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Alcohol Use Disorders

NICE Clinical guideline [CG115] Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. Last updated: Oct 2014. NICE Clinical guideline [CG100] Alcohol-use disorders: diagnosis and management of physical complications. Last updated: Apr 2017. NICE CKS Alcohol - problem drinking. Last revised May 2025.

Alcohol Misuse Guidelines

NICE recommends the following assessment tools:
 
Assessment tool Purpose
AUDIT Identification of alcohol misuse and routine outcome measure
  • 0-7: low risk
  • 8-15: increasing risk
  • 16-19: higher risk
  • ≥20: possible dependence

AUDIT PC and AUDIT-C questionnaire is shorter and can be used in primary care or where time is limited
SADQ / LDQ Assess severity of alcohol dependence

Offer motivational intervention at initial assessment
  • Consider residential rehabilitation (maximum 3 months) in those who are homeless


For harmful drinkers with mild alcohol dependence
  • 1st line: psychological intervention (e.g. cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies)
 
  • 2nd line: psychological intervention + drug (acamprosate / naltrexone)
    • NICE noted that evidence for acamprosate is less robust than naltrexone
    • Nalmefene is an option if there is no need immediate detoxification + alcohol consumption >60g per day (men) >40g per day (women) + without withdrawal symptoms

Alcohol Withdrawal Guidelines

Medically assisted withdrawal is indicated in the appropriate setting if the following are met, otherwise patient could be managed with active observation without meidcation.

>15 units per day and/or AUDIT ≥20 (possible dependence):
  • Community-based assisted withdrawal or
  • Specialist alcohol service (if there are safety concerns)

Inpatient or residential assisted withdrawal indicated if any of the following:
  • >30 units per day
  • ≥30 on SADQ
  • History of epilepsy / experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes
  • Need concurrent withdrawal from alcohol and benzodiazepines
  • Regularly drink between 15-30 units per day and significant psychiatric or physical comorbidities (e.g. chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or significant learning disability or cognitive impairment
 

Choice of regimen:
  • Community settings:  fixed dose regimen 
  • Inpatient / residential settings: fixed dose regimen or  symptom-triggered regimen

Benzodiazepine is the class of choice for medically assist withdrawal:
  • 1st line: chloridazepoxide / diazepam
  • If patient has liver impairment: lorazepam preferred
 
  • Family member or carer should preferably oversee the administration of medication
  • Monitor the patient every other day during assisted withdrawal

Use fixed dose regimen or symptom-triggered medication regimens for inpatient or residential settings
  • Last 2-3 weeks or longer

  • 1st line: psychological intervention + acamprosate / naltrexone
  • 2nd line: psychological intervention + disulfiram

CIWA-Ar is used to assess the severity of alcohol withdrawal and to decide where medication is needed or not:
  • Score ≥10 is a threshold to consider medications to treat withdrawal symptoms
 
  • 0-9: mild withdrawal symptoms
  • 10-15: moderate withdrawal symptoms
  • >15: severe withdrawal symptoms


Use a symptom-triggered regimen in hospital or where 24 hours assessment and monitoring are available
  • 1st line: benzodiazepine (chloridazepoxide / diazepam, use lorazepam in liver impairment) or carbamazepine
  • 2nd line: clomethiazole
 

 Disclaimer: NICE does not explicitly recommend a CIWA-Ar score cutoff to guide when medically assisted withdrawal is indicated., NICE recommends using clinical judegement combined with CIWA-Ar.

However, many clinical protocols and other guidelines uses approximately CIWA-Ar score of 10 as a cut-off to consider medically assisted withdrawal to prevent progression.

  • 1st line: oral lorazepam
  • 2nd line: parenteral lorazepam or haloperidol 

  • 1st line: IV lorazepam

Do not offer phenytoin to treat alcohol withdrawal seizures

References

Author: Adams Lau
Reviewer:
Last edited: 03/08/25