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.