Clinician reference tool — not medical advice. This is a clinical decision-aid intended for healthcare professionals: it gives deterministic suggestions to think with, not a diagnosis or a prescription. If you’re a patient, you’re welcome to look around — but please review anything here with your own doctor; it isn’t a substitute for personalized medical care.

Ajax Harwood Clinic · clinician reference

Alcohol use disorder — decision aid

Safety gates, then the guideline-standard options for this patient, then targeted naltrexone done properly. Canadian guideline by default; switch the lens to see where NICE and the US bodies differ.

Refer to the Naltrexone Group · Fridays 3 – 4 pm · Ajax ↓

Evidence: Screening for high-risk drinking and alcohol use disorder… 2026 · sources last checked 2026-09-24

Guideline lens

1 · Safety first

Anything here changes the plan before any medicine does. Hover for detail.

Emergency — ED now

Withdrawal risk

Same-day assessment

Opioids, liver, pregnancy, surgery

PAWSS

2 · Drinking

CCSA continuum; CMAJ 2026 screens against it instead of AUDIT-C.

“Do you ever have challenges controlling your alcohol use, or find that you continue to consume alcohol despite it causing significant problems in your work or social relationships, or with your physical or mental health?”

3 · DSM-5 criteria and goal

Criteria met (of 11)

The patient’s goal

4 · Modifiers

Withdrawal context

Kidney & liver

Other conditions & medicines

Age & weight

History & preference

Start with safety, then drinking and DSM-5.

e.g. Morning symptoms + PAWSS 2 + 4–5 criteria + Cut down.

Where the guidelines differ
TopicCanada (CMAJ 2023)UK (NICE 2011/2014)US (APA 2018 / VA-DoD 2021)
Goal of cutting downNaltrexone (Rec 10A). Acamprosate is for abstinence only.Nalmefene as needed (TA325) — not available in Canada.Naltrexone or acamprosate for either goal (APA 9).
Mild AUDPsychosocial + peer support; medication recs are for moderate–severe.Psychological intervention first; medication if no response or on request.Medication recs are for moderate–severe.
TopiramateSecond line (strong, moderate certainty).Not addressed.APA second line (2C); VA/DoD ranks it with naltrexone (strong).
DisulfiramNo recommendation.Second line for abstinence, supervised.Alternative (APA 2C; VA/DoD weak).
PregnancyPer-agent cautions; topiramate contraindicated.—No AUD pharmacotherapy (APA 14).
Withdrawal settingPAWSS ≥ 4 or prior seizure/DTs → inpatient ideally.> 30 units/day, SADQ > 30, epilepsy, prior seizure/DTs, benzodiazepine co-withdrawal → inpatient.—

Targeted naltrexone (the Sinclair Method)

Naltrexone taken before drinking, on drinking days only, while the patient continues to drink. The aim is pharmacological extinction of the reward loop rather than abstinence. It is one option within the care above, not a replacement for it.

Supported

Naltrexone for AUD: Cochrane (Rösner 2010, 50 RCTs) — heavy-drinking risk 83% of placebo. Targeted dosing has RCT support (Heinälä 2001; Kranzler 2003). NICE endorses the as-needed principle for reduction via nalmefene (TA325, 2014).

Not supported

The “cure for alcoholism” framing of the popular literature; there is no class-level systematic review of targeted dosing. And the alcohol evidence does not transfer to opioids or other drugs — naltrexone is not a general anti-addiction drug.

Counsel it correctly

The protocol fails silently when dispensed as “take one daily”. A treatment that asks the patient to keep drinking sits against the abstinence-first frame, so the “and drink” part often goes unsaid — including at the pharmacy counter.

  • Timing: 50 mg about 1 hour before the first drink, on drinking days only; not on days without alcohol.
  • The one rule: never drink without having taken it first.
  • Sig to write: “Naltrexone 50 mg: 1 tab ~1 hour before drinking, on drinking days only. Do not drink without taking it first.” Add a note to the pharmacist that this is targeted dosing.
  • Expectations: reduction over weeks to months, not an immediate effect; review drinking and liver enzymes at follow-up.
  • Opioids: confirm an opioid-free interval before the first dose; advise a wallet card for emergency and surgical care.
  • Nausea: starting at a low dose reduces adverse effects (CMAJ Table 3) — 25 mg for the first few drinking days is reasonable.
  • Explaining it to a sceptical patient: it is the same logic as varenicline — keep using while the medicine blunts the reward, and the pull fades. Liver tests and what they do and don’t show: TestSelect.
  • Co-occurring low mood or anxiety: common with AUD and a frequent driver of drinking. Guidelines advise against starting an SSRI for the AUD itself (CMAJ Rec 13; APA 12) — treat the AUD first and reassess mood; if a depressive or anxiety disorder persists, the antidepressant-choice aid is depression, and sleep is insomnia.
Coverage (Ontario). Naltrexone 50 mg is an ODB General Benefit — no Limited Use criteria, about $2.81 a tablet — so targeted dosing is not restricted by coverage. Acamprosate is Limited Use (code 531): it requires a commitment to abstain, at least 3 days’ abstinence before starting, and confirmed counselling. (ODB e-formulary, checked 2026-09-24.)

The Naltrexone Group

For anyone taking naltrexone, or thinking about it.

When
Fridays, 3 – 4 pm
Every Friday
Where
AHC group room
88 Harwood Ave S, Ajax

Free · Drop in — no need to sign up first

  • How it worksDr. Carlos Yu explains the science in plain language and answers your questions.
  • What it's really likeAnyes, a peer educator with lived experience, shares what helped her.
  • You're not doing it aloneA small, supportive group that meets every week. Share as much or as little as you like.

Open to anyone taking naltrexone or considering it — daily or targeted — and to people supporting them. Attendees don't need to have stopped drinking.

Attendance can be anonymous. Attendees are offered optional AHC registration (enables OHIP billing and follow-up); it is never a condition of attending.

Questions? 905-683-0690

All upcoming dates, printable flyer →

Guidelines

References

  1. [1]Wood E, Bright J, Hsu K, et al. Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder. CMAJ 2023;195(40):E1364–79. link
  2. [2]Screening for high-risk drinking and alcohol use disorder: update of the 2023 national clinical practice guideline. CMAJ 2026;198(17):E655. link
  3. [3]Canadian Centre on Substance Use and Addiction. Canada's Guidance on Alcohol and Health: Final Report. 2023. link
  4. [4]NICE CG115. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. 2011, last updated 2014. link
  5. [5]NICE TA325. Nalmefene for reducing alcohol consumption in people with alcohol dependence. 2014. link
  6. [6]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. Am J Psychiatry 2018;175(1):86–90. Wording here is from a mirrored copy of the official PDF — not yet checked against the publisher's version. link
  7. [7]VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Version 4.0, 2021. link
  8. [8]RPC-Naltrexone (naltrexone hydrochloride 50 mg) product monograph. Rusan Pharma Canada, 2025-06-17. Health Canada Drug Product Database. link
  9. [9]Ontario Drug Benefit e-Formulary — naltrexone 50 mg General Benefit; acamprosate Limited Use code 531 (checked 2026-09-24; formulary updated 2026-09-02). link
  10. [10]Rösner S, Hackl-Herrwerth A, Leucht S, et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev 2010;(12):CD001867. link
  11. [11]Heinälä P, Alho H, Kiianmaa K, et al. Targeted use of naltrexone without prior detoxification in the treatment of alcohol dependence: a factorial double-blind, placebo-controlled trial. J Clin Psychopharmacol 2001;21(3):287–92. link
  12. [12]Kranzler HR, Armeli S, Tennen H, et al. Targeted naltrexone for early problem drinkers. J Clin Psychopharmacol 2003;23(3):294–304. link
  13. [13]Maldonado JR, Sher Y, Das S, et al. Prospective validation study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in medically ill inpatients. Alcohol Alcohol 2015;50(5):509–18. link
  14. [14]Health Canada Drug Product Database — disulfiram: all DINs Cancelled Post Market (Antabuse 250/500 mg, 2001-05-07; queried 2026-09-24). link
  15. [15]Non-Insured Health Benefits Drug Benefit List, Winter 2018 (newest edition publicly retrievable; current list is on the Express Scripts Canada NIHB portal). link

Reference tool — not medical advice. Deterministic suggestions to think with, grounded in the sources above; clinician judgement, current product monographs and live coverage always required. Targeted naltrexone is off-label in Canada. Runs in your browser; no data is collected.