A systemic failure to address at-risk drinking and alcohol use disorders: the Canadian story.

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Can adian Medical Association. A lcohol use disorders, defined as clinic­ ally significant impairment or distress from the use of alcohol, are common in Canadian society. 1 In addition, 15% to 20% of Canadians who do not meet the criteria for an alcohol use disorder drink more than what is recommended by the low­risk guidelines. 2 Alcohol­related harms attributable to both at­ risk drinking and alcohol use disorders are responsible for 9.3% of disability­adjusted life­ years lost and 7.1% of all deaths in Canada. 3 The costs to the health care system are high. As Moyer and Finney 4 outline in their clinical review, patients with at­risk drinking and alco­ hol use disorders can be easily identified with validated screening procedures. Conversely, when physicians rely on case identification alone, patients with at­risk drinking and milder alcohol use disorders (who typically have stable lives and few consequences from drinking) are often missed. These patients, however, are at high risk of harm and of progression to more severe disease, so effective interventions are important. Evidence has shown that they respond well to brief interventions. Moyer and Finney 4 review the robust evidence for such interventions and describe how they can be delivered. Indeed, Canada's national alcohol strategy calls for widespread implementation of systematic screening and brief intervention programs in health care settings. 5 Patients with more severe alcohol use disor­ ders also respond to medical interventions, pro­ vided such interventions are more intensive. 6 These patients are often interested in treatment: increased severity of an alcohol use disorder is associated with increased perception of problems, which in turn is a predictor of treatment readi­ ness. 7 Therefore, most experts recommend that providers refer these patients to specialized addiction care. However, specialized clinics have high no­show rates and low retention in treat­ ment, 8 and real­world success rates are likely lower than those achieved in research trials. A newer treatment model may address the high no­show rates in specialized clinics through provision of addiction care at each patient's own primary care clinic. In this model, primary care providers without specialized addiction training or counselling skills deliver multiple brief coun­ selling sessions, appropriate pharmacotherapy and connections to other addiction resources. The COMBINE study 9 was designed to compare this primary care management model with spe­ cialized addiction …