Alcohol use disorder

Red Flags

Severe alcohol withdrawal (delirium tremens — confusion, agitation, autonomic instability, hallucinations) — admit for IV benzodiazepine, thiamine, supportive care; mortality 5–15% untreated^[1]
Alcohol withdrawal seizure or status epilepticus — IV benzodiazepine; admit; investigate other causes (intoxication, electrolytes, head injury)^[1]
Wernicke's encephalopathy (confusion, ophthalmoplegia, ataxia) — emergency parenteral thiamine 500 mg IV TDS × 2–3 days BEFORE any glucose; do not wait for full triad^[1]
Cirrhosis with alcohol use — variceal bleeding, ascites, encephalopathy, hepatocellular carcinoma; hepatology referral; absolute alcohol cessation^[1]

First-line treatment

Interventions

Brief intervention for hazardous use^[1]
5As (assess, advise, agree, assist, arrange) for AUDIT 8–15; structured discussion of risks, units, sensible-drinking limits; arrange follow-up
Setting of care for detoxification^[1]
Outpatient detox for mild–moderate dependence with adequate support and no complications. Inpatient detox for severe dependence (>30 units/day), prior complicated withdrawal, comorbidity, pregnancy, or unstable housing
Psychosocial interventions^[1]
Motivational interviewing, cognitive behavioural therapy, relapse-prevention skills, contingency management; mutual aid (AA, SMART Recovery); family involvement; treat comorbid mental health

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Chlordiazepoxide (long-acting benzodiazepine)^[1]	Benzodiazepine — long-acting	20–30 mg PO QDS day 1, taper over 5–10 days. Symptom-triggered with CIWA-Ar; front-loading 50 mg every 1–2 h until symptoms controlled	—	First-line for alcohol withdrawal; long-acting smooths taper; switch to lorazepam if hepatic impairment or elderly
Lorazepam (short-acting; hepatic impairment)^[1]	Benzodiazepine — short-acting	1–2 mg PO/IM/IV every 4–6 h, symptom-triggered taper	—	Preferred in cirrhosis or elderly because no active metabolite; IV/IM available for severe withdrawal or DT
Thiamine (parenteral then oral)^[1]	B-vitamin	Wernicke prophylaxis: 250 mg IM/IV daily × 3–5 days. Suspected Wernicke: 500 mg IV TDS × 2–3 days, then 250 mg/day. Long-term: thiamine 100 mg PO TDS for ≥3 months	—	Give BEFORE any IV glucose to avoid precipitating Wernicke encephalopathy; oral absorption poor in dependence — start parenteral
Acamprosate^[1]	Glutamate-modulating agent	666 mg PO TDS (333 mg TDS if <60 kg)	—	Maintenance abstinence after detox; renal dose adjustment; start within 5 days of last drink and continue ≥6 months; combine with psychosocial therapy
Naltrexone (oral or IM long-acting)^[1]	Opioid antagonist	Oral 50 mg PO daily; IM 380 mg every 4 weeks	—	Reduces craving and heavy drinking days; contraindicated with current opioid use, hepatic failure; check LFTs; warn about reduced opioid analgesic response in emergency
Disulfiram^[1]	Aldehyde dehydrogenase inhibitor	500 mg PO daily × 1–2 weeks then 250 mg daily	—	Aversive — causes flushing, nausea, hypotension if alcohol consumed; supervised administration improves adherence; contraindicated in cardiac disease, psychosis, pregnancy
Baclofen (selected liver disease)^[1]	GABA-B agonist	5–10 mg PO TDS start, titrate to 30–80 mg/day	—	Useful in alcohol use with cirrhosis — does not require hepatic metabolism; sedation at higher dose; potential for misuse and seizure on abrupt withdrawal

Chlordiazepoxide (long-acting benzodiazepine)^[1]

Benzodiazepine — long-acting

Adult: 20–30 mg PO QDS day 1, taper over 5–10 days. Symptom-triggered with CIWA-Ar; front-loading 50 mg every 1–2 h until symptoms controlled
Paediatric: —

First-line for alcohol withdrawal; long-acting smooths taper; switch to lorazepam if hepatic impairment or elderly

Lorazepam (short-acting; hepatic impairment)^[1]

Benzodiazepine — short-acting

Adult: 1–2 mg PO/IM/IV every 4–6 h, symptom-triggered taper
Paediatric: —

Preferred in cirrhosis or elderly because no active metabolite; IV/IM available for severe withdrawal or DT

Thiamine (parenteral then oral)^[1]

B-vitamin

Adult: Wernicke prophylaxis: 250 mg IM/IV daily × 3–5 days. Suspected Wernicke: 500 mg IV TDS × 2–3 days, then 250 mg/day. Long-term: thiamine 100 mg PO TDS for ≥3 months
Paediatric: —

Give BEFORE any IV glucose to avoid precipitating Wernicke encephalopathy; oral absorption poor in dependence — start parenteral

Acamprosate^[1]

Glutamate-modulating agent

Adult: 666 mg PO TDS (333 mg TDS if <60 kg)
Paediatric: —

Maintenance abstinence after detox; renal dose adjustment; start within 5 days of last drink and continue ≥6 months; combine with psychosocial therapy

Naltrexone (oral or IM long-acting)^[1]

Opioid antagonist

Adult: Oral 50 mg PO daily; IM 380 mg every 4 weeks
Paediatric: —

Reduces craving and heavy drinking days; contraindicated with current opioid use, hepatic failure; check LFTs; warn about reduced opioid analgesic response in emergency

Disulfiram^[1]

Aldehyde dehydrogenase inhibitor

Adult: 500 mg PO daily × 1–2 weeks then 250 mg daily
Paediatric: —

Aversive — causes flushing, nausea, hypotension if alcohol consumed; supervised administration improves adherence; contraindicated in cardiac disease, psychosis, pregnancy

Baclofen (selected liver disease)^[1]

GABA-B agonist

Adult: 5–10 mg PO TDS start, titrate to 30–80 mg/day
Paediatric: —

Useful in alcohol use with cirrhosis — does not require hepatic metabolism; sedation at higher dose; potential for misuse and seizure on abrupt withdrawal

Safety-net

Stopping alcohol abruptly after heavy long-term use can cause fits and life-threatening withdrawal — never go cold turkey without medical supervision^[1]
Take prescribed thiamine without missing doses for at least 3 months — protects against irreversible brain damage^[1]
Tell every prescriber, dentist, and emergency clinician about disulfiram or naltrexone — interactions matter for analgesics, anaesthetics, and alcohol-containing medications^[1]

Referral criteria

Severe alcohol dependence requiring inpatient detox (DT history, seizures, severe comorbidity)Specialist addiction unit or psychiatric inpatient^[1]
Wernicke encephalopathy or alcoholic hepatitisEmergency department; gastroenterology / neurology^[1]
Pregnancy with alcohol dependenceJoint addiction and obstetric service; consider fetal alcohol spectrum disorder counselling^[1]
Comorbid severe mental illness or homelessnessMulti-agency team — psychiatry, addiction, social work^[1]

Clinical summary

Diagnosis and stepwise management of alcohol use disorder including detoxification, thiamine prophylaxis, and relapse-prevention pharmacotherapy.

References

1.MoHFW Standard Treatment Guideline — Management of Alcohol Dependence (2021); IPS Substance Use Disorders CPG; NICE CG115; ASAM National Practice Guideline (2021)