspicion alone suggests that primary care providers who use this method may not recognize AUD in more than half of their affected patients. It is unclear if the low sensitivity reported by Mitchell et al. (2012) directly translates to the use of clinical suspicion followed by a validated screening tool. Unlike the situations tested by 92 Mitchell et al. (2012), the BC Guidelines do recommend the use of a validated screening tool; however, this usage is only recommended after clinical suspicion of AUD has already been aroused. There was no evidence found in the reviewed studies that directly examined the sensitivity of clinical suspicion followed by the application of a validated screening tool. Overall, the studies included in this integrative review demonstrated that there is strong evidence to support the efficacy of validated screening tools for the detection of AUD (Schorling, 2005; Smith et al., 2009; Spithoff & Kahan, 2015b). There was a lack of evidence found to support the use of only clinical suspicion to prompt the primary care provider to utilize a screening tool. This suggests that, despite the cumulative time requirement involved in annual screening, the best method for identifying patients with AUD is annual screening of all adult patients using a screening tool; this is consistent with the recommendations made in the Canadian Guidelines (Spithoff & Kahan, 2015b). There was no source provided within the BC Guideline to support its recommendation of clinical suspicion, followed by a screening tool, and there was no further evidence found through this integrative review for this method. It is important that primary care providers in rural, remote and northern BC employ annual screening for adult patients as part of their practice. Individuals living in these areas tend to drink more alcohol per capita than the Guidelines for Low-Risk Drinking suggest, suffer significant rates of alcohol-related death, and utilize significant health care resources because of their alcohol consumption (University of Victoria, 2017a, 2017b). The time commitment required for the primary care provider to ask the single screening question is relatively minimal and the benefits could be significant. The completion of the single screening question for all adult patients in rural, remote, and northern BC could help to 93 improve AUD detection rates without significantly increasing the burden on the primary care provider, and it could act as a precursor to the final diagnosis of AUD being made using the DSM-V (American Psychiatric Association, 2013). Once a patient has been diagnosed with AUD, the next challenge for the primary care provider is determining the most appropriate therapeutic management of that particular patient. The following section will discuss the brief intervention counseling technique, as it was found to have robust evidence in the literature and is particularly applicable in the rural, remote, and northern BC setting. Theme Two: Brief Intervention The brief intervention technique is a form of motivational interviewing that highlights substance use behaviours so that patients can learn to recognize and overcome these behaviours (Barry, 2012). Within the brief intervention framework, the primary care provider works with the patient to highlight their perceived susceptibility to, and perceived severity of AUD. According to the HBM, patients must believe that they are susceptible to AUD, and that it is a serious threat to their health, before they are likely to make the changes necessary to overcome it (Champion & Skinner, 2008). In the brief intervention technique, patients undergo a series of sequential appointments. These appointments assist the patient to develop self-efficacy, which is the self-belief that they can overcome triggers to drink, maintain abstinence, and transition into remission (Barry, 2012). Perceived barriers that may inhibit patients from addressing their AUD are addressed by making strategies to overcome and avoid triggers for drinking, such as avoiding parties, replacing social drinking with other social activities, and spending time with people other than their usual drinking partners. Finally, self-efficacy is achieved through progressive goal setting, in conjunction with 94 guidance from the primary care provider on how to achieve these goals. The brief intervention technique is particularly amenable to the primary care setting because the individual sessions typically last between five and fifteen minutes and are normally repeated over multiple visits (Barry, 2012; Bertholet et al., 2005). There is no specified number of sessions that constitute a brief intervention because the number of sessions required will depend on the needs of each individual patient. Although the brief intervention technique can be applied to a number of substance use disorders, it was only examined in the context of AUD for this integrative review (Barry, 2012). Through meta-analysis, the brief intervention counseling technique was found to be effective in reducing drinking by 50g of ethanol (five standard drinks) per week in patients with AUD (Bertholet et al., 2005). The evidence is most robust for males, and for those with less severe AUD, but is less clear for women and for those with severe AUD (Bertholet et al., 2005; Spithoff & Kahan, 2015c). The literature is unclear as to whether the results of a brief intervention will typically be noted immediately or if effects are only found after the patient completes a number of sessions. Additionally, it is unclear how enduring the reductions in drinking have proven to be. For rural, remote, and northern BC, the brief intervention technique could help patients to develop self-efficacy to overcome AUD and, in turn, reduce AUD-related disease and harm. Additionally, expansion of primary care providers’ ability to perform brief interventions could minimize some of the 3.3 billion dollars spent per year in Canada on direct health care expenditures associated with AUD (Thomas, 2012). By providing effective management of AUD, the overall health care costs would be reduced because there would be less intoxication-related injury and disease, such as FASD, liver cirrhosis, and depression, 95 associated with increased alcohol consumption. Furthermore, if more primary care providers were trained in the brief intervention technique, then it could be effectively utilized within the patient’s home community. This would address one of the perceived barriers to treatment in these settings, and there would be far less incurred costs associated with transport and housing of patients during their treatment process. In BC’s Northern Health Authority in particular, there is a relatively small population spread over a large geographical area, with specialized alcohol services centralized within only a few major centres (Northern Health Authority, n.d.). This sparse population and geographical isolation acts as a perceived barrier to treatment and therefore the brief intervention technique, when applied in the context of a rural, remote, and northern BC primary care setting, could provide many benefits, including improving remission rates and reducing travel costs. One challenge with the brief intervention technique is that its utilization remains highly dependent upon the knowledge and comfort with the technique of an individual primary care provider. Brennan et al. (2013) found that many primary care providers lacked knowledge about the brief intervention technique and therefore did not use it as a treatment strategy for AUD patients. Fortunately, a one-hour face-to-face training session with a brief intervention specialist was found to improve primary care providers’ knowledge and confidence regarding brief interventions for patients with AUD (Brennan et al., 2013). The one-hour training session increased clinical use of the technique once the primary care providers returned to their home communities, suggesting that, with additional focused training, primary care providers could gain the ability and the confidence to utilize the brief intervention technique for patients with AUD. A brief intervention conducted by a trained primary care provider could be a cue to action for patients, because a primary care provider 96 can highlight behaviours and address motivations for change. Increasing the utilization of the brief intervention technique in rural, remote and northern BC has the potential to positively influence patients in a number of ways; this is well-highlighted using a number of key constructs within the HBM. In addition, expanding the use of the brief intervention technique in this setting could help patients to reduce the amount of alcohol consumed, reduce adverse health effects related to alcohol consumption, and reduce alcohol-related costs to the health care system. Theme Three: Electronically Delivered Counseling As discussed in the preceding sub-section, counseling patients is a mainstay of current AUD treatment and has been found to effectively increase rates of remission (Bertholet et al., 2005). Counseling patients within their home community provides an alternative to referring them to specialist services in a larger centre for counseling. Unfortunately, primary care providers are not always confident in the counseling techniques available for patients with AUD and, in the case of rural, remote, and northern BC, specialist services may be more difficult to access because of the sparse population distributed over a large geographical area. Utilization of electronically delivered counseling services may be one method to address the perceived barriers associated with accessing counseling services in the remote locations. Physical distance to treatment, costs of treatment, costs of lost work and time away from family could all be reduced by improving access through electronically delivered counseling services within the home community. Increasing access to specialist services in rural, remote, and northern BC could reduce perceived barriers to treatment and improve the chances that a patient with AUD would consider and engage with treatment. 97 Two articles included in this integrative review addressed the possibility of using electronically delivered counseling services (Finfgeld-Connett, 2006; Staton-Tindall et al., 2012). The Finfgeld-Connett (2006) article reviewed a number of studies that assessed Internet-based programs aimed at treating AUD. These computerized programs were mainly based in a motivational interviewing model, which included the brief intervention technique. These programs were hosted on the Internet and required the patient to log on to a specific website to participate in the counseling service. The electronically delivered counseling programs were produced by a variety of different manufacturers, making the programs themselves quite heterogeneous and limiting the researchers’ ability to draw conclusions regarding the efficacy of this treatment modality more broadly. Receiving counseling services for AUD by logging onto a website does have some potential benefits, particularly in areas where there are geographical barriers to accessing treatment, such as in rural, remote, and northern BC. The primary advantage associated with heightened electronically delivered counseling is increased accessibility because Internet access has become almost ubiquitous. An additional advantage of this modality is that, when private Internet access can be made available, confidentiality in the physical space is relatively certain (FinfgeldConnett, 2006). However, a worthwhile consideration for any Internet-based treatment modality is the risk of confidential data being “hacked” or viewed by an unauthorized party. The risks relating to confidential patient information being compromised was not specifically mentioned in the study; nonetheless, this risk warrants consideration prior to a primary care provider recommending an Internet-based treatment modality. Finfgeld-Connett (2006) suggestion that private Internet access improves confidentiality could be seen as a perceived benefit to a patient with AUD in a rural, remote and northern BC community because it 98 could allow the patient to receive treatment without fear of being stigmatized by their peer group. With public Internet access in most communities, access to this type of counseling should be nearly universal; however, due to the sensitive nature of the counseling and the public space, patients may prefer to access online treatment in a private location (FinfgeldConnett, 2006). With an Internet-based modality, a primary care provider could refer patients to a specific website, thereby facilitating appropriate AUD treatment without the patient being required to leave their home community. The online counseling programs included in the Finfgeld-Connett (2006) article were quite heterogeneous in origin, with no discussion regarding the validity of the treatment and counseling information provided within each program. Nonetheless, the potential for an Internet-based treatment program that primary care providers could prescribe is very intriguing, as referral outside of a patient’s home community is an ongoing and recognized barrier to treatment (Slaunwhite & Macdonald, 2015). Prior to being recommended to patients, the specific Internet-based treatment program would likely need to be validated by the local Health Authority to ensure that the information provided is congruent with the current standard of care. The article by Staton-Tindall et al. (2012) also addresses electronically delivered counseling services; however, in this particular study the counseling was delivered via a Telehealth video link with a live specialist counselor present in another location. Telehealth is a proprietary secure video conferencing system that facilitates consultation between rural patients and urban health care providers; it is already widely available for various health services in BC (Provincial Health Services Authority, 2017). The Provincial Health Services Authority (2017) website lists a number of specialist services that are available via 99 Telehealth, including adult mental health, but addictions medicine and addictions counseling are not currently included in this list. For rural, remote, and northern BC populations, Telehealth-delivered counseling represents a sensible option for providing AUD treatment services. A similar format to the current Telehealth system, one that is already being utilized for various specialist services in BC, could enable patients to visit their provider’s clinic for regularly scheduled counseling sessions. This could facilitate expert specialist counseling services in a local setting via the secure Telehealth video conferencing system. Two salient reasons to consider Telehealthdelivered counseling would be if a primary care provider does not have the training to perform a brief intervention or if the patient suffers from particularly severe AUD/AUD that is proving more resistant to other therapies. A potential downfall to this counseling modality is the availability of the Telehealth system. This system is widely available in BC but this does not mean it is available everywhere that patients require counseling services for AUD, and patients may still be required to travel to a clinic location to access the necessary Telehealth equipment. Theme Four: Pharmacotherapy Pharmacotherapy for AUD has been available but underutilized for a number of years because there has been some question in the past as to whether these medicines were effective (Jonas et al., 2014; Mark et al., 2003). Evidence from this integrative review demonstrated that pharmacotherapy significantly improves outcomes for patients with AUD, although it is not recommended for all patients because there are contraindications in some cases (British Columbia Ministry of Health, 2013; Jonas et al., 2014; Spithoff & Kahan, 2015c). The three on-label medications for AUD in Canada are disulfiram, acamprosate, and 100 naltrexone (British Columbia Ministry of Health, 2013). Both acamprosate and naltrexone demonstrated significant improvement in alcohol abstinence rates (NNT 20 and 12 respectively), and naltrexone alone significantly improved remission from heavy-drinking (greater than, or equal to, four drinks per day for women; greater than, or equal to, five drinks per day for men) (NNT 12) (Jonas et al., 2014). For patients with no medical reason to avoid pharmacotherapy, acamprosate or naltrexone could be considered as a part of the AUD treatment plan. There was no compelling evidence found for the usage of disulfiram in this integrative review, and as such, it does not appear to be a recommended agent. Actual utilization rates of pharmacotherapy for AUD in BC were not obtainable for this integrative review; however, the literature suggested that pharmacotherapy strategies are generally underutilized in the treatment of AUD (Jonas et al., 2014; Mark et al., 2003). It is unclear why pharmacotherapy has traditionally been underutilized for AUD, but Mark et al. (2003) suggest that there is a combination of reasons why providers have been unlikely to suggest using medicines for AUD. Principally, the small effect size was discussed as a primary reason for medication underutilizations, meaning that prescribers were unsure if the benefits of using such medications outweighed their risks (Mark et al., 2003). This integrative review found convincing evidence to the contrary of these perceptions. There is robust evidence that both acamprosate and naltrexone significantly reduce drinking, and do so with minimal adverse effects (Jonas et al., 2014). It is unclear why there is a reluctance of primary care providers to prescribe these medicines when primary care providers could expand the available treatment options in their communities by prescribing acamprosate or naltrexone to appropriately selected patients. Expansion of treatment options could improve remission rates from AUD, reduce patient transport expenditures incurred because of the 101 necessity to travel for treatment, and avoid disruption to family and employment commitments when patients are required to travel to access other treatment options. One of the challenges faced in BC involves changing the culture that already exists regarding pharmacotherapy for AUD treatment. Navarro (2012) found that increasing primary care providers’ knowledge regarding AUD prevalence and the efficacy and safety of pharmacotherapy increased the overall medication prescription rates for AUD. Pharmacotherapy options, when presented to a patient by a well-informed primary care provider, would address the perceived benefit construct of the HBM. If primary care providers accurately portrayed the efficacy statistics and the rates of adverse reactions for pharmacotherapy, then patients may be more likely to acknowledge the potential benefits of this treatment modality and consent to a trial of pharmacotherapy. Navarro (2012) found an association between increased pharmacotherapy prescription rates and a reduction in alcoholrelated hospitalizations and health care costs (Navarro et al., 2012). Navarro’s (2012) findings suggest that it is possible to increase the use of pharmacotherapy by educating primary care providers about the evidence supporting the prescription of these medications. These finding suggest that if a similar strategy were put in place in rural remote, and northern BC, an increase in prescription rates and a corresponding reduction in AUD prevalence could be anticipated. Theme Five: Universal Trauma-informed Practice Trauma-informed practice is a framework that enables a health care practitioner to acknowledge trauma that patients have experienced and places priority on the individual’s safety and autonomy (Authur et al., 2014). Trauma-informed practice seeks to rebuild a patient’s sense of control, while not requiring them to disclose specifics about the trauma. 102 Primary care providers who utilize trauma-informed practice can facilitate health care delivery in a manner that supports the physical and emotional safety while promoting patient autonomy within health care (Authur et al., 2014). Trauma is a common comorbidity found in patients with AUD (Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015b, 2015c). Trauma, irrespective of the cause, can overwhelm an individual’s available coping mechanisms and have deleterious effects on their life (Authur et al., 2014). The literature included in this integrative review highlighted the frequent co-existence of AUD and trauma, but did not link trauma as a definitive precursor to AUD (Allan, 2010; Slaunwhite & Macdonald, 2015; Spithoff & Kahan, 2015b). The included literature also highlights that Aboriginal Peoples of BC have been particularly affected by historical trauma associated with the residential school system (Slaunwhite & Macdonald, 2015). Considering that AUD and trauma frequently coexist, it was important for this integrative review to address trauma within the context of AUD treatment in rural, remote, and northern BC, by means of trauma-informed practice. By universally applying trauma-informed practice, primary care providers could ameliorate some of the perceived barriers experienced by patients seeking care for AUD. Implementation of universal trauma-informed practice for all primary care providers in rural, remote, and northern BC could help remove perceived barriers to AUD treatment and facilitate the development of a safer and more therapeutic environment for patients. Without applying utilizing trauma-informed practice, primary care providers risk misdiagnosing trauma coping mechanisms, such as AUD, as organic mental health disorders (Authur et al., 2014). Furthermore, by utilizing trauma-informed practice, primary care 103 providers can avoid re-traumatizing patients and closing off opportunities to help individuals overcome their AUD. Perhaps the most crucial step in enacting any primary care intervention is being able to therapeutically and compassionately engage with patients. If patients avoid visiting their primary care provider because they feel re-traumatized every time they access health care, they are unlikely to seek care again and they are unlikely to subscribe to any recommended treatment modality. In order to facilitate therapeutic interactions and to avoid re-traumatizing patients, the evidence included in this review suggests that primary care providers should utilize a trauma-informed practice (Authur et al., 2014). It would appear from the available evidence that trauma-informed practice should already be employed ubiquitously in today’s health care system. The studies included in this integrative review demonstrate that this is not currently happening in practice and that patients often continue to feel stigmatized by primary care providers because of their drinking (Allan, 2010; Mark et al., 2003; Slaunwhite & Macdonald, 2015). Considering that AUD and trauma frequently coexist, a much stronger emphasis should be placed on trauma training within primary care provider education. Methods to increase utilization of universal trauma-informed practice in the primary care context will be discussed in the education section below. Recommendations for Nurse Practitioner Education Regarding Alcohol Use Disorder Nurse practitioners are educated at a graduate level in BC and throughout Canada (Canadian Nurses’ Association, 2010; College of Registered Nurses of British Columbia, 2017a). Nurse practitioner graduate education programs are accredited by the Canadian Association of Schools of Nursing (CASN), which ensures a national standard of excellence 104 in nursing education (CASN, 2015). In order to affect change for the future of AUD treatment in rural, remote, and northern BC, it was important for this integrative review to discuss four of the five main themes from this literature review in the context of nurse practitioner education. The four themes that will be discussed as topics for nurse practitioner education are: AUD emphasis and pathophysiology; the brief intervention technique; pharmacotherapy specifically related to AUD; and, comorbid mental health and trauma associated with AUD. The fifth theme, electronically delivered counseling, will not be discussed in the context of graduate nurse practitioner education because further research is needed to validate this particular method of AUD treatment. The following discussion regarding nurse practitioner education will be supported using the framework set out by CASN. This framework contains six over-arching domains: knowledge; research, methodologies, critical inquiry, and evidence; nursing practice; communication and collaboration; professionalism; and leadership (CASN, 2015). These domains are further broken down into ‘essential components’ that are “core domain-related outcomes expected of students” (CASN, 2015, p. 9). The CASN domains and their essential components ensure that nurse practitioner education programs will adequately prepare students for the rigorous expectations upheld by both the nurse practitioner profession and Canadian society. The first educational topic found in this integrative review is the need for further emphasis on AUD and its pathophysiology within nurse practitioner education. It is clear from this integrative review that AUD is common across Canada, and is even more common in rural, remote, and northern BC populations (Statistics Canada, 2014, 2016b; University of Victoria, 2017a). In these locations, primary care providers routinely face multiple 105 challenges associated with treating patients with AUD. Given the prevalence of AUD and the severity of its sequelae, nurse practitioner education could benefit from an additional educational emphasis pertaining to AUD. In my own nurse practitioner education, AUD was primarily discussed in reference to sequelae, such as liver cirrhosis, but there was limited discussion related to AUD pathophysiology and treatment as its own disease process. It is unclear from the literature included in this integrative review whether or not in-depth AUDspecific education is provided for nurse practitioner students at other Canadian educational institutions. Considering the seriousness of the health, social, and financial consequences related to AUD, a specific educational emphasis is warranted. The suggested education proposed by this integrative review include: the pathophysiological processes; adverse health effects, adverse social effects; and current evidence-based treatment modalities. By emphasizing AUD within formal nurse practitioner educational, AUD could be further legitimized as a medical condition and stigmatization of patients by providers could be reduced (Slaunwhite & Macdonald, 2015). The CASN knowledge domain requires that “programs provide a comprehensive and substantive understanding of nursing knowledge, and a critical awareness of complex problems and/or new insights” (CASN, 2015, p. 10). The evidence included in this integrative review suggests that nursing knowledge could be bolstered, to the benefit of patients, if a more substantive and comprehensive understanding of AUD were included within the graduate nurse practitioner education process. One option to achieve this educational goal could be the implementation of a standardized addictions medicine module and a brief, but focused, practicum that is relevant to AUD practice. 106 The second education topic to be addressed within this integrative review is the need for formal education in the brief intervention technique. As discussed in the Findings chapter, brief interventions have been found to be effective at reducing alcohol consumption in patients with AUD and are particularly conducive to the primary care setting because of their brevity and longitudinal format (Bertholet et al., 2005). It is unclear if any nurse practitioner programs in Canada currently educate their students in the brief intervention technique. However, because of the significant rates of AUD found in rural, remote, and northern BC, evidence included in this integrative review underlined the importance of comprehensive AUD treatment within patients’ home communities (Slaunwhite & Macdonald, 2015). The CASN framework supports the inclusion of the brief intervention technique in formal nurse practitioner education because an essential education component within the CASN framework is “the ability to exercise the full scope of extended RN practice as defined by the provincial/territorial regulatory body” (CASN, 2015, p. 13). By enhancing nurse practitioners’ ability to comprehensively treat patients with AUD through education in the brief intervention technique, educational institutions would further support nurse practitioners in practicing to their full scope. By fostering full-scope nurse practitioner practice in rural, remote, and northern BC, the capacity to treat patients with AUD within their home communities could be expanded and result in greater numbers of patients engaging in treatment. Increasing the number of patients who participate in treatment for AUD could improve rates of remission and reduce disease burden. The third educational topic found in this integrative review is for nurse practitioner education to include medications for AUD. Both naltrexone and acamprosate were shown to significantly reduce drinking in patients with AUD (Jonas et al., 2014; Mark et al., 2003). 107 Although the actual utilization rates of medication for AUD in BC could not be obtained for this review, the literature included in this integrative review suggests that medications are generally underutilized in the primary care setting (Jonas et al., 2014; Mark et al., 2003). Inclusion of these medications within the formal nurse practitioner education could increase prescription rates, as seen in the Navarro (2012) study, thereby improving AUD remission rates. The CASN domain of nursing knowledge requires that educational programs provide “practice learning experiences to foster the use of best available evidence, theories, and expertise in advanced nursing” (CASN, 2015, p. 13). Naltrexone and acamprosate both meet the criteria for inclusion in the category of best available evidence for AUD treatment because there is robust clinical evidence to support their efficacy (Jonas et al., 2014). This integrative review has already established that there are numerous challenges associated with referring patients to specialist services from rural, remote, and northern BC (Slaunwhite & Macdonald, 2015). Furthermore, this integrative review has also established that expanding treatment options for AUD within a patient’s home community could increase treatment participation and increase rates of remission. By including medications specifically used for AUD treatment in nurse practitioner education, the need for referrals outside of the community could be reduced and the remission rates from AUD could be improved. The final educational topic identified by this integrative review is the need for education preparation to meet the specific health care needs of Aboriginal Peoples of BC (Slaunwhite & Macdonald, 2015). This is a large topic because it encompasses the continuing effects of the residential school system and the multi-generational historical trauma associated with it (Slaunwhite & Macdonald, 2015). The Provincial Health Services 108 Authority provides an online Indigenous cultural training program, which could be readily adopted into nurse practitioner education. The training program is “designed to increase Aboriginal-specific knowledge, enhance individual self-awareness and strengthen skills for any professional working directly or indirectly with Indigenous people” (Provincial Health Services Authority, n.d., para. 5). Inclusion of this program would enrich all future nurse practitioners’ understanding of the historical trauma experienced by Aboriginal Peoples in BC, and would reduce barriers to AUD treatment through trauma-informed practice. The CASN framework also supports this recommendation within the professionalism domain by stating that education programs must “prepare students to initiate a model of best practices, and to promote their own personal and professional growth in an advanced nursing role” (CASN, 2015, p. 16). In the UNBC School of Nursing (2017) mandate, there is currently an emphasis on Aboriginal Peoples’ health; however, the inclusion of the Public Health Service Authority’s Indigenous cultural awareness course could contribute additional education and understanding of AUD for nurse practitioners who plan to practice in rural, remote, and northern BC. The four educational topics discussed above are supported by the CASN framework and, if applied, would strengthen nurse practitioners’ understanding of AUD and encourage evidence-based treatment. This increased educational focus on AUD would reduce barriers and result in positive changes in the way that AUD is understood and treated. For nurse practitioners working in rural, remote, and northern BC, this enhanced educational preparation would provide an opportunity to immediately impact positive changes in the patients for whom they provide care. 109 Gaps in Current Research Pertaining to Alcohol Use Disorder in Rural, Remote and Northern Canadian Communities This integrative review assessed both domestic and international research from a variety of health care disciplines. Conspicuously absent from this integrative review were any studies that directly addressed the research question: in rural, remote, and northern primary care settings, what is the optimum treatment for adults with AUD? Consequently, there are a number of areas for future research that could improve the body of evidence available for treating AUD in this population. The evidence examined in this integrative review suggested that primary care management of AUD is quite common-place (British Columbia Ministry of Health, 2013; Spithoff & Kahan, 2015a, 2015b, 2015c). When examining populations in rural, remote, and northern BC, it is clear that there are a significant number of patients with AUD and that these populations suffer health problems related to drinking (University of Victoria, 2017a, 2017b). Furthermore, access to treatment services outside those offered by a primary care provider is limited (McEachern et al., 2016; Northern Health Authority, n.d.; Slaunwhite & Macdonald, 2015). Studies included in this review suggest that primary care providers have the capacity to effectively screen, assess, and treat patients with AUD; however, no studies have been undertaken to quantify or describe the success rates of primary care AUD treatment in these populations (British Columbia Ministry of Health, 2013; Jonas et al., 2014; Spithoff & Kahan, 2015a). In today’s current climate of finite health care funding and health care resources, it is important to directly study whether AUD is most effectively treated in the primary care setting or if specialized services show superior outcomes. This research 110 would enable policy makers to maximize the health care resources available for AUD treatment. Further research is also needed to assess the barriers experienced by primary care providers treating AUD in rural, remote, and northern BC. Slaunwhite and Macdonald (2015) qualitatively described the experience of family physicians in “isolated” BC, which provided some valuable insight into the current challenges facing AUD treatment providers in this setting. However, this one article is only a small piece of what is needed to thoroughly examine the barriers faced by primary care providers when treating AUD in rural, remote, and northern BC. Research to directly assess these barriers would help primary care providers to cultivate strategies to work within the current health care system. In addition, clear analysis of these barriers would help policy makers develop systemic changes to facilitate more effective AUD treatment, with the goal of reducing AUD rates and disease burden. There was robust evidence found in this integrative review for some specific AUD treatments modalities, including pharmacotherapy and the brief intervention counseling technique; however, only two studies included in this review addressed electronically delivered counseling modalities (Bertholet et al., 2005; Finfgeld-Connett, 2006; Jonas et al., 2014; Staton-Tindall et al., 2012). These two articles did not address the efficacy of these interventions, indicating that more research is warranted for both Internet-based counseling and Telehealth based counseling options. If future research supports the utilization of electronically delivered counseling services, patients in rural, remote, and northern BC could benefit from improved access to specialist treatment without needing to leave their home 111 community. Furthermore, this research could provide policy makers with the evidence to appropriately allocate health care resources in the future. 112 CHAPTER FIVE: CONCLSION Throughout my career as an emergency department RN, I observed many individuals who had consumed more alcohol then the Guidelines for Low-Risk Drinking recommend. This observation was present for many different populations, and was irrespective of gender, age, social status, race or religion. My time working as a RN in northern emergency departments compounded the sense that AUD was a much bigger health care, societal and financial issue than I had previously realized. During the course of my nurse practitioner education, I completed 532 hours of practicum experience in rural, remote and northern communities and I commonly observed alcohol-related health problems in these areas. These experiences further reinforced my belief that AUD is not only a significant cause of morbidity and mortality, but that there may also be areas that could be improved within primary care treatment of AUD. These experiences lead me to the research question for this integrative review, which was: in rural, remote, and northern primary care settings, what is the optimum treatment for adults with AUD? This integrative literature review produced some valuable insight into this very complex issue. The focus area for this integrative review was northern BC, primarily because it was the site of the author’s nurse practitioner education, but also because it is a large geographical area that is sparsely populated. In addition, unlike urban areas of BC, accessing specific resources for AUD treatment often proves challenging for patients and primary care providers alike. It was important to investigate how best to approach the challenges of treating patients with AUD in the primarily care setting because both the BC and Canadian Guidelines for AUD include recommendations for referral to specialized AUD services; however, it also quickly became evident through the integrated review that one of the most 113 salient barriers to treatment was referral outside of the patient’s home community. Another reason that northern BC was chosen as the focus area for this integrative review was because, on average, people in this region tend to drink more than is considered safe by the Guidelines for Low-Risk Drinking, and they consequently experience higher rates of alcohol-related illness and death. Irrespective of the health effects, there is also a significant financial burden associated with AUD and, in the current era of finite health care resources, it is increasingly important to maximize potential benefits from available resources. This integrative review elucidated five common themes within the literature that could provide avenues for improvement in the treatment of AUD in rural, remote, and northern BC. These themes were: screening for AUD; the brief intervention technique; electronically delivered counseling; pharmacotherapy; and universal trauma-informed practice. There was no evidence found to suggest that primary care providers currently working within the health care system in rural, remote and northern BC were underperforming in their roles; however, there were a number of recommendations for improvement that, if implemented, could enhance the AUD-specific health care available to patients within their home communities. The HBM was used to further explore and substantiate the five common themes found within the literature because it provided a foundational understanding of the complexities involved in AUD treatment, and it helped identify areas that could be enhanced within the rural, remote and northern primary care setting. Through the application of the HBM, this integrative review was able to identify barriers that could inhibit patients from participating in AUD treatment as well as identify possible methods to overcome these barriers. 114 Nurse practitioners are becoming responsible for an increasingly larger portion of primary care delivery in rural, remote, and northern BC. Accordingly, it was important for this integrative review to highlight areas within nurse practitioner education that could be enriched in order to improve the care of patients with AUD. The educational topics identified for nurse practitioner education were: AUD as a focus in education; the brief intervention technique; pharmacotherapy for AUD, and universal trauma-informed practice. These educational topics satisfy domains within the CASN accreditation framework, and as such, cultivating them could be instrumental in advancing nurse practitioner practice and the care of patients with AUD. By implementing these changes within the formal nurse practitioner education process, future graduates could gain valuable knowledge and skills to care for patients with AUD in rural, remote, and northern BC. Surprisingly, this integrative review did not find any studies that directly addressed the research question, which suggests that treatment of AUD is understudied in rural, remote, and northern populations. Since the findings from this integrative review indicate that AUD is a significant causal factor of morbidity and mortality in rural, remote, and northern populations, further research to address optimum treatment modalities in this population is warranted. Additional research is also needed to assess remission rates associated with primary care management versus specialist management of AUD. This research could assist policy makers with resource allocation to improve the care of patients with AUD. Lastly, nurse practitioners hold a unique and privileged position within the current health care system in BC. It is my hope that this integrative review will expand knowledge and awareness of the primary care treatment options for AUD and thereby improve remission rates for individuals with AUD in rural, remote and northern practice settings. 115 REFERENCES Alcoholics Anonymous. (2017). Alcoholics Anonymous. Retrieved from http://www.aa.org/ Alderazi, Y., & Brett, F. (2007). 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Strengths Limitations Utility and Important Findings Relatively large sample (n=47). The study was undertaken by a drug and alcohol service provider. Some subjects were employed by this agency, possibly biasing data. Mental health problems and a trauma history often coexist with substance users. In-depth, semi-structured interviews were used. Sociological action research framework was used. Qualitative data analysis software used. Qualitative study. Sociological action research approach. Themes were extracted from Utilized semi-structured data sets and two actions were interviews. planned: 1) Further education and support for primary care Evidence level 3 workers. 2) Promote expertise in primary care by giving specialist primary care experience in order to better facilitate intervention in primary care. Subjects not employed by the agency were made aware of the researchers ties to the agency. Possibly biasing data. Australian study – challenges faced in rural service delivery may be slightly different than my research population. Conflict arises between primary care workers and specialized drug and alcohol services when the other’s perspective/professional scope is not well understood. Drug and alcohol problems were viewed by primary care workers as treatable, but if on going, they were viewed as weakness in the individual or lack of effective treatment from the drug and alcohol worker. Missed opportunities for change exist in remote areas because of long wait times to see specialists. Utility: Elucidates some of the experiences of treating substance use in the primary 128 Article / Study Design and Overview / Evidence Level (Bertholet et al., 2005) Reduction of alcohol consumption by brief alcohol intervention in primary care. Location unspecified Systematic review and metaanalysis of (n=19) trials (n=24 articles). Examines the efficacy of brief alcohol interventions in the primary care setting for patients that are not actively seeking alcohol-related treatment. Level of evidence 1 Strengths Limitations and specialist care settings. Utility and Important Findings Extensive database searches (n=612 articles screened). Some between-study heterogeneity was found (likely due to lack of detailed study-element description). BAI is effective to reduce alcohol consumption for both men and women at 6 and 12 months post-intervention. The use of “standard treatment” as the control introduces heterogeneity. Effect can be sustained for up to 48 months. Two authors carried out study selection independently and in duplicate. A third author reviewed studies in dispute. Large pool of subjects (n=5639). Authors unable to assess if the intervention was carried out effectively. Systematic review analysis was completed using a Cochrane review tool with No grey literature searched. additional elements from the Consolidated Standards of Reporting Trials (CONSORT) statement. Meta-analysis was completed for primary outcome of alcohol consumption (expressed in grams per week). Conservative approach in the intention-to-treat analysis (missing data assigned to nochange group). Pooled reduction of 50g alcohol per week (5 drinks, or 15% mean reduction). High-quality studies were more likely to report positive effects from the intervention (x2=3.9, p=0.048). No studies reported negative effects of intervention. No effect difference was found between men and women. Minimal between-study heterogeneity accounting for 25.8% of outcome variance. 129 Article / Study Design and Overview / Evidence Level (Brennan et al., 2013) Training general practitioners in remote Western Australia in a method of screening and brief intervention for harmful use: A pilot study. Western Australia Observational pilot study examining a model for training remotely located GP’s in screening and brief intervention techniques. Evidence level 3 Article / Study Design and Overview / Evidence Level (Ferguson et al., 2003) Robust statistical analyses (between-study heterogeneity, weighted averages, percent of outcome variation r/t heterogeneity, and publication bias). Strengths Likert scale used on questionnaire. T-test analysis for pre- and post-intervention comparison. Teaching session was conducted by a specialised clinical psychologist. Educational segments included standardized screening approaches, motivational interview principles, and the validated brief intervention technique SLEEP (Setting the stage, Listening for change talk, Exploring the importance and confidence, Exchange of information, Putting it all together). Strengths Barriers stratified using Likert Limitations Utility and Important Findings Small pilot study (n=8) 6-months post intervention, respondents found training to improve knowledge and confidence with treat with BI. For confidentiality reasons (small/remote community), no demographic information was collected. Non-validates pre-workshop and post-training questionnaires. Response bias could have been introduced because postintervention surveys response rate was low. GP’s that utilized the techniques in their practices may have been more likely to respond. The intervention increased frequency of screening and BI in participants practice. Internet or tele-health training may be a feasible way to reach rural and remote GP’s for training purposes. Utility: Training primary care practitioners in brief intervention and motivational interview techniques may increase their use in practice. Australian study – training may be different for Canadian primary care providers. Limitations Utility and Important Findings Dated article Patient denial and lack of 130 Barriers to identification and treatment of hazardous drinkers as assessed by urban/rural primary care doctors. Washing and Idaho, USA Cross-sectional survey design. Aim of the study is to determine the nature of barriers for family physicians to screen, identify, and intervene with hazardous drinking and alcohol dependence. Three groups of barriers were evaluated: patient centered, physician centered, and systemic centered. Level of evidence 3 scale (widely used and accepted). Statistical analyses for distributions were performed by computerized software. Ttest was used to compare dichotomous values and then significance was checked via the chi-squared test. Small sample size of physicians surveyed (n=40). Most physicians surveyed were male (n=37). Selection bias (no randomizations). Answers from the Likert scale were grouped into dichotomous values (is a barrier, or is not a barrier), potentially limiting the depth of the conclusions drawn. Rural Washington and Idaho may not represent rural Canadian populations. patient motivation were ranked the highest barriers to identification and treatment of alcohol problems (patientcentered category). Lack of physician time and lack of addictions training were ranked as lowest on the barriers to identification and treatment. The more problematic the patient’s denial/lack of motivation, the less problematic the physician time and education were rated (negative correlation). Potentially limiting physician assessment/treatment in more severe addiction. Younger and rural-based physicians ranked system centered category (ie. distance to treatment) highest on the barrier list. Rural patients were believed to be in self-help groups or treatment significantly less than urban patients. 131 Article / Study Design and Overview / Evidence Level (Finfgeld-Connett, 2006) Web-based treatment for problem drinking. United States This is a non-systematic review of 14 exploratory and evaluative studies on webbased alcohol treatment services. Evidence level 3 Strengths Limitations Searched multiple academic databases (CINAHL, Medline, and PsychINFO) Dated article. Description of motivational interviewing, which is the theoretical basis for the webbased interventions. Utility and Important Findings Web-based treatment is more popular with woman than Non-systematic review of men. Potentially because of literature. stigma associated with seeking treatment for AUD. Treatment Not an exhaustive literature groups are typically male search. dominated, which may present a barrier for some women to Does not detail search method, utilizing this format. databases used, inclusion/exclusion criteria, or Web-based treatment can be analysis techniques. accessed by most members of society, including No detailing or discussion of marginalized populations. statistical analyses. Internet access can be a barrier for those who live rurally, or those who would require public internet connections, such as at the library (confidentiality barrier). English language literacy may also be barrier. More research is suggested to elucidate the effects of webbased treatment of patterns of abuse, problem severity, and chronicity. 132 Article / Study Design and Overview / Evidence Level (Hiller et al., 2007) Client outcomes for rural substance abuse treatment. Kentucky, USA Six-month cohort study. N=604 clients admitted to rural substance abuse treatment, ≥ 18 years old, not admitted for educational purposes (eg, DUI), and not being admitted for mental health or mental retardation (sic) purposed. Evidence level 3 Strengths Limitations Addictions Severity Index Lite Data collected seven years (ASI–Lite) instrument is a prior to publication date. validated instrument. Lack of blinding and Sample size (n=604). randomization is a weakness, which impairs this study’s Follow-up interviews were generalizability. primarily by telephone with some face-to-face sessions; This study relies solely on yielding a 95% follow-up rate. self-reporting (? Response bias). Changes over time were analysed for significance using Study participants were mostly the chi-squared test and the twhite males limiting test. generalizability. Study did not focus on alcohol use but incorporated many different substances and criminality. Kentucky population studied may be affected differently by treatment than my research population. Rural inpatient programs are likely not available in rural Canada. Utility and Important Findings Statistically significant reductions were noted with rural treatment programs for: alcohol use to intoxication p<.001, and for average number of days of alcohol use to intoxication p<.05 (these were inpatient programs). Less significant improvements were noted in the outpatient treatment modality (reasoned that the patients referred to outpatient services had less severe disease at the outset, thus had less room to improve). 133 Article / Study Design and Overview / Evidence Level (Jonas et al., 2014) Pharmacotherapy for adults with alcohol use disorders in the outpatient setting. USA article including international studies. Systematic Review of RCTs with meta-analyses to assess the benefits and harms of US FDA approved medications (naltrexone, acamprosate, and disulfiram) for reduction of drinking behaviours. Off-label medications were also included. Studies: 151 articles from 123 studies. 95 articles included in meta-analysis. Study dates from years 1970-2013. Participants: n=22803 patients with alcohol use disorders per the DSM criteria (no restrictions on age, gender, or coexisting conditions). Evidence level 1 Strengths Limitations Large and thorough systematic Substantial between-study review with meta-analysis. heterogeneity. I2 (28% greater than 60%) Robust statistical analysis: random-effects model for RCT Concurrent psychosocial meta-analyses, weighted mean interventions are briefly discussed, but not accounted difference for continuous for in the meta-analysis due to variables, risk differences for heterogeneity of the binary variables, funnel plots interventions. for bias, and I2 for heterogeneity. Costs are discussed in terms of side effects only, not financial Statistical significance was costs, or morbidity and assumed when 95% CIs of pooled results did not cross 0. mortality. Studies that were at a high or unclear risk of bias were not included in the main analysis. Graded strength of evidence by established/validated method. US FDA approved medicines are the same as the Canadian approved meds for AUD. Utility and Important Findings Naltrexone and acamprosate NNT to prevent return to any drinking was 12 and 20 respectively. NNT to return to heavy drinking was 20 for naltrexone. No statistical difference in affect between acamprosate and naltrexone for alcohol consumption. Generally tolerable to patients, with acamprosate being more tolerable than naltrexone. Disulfiram results were inconclusive. No investigation of a supervised delivery system. Naltrexone/acamprosate benefits to patients are modest but should not be overlooked given the relative tolerability of these drugs. Given their current underutilization, naltrexone 134 and acamprosate may represent a valuable adjunct in primary care because patients may be unwilling or unable to access specialist care. Article / Study Design and Overview / Evidence Level (Malek-Ahmadi & Degiorgio, 2015) Risk of alcohol abuse in urban versus rural DUI offenders. Strengths Limitations Large sample size (n=11,066) Tool uses a “truthfulness scale” to try and identify individuals who minimize their alcohol problem. Those who scored severe were omitted from the analysis (effect of this is unclear). Use of validated tool to stratify substance-related risky driving behaviours (Driver Risk Inventory II) Nebraska, USA This is a cross-sectional study that examines the relationship between living in an urban or rural setting, and the difference in alcohol use behaviours in previous DUI offenders. Evidence level 3 Statistics: t-test for continuous variables. Chi-squared for frequency among categorical variables. Cohen’s d for effect sizes differences in continuous variables. Cronbach’s alpha for internal consistency of each of the scales. Logistical regression was performed to assess associations between Self-reporting method for risk behaviours places data at risk for recall bias. This sample was already involved with the legal system, potentially increasing bias. Study participants were primarily young-adult, For patients who adhere strictly to the medication regime, their results would likely be more positive than this review demonstrates, because dropouts were assigned to the relapse category. Utility and Important Findings Rural DUI offenders are slightly more likely to report problem alcohol use compared to their urban counterparts. Rural DUI offenders are slightly more likely to belong to the Medium, Problem, and Severe alcohol subscales than their urban counterparts. Utility: Rural populations are at greater risk for risky driving behaviours, thus may have a greater health/safety benefit from treatment. 135 risk categories and urban/rural status. Caucasian, and male. Limiting generalizability. No demographic differences other than blood alcohol content, which was actually quite small (likely driven by the large sample size). Data only from Nebraska, not representative of USA as a whole, and may not be consistent with my research population. Article / Study Design and Overview / Evidence Level (Marienfeld et al., 2014) Strengths Limitations Utility and Important Findings Large sample (n=101,026) Sample is predominately males (96%) and middle-aged. Long-acting injectable depot naltrexone use in Veterans’ Health Administration: A national study. T-test for bivariate continuous data. Chi-squared test for categorical significance (those prescribe depot naltrexone and those not). Multivariate logistical regression was used to identify factors linked to filling and being prescribed a depot naltrexone prescription. Patients with severe mental illness were more likely to receive a prescription for depot naltrexone. The reasoning for this is unclear. USA This is a cross-sectional study to examine prescription rates of depot naltrexone in qualifying veterans with AUD during the 2010 fiscal year. Depot naltrexone was FDA approved in 2006. Examines prescription rates in normal clinical settings. No data on compounding factors for lack of prescriptions (liver disease or other prescriptions). No data regarding reasoning behind the decision to use naltrexone or not. Sample population may not represent my research population. Only 7.5% of those receiving naltrexone received the depot formulation (0.24% of total sample). Strengths Limitations Reasons for lack of depot naltrexone prescriptions are unclear. More research is needed. Utility and Important Findings An experienced facilitator and Dated article (though there Generalised lack of Evidence level 3 Article / Study Design and Overview / Evidence Level (Mark et al., 2003) Efficacy and tolerability of depot naltrexone has been established. 136 Barriers to the use of medication to treat alcoholism. Washington DC and Virginia, USA Qualitative design utilizing two focus groups. Aim was to understand both patient and physician attitudes towards medications used to treat alcoholism. co-facilitator chaired the focus groups. Diverse sample in the focus groups. Many barriers to prescribing medications for AUD were identified. The study did succeed in answering its research question. does not appear to be any contemporary articles addressing this question). information for patients and prescribers about naltrexone limits its use. Small sample size; n=11 physicians, and n=11 patients. Perceived lack of efficacy and perceived insufficient research dissemination to prescribers. Effect size is perceived as small. No statistical analysis of subject demographics. No electronic data analysis software was used. Only assessed naltrexone and disulfiram because that they were the only approved agents at the time. Evidence level 3. Questionable significance of each barrier identified because the study did not have a representative sample. Sample may not represent my research population. Article / Study Design and Overview / Evidence Level (Moos & Moos, 2006) Rates and predictors of relapse after natural and treated Strengths Limitations Large sample (n=461). 90% of the sample completed at least two of the four follow-up intervals. Dated article. Sample is mostly Caucasian. Cost-benefit analysis is questionable with naltrexone ($5 per pill) if patients have to pay. Programs focussed on abstinence were more likely to request disulfiram. Concerns regarding stigma may inhibit patients from seeking treatment. Primary care prescribers echoed the lack of familiarity, and reported difficulty with continuity of care. Utility and Important Findings Self-efficacy, not avoidance coping showed greater chance of successful remission. 137 remission of alcohol use disorders. USA Prospective cohort study comparing relapse and remission rates between individuals who were treated for AUD and those who were not treated. Follow up was completed one year, three years, eight years, and 16 years later. Evidence level 3 Survey: questions to assess drinking based on the DSMIII-R diagnostic criteria. Also included previously employed tools (Health and Daily Living form, and the Life stressors and Social Resource Inventory). Robust statistical analysis. Chi-squared test to compare helped, vs no help groups, as well as, AA treatment vs no AA treatment in two-three year and four-eight years groups. Two-way analysis of variance (ANOVA) was used to compare demographics and life history, and baseline drinking factors. Partial correlation and logistic regression analyses used to identify predictors of threeyear remit and 16 year relapse. Results from this study are compared with previously published study results. Sample self-selected themselves, thus may have been more motivated to change. Sample had already recognized the problem and sought help. Sample had never been in treatment before and were at relatively earlier stages of alcohol use disorder. Examining six-month windows of drinking behaviours at each follow up time may not have accounted for the sample’s entire 16 years alcohol history. Sample may not represent my research population. Treatment and/or AA were positively associated with greater rates of remission at three years. Individuals who remitted without help were more likely to relapse (relapse rate of 60%). Predictive factors for shortterm remission include: female sex, older age, and more socioeconomic resources. Predictive factors for relapse after remission: less education, lower likelihood of employment, more lifetime drinking problems, more frequent consumption when remitted, view drinking as less problematic, report less selfefficacy, and relied more on drinking to reduce tension. 138 Article / Study Design and Overview / Evidence Level (Navarro et al., 2011) Strengths Limitations Utility and important findings Large sample size (n=1540). Randomization technique is not described. The potential costeffectiveness of general practitioner delivered brief intervention for alcohol misuse: Evidence from rural Australia. Use of AUDIT tool, which is validated and widely used. Projects that if all GPs in rural Australia employed screening and BI, reduction of risky drinking to low-risk levels would improve from 0.7% (current rates) to 36% per year = cost effective way to improve drinking rates. Addresses a difficult question to research. Questions used in the survey were of unknown validity. Combining survey data with community data may limit accuracy of estimates. New South Wales, Australia Sample demographics are not clearly laid out for accurate analysis of population representation. A cross-sectional study using a survey mailed to randomly selected individuals within 10 rural communities. Data used in combination with previously published census values to model the cost effectiveness of GP delivered screening and/or BI for AUD. Evidence Level 3 Article / Study Design and Overview / Evidence Level (Navarro et al., 2012) The cost-effectiveness of tailored, postal feedback on general practitioners’ prescribing of pharmacotherapies for alcohol Appears to over-estimate effect of BI and screening compared to other studies. Strengths Australian sample may not represent my research population. Limitations Large study (n=155,170) in 20 communities. Randomization technique not described. Use of AUDIT tool (validated). More GPs in the control group (n=160) compared to the experimental group (n=115). Demographics between each Difficult to implement universal screening and BI because of independent practice preferences, education challenges in BI techniques, policy for training, and difficulty accessing young male drinkers (disproportionately high rates of risky drinking who are less likely to access care). Utility and Important Findings When GPs were informed about the number of drinker’s in their communities that could benefit from pharmacotherapy, Rx rates for acamprosate increased and naltrexone decreased (overall 139 dependence. New South Wales, Australia This is a RCT to evaluate the cost-effectiveness of tailored postal feedback on GP prescription of acamprosate and naltrexone; and to see if a change is prescription rate would impact alcohol dependence hospitalizations. community were matched in pairs, then each pair was randomized to experimental or control. Multiple imputation method was used to complete hospitalization and prescriptions rate that were retained by Medicare Australia to protect confidentiality (<8.2% of the longitudinal sample). Number of drinkers in each community was estimated by a previously completed survey, which only had a 40% response rate. This study used the number of prescriptions filled to represent the number of prescriptions written by GPs. Bias may be introduced because one drug may be filled less than the other. Evidence level 1 Funding source is divulged. Article / Study Design and Overview / Evidence Level (Shakeshaft, Petrie, Doran, Breen, & Sanson-Fisher, 2012) An empirical approach to selecting community-based alcohol interventions: Combining research evidence, rural community views and Strengths Rural community survey response rate was 39% (n=2977), which is better than governmental surveys preceding this study. Hospital admissions were recorded only if the admission ICD-10 code was alcoholrelated. This may bias data. Australian sample may not represent my research population. Limitations Professional response rate was 20% (n=41). Over-representation of women and elderly people in rural respondents. Tobit regression model did not show an association between Unclear if the professionals professionals’ characteristics were rural or urban-based. increased in pharmacotherapy use). In the quarter after the intervention was made, hospitalizations for alcohol dependence were significantly reduced. Cost-savings were found to be $3243 AUD per extra prescription (with the associated reduction in hospital costs). Utility: An increase in pharmacotherapy may reduce hospital admissions for alcohol dependence. Utility and Important Findings Rural respondents selected in order of preference: schoolbased interventions, promotion of safer drinking practices (training of premises staff and media advocacy), communitywide activity (group integration, social work, counselling services, and 140 professional opinion. and their responses. Australian sample may not represent my research population. Australia This is a cross-sectional study to elicit the alcohol-related intervention preferences of rural communities and professional. community development programs), and police activity (enforcement of liquor laws). Professional respondents selected in order: GP and hospital/ED training, schoolbased interventions, community programs, and promoting safer drinking practices. Evidence level 3 Impact of these strategies is unclear. Article / Study Design and Overview / Evidence Level (Slaunwhite & Macdonald, 2015) Alcohol, isolation, and access to treatment: Family physician experiences of alcohol consumption and access to health care in rural British Columbia Strengths Limitations Respondents had an average of 15.8 years of experience in primary care. Study response rate of 22% (n=67) limiting generalizability. Inductive theoretical framework for data analysis is appropriate given the authors did not know the response themes prior to the research. Survey instrument was not previously validated. Utility: Rural communities support integration of alcohol reducing strategies in the school system and with the community. Harm-reduction may be the most viable in the school setting. Utility and Important Findings Limited alcohol related services in rural communities (lack of: detoxification and residential care). Barriers to accessing treatment include: long wait lists, travel costs, treatment costs, transportation issues, lost 141 BC, Canada Qualitative design using a cross-sectional survey. Evidence level 3 work (opportunity costs), and family commitments Rural Coordination Centre of BC scoring system used to select physicians with rural primary care practices. Relapse on returning to home community is exceedingly common. Survey was piloted on 8 administrator and substance use researchers. Lack of First Nations specific and trauma informed care options. Minimal researchers influence over the responses because it was a survey. Lack of confidentiality when seeking treatment in small/rural communities. Study answered its original research question. Article / Study Design and Overview / Evidence Level (Spithoff & Kahan, 2015a) Strengths Limitations Utilizes contemporary research to support conclusions. This non-systematic review article. Utility: Population and geographical location are directly applicable to my integrative review. Utility and Important Findings Canada Highlights the limitations of specialist care: frequently missed appointments (30-75% no show rates), lack of accessibility (costs, transport, logistics), and the lack of therapeutic alliance between specialist and patient. Non-systematic review article. Contrasts specialist vs primary care treatment of patients with Highlights the benefits of primary care management: increased accessibility, Paradigm shift: Moving the management of alcohol use disorders from specialized care to primary care. Canadian article that is applicable to my research population. No details regarding the literature search, inclusion or exclusion criteria, or literature evaluation. 142 AUD. increased follow-up on missed appointments (longitudinal care), less costs associated with access, and an established therapeutic relationship. Evidence level 3 Article / Study Design and Overview / Evidence Level (Spithoff & Kahan, 2015b) Primary care management of alcohol use disorder and atrisk drinking. Part 1: Screening and assessment. Strengths Limitations Mostly contemporary literature included, except where more dated literature is still used as the gold-standard (validation of CAGE and AUDIT tools, and alcohol withdrawal treatment). Non-systematic review of literature. Canada This is the first of a two-part non-systematic literature review series. Aim was to create evidence-based guidance for screening and assessment of primary care patients with at-risk drinking and AUD. Utilizes Canadian and international statistics and guidelines. Utilizes RTC’s, systematic reviews, and a meta-analysis. Canadian article that is applicable to my research Not an exhaustive literature search. Primary care management for moderate to severe AUD should include: frequent BI counselling sessions, prescription AUD medications, and connecting patients to other addictions and mental health services. Utility and Important Findings All patients should be screened (using a validated screening tool) at least yearly for at-risk drinking and AUD. Screening also should include a PE and Labs. Does not detail search method, databases used, Strong association between inclusion/exclusion criteria, or mental health and substance analysis techniques. use. Strong association between trauma and substance use. Suggests screening for at-risk dependant children. 143 population. Suggests screening for drinking and driving habits. Evidence level 3 Suggests screening for children who may be at risk in the home. Article / Study Design and Overview / Evidence Level (Spithoff & Kahan, 2015c) Primary care management of alcohol use disorder and atrisk drinking. Part 2: Counsel, prescribe, connect. Strengths Limitations Mostly contemporary literature included, except where more dated literature is still used as the gold-standard (validation of CAGE and AUDIT tools, and alcohol withdrawal treatment). Non-systematic review of literature. Canada This is the second of a twopart non-systematic literature review series. Aim was to create evidence-based guidance for management of primary care patients with atrisk drinking and AUD. Evidence level 3 Utilizes Canadian and international statistics and guidelines. Utilizes RTC’s, systematic reviews, and meta-analyses. Canadian article that is applicable to my research population. Advises against prescriptions for in-home withdrawal. Utility and Important Findings BI effective for mild AUD. Counselling and Not an exhaustive literature pharmacotherapy in the search. primary care setting is as effective in reducing heavy Does not detail search method, drinking as specialized databases used, addictions management. inclusion/exclusion criteria, or analysis techniques. High-rates of engagement with primary care, trusting relationship already in place, little to no delay for treatment, frequent/long-term follow-up. Three arms of treatment in primary care: counsel, and if indicated (mod-severe AUD) prescribe and connect with addictions and mental health services. 144 If medications are prescribed early in treatment, it may improve outcomes. Council with frequent appointments. Strong relationship helps improve the success. Connect to support groups, counselling services, treatment programs, trauma services, and addictions medicine. Article / Study Design and Overview / Evidence Level (Staton-Tindall et al., 2012) Strengths Limitations Computerized randomization. Preliminary article. Full trial has not been published. Telemedicine-based alcohol services for rural offenders. Great lengths (federal confidentiality warrant, and private sessions) to maintain confidentiality for the study participants. Kentucky, United States This is a preliminary report for a RCT of the telemedicine Use of validated AUDIT tool delivered motivational to assess participants’ enhancement therapy to eligibility. previously incarcerated Predominantly young, white males in the study. This is a good representation of the population in this area, however, it limits generalizability. Utility: Mostly applicable to the rural setting; however, connecting and having patients follow up with specialized care is a barrier. Utility and Important Findings This population reports very high alcohol use, an average of 15.3 drinks per day. Only 1/3 of the population had ever received treatment for alcohol use. 2/3 of the population reported alcohol was a factor in the Alcohol use was based on self- crime that lead to reporting prior to incarceration. 145 participants on parole. This report focuses on creating a profile of at-risk rural alcohol users, describing the intervention, and describing the telemedicine-based approach. Evidence level 1 Use of the Addictions Severity incarceration. Potential to Index to grade alcohol use. introduce recall bias. Computerized randomization. Preliminary results indicate that telemedicine may be a feasible option for rural populations. 72.7% participating in some of the telemedicine session, and 50% completing all of the sessions.