Alcohol-use disorders are common, clinically important, and frequently encountered in the Emergency Department. Presentations may include intoxication, falls, trauma, overdose, self-harm, gastrointestinal bleeding, seizures, confusion, withdrawal, safeguarding concerns, or repeated alcohol-related attendances. NICE guidance provides a structured approach to identifying harmful drinking, assessing alcohol dependence, managing withdrawal, and supporting relapse prevention.
The central message is clear: alcohol misuse should be approached with clinical curiosity, dignity, and a non-judgemental attitude. Patients may minimise their drinking because of stigma, fear, shame, dependency, or previous negative healthcare experiences. A brief ED attendance may therefore represent an important opportunity to identify risk and initiate referral.
NICE CG115 covers the diagnosis, assessment and management of harmful drinking, also described as high-risk drinking, and alcohol dependence. Harmful drinking refers to a pattern of alcohol use that is already causing physical, psychological or social harm. Alcohol dependence implies a stronger syndrome, often involving craving, impaired control, tolerance, withdrawal symptoms, continued drinking despite harm, and prioritisation of alcohol over other responsibilities.
For clinicians, the distinction matters because it affects treatment goals, need for withdrawal support, risk stratification, safeguarding, psychological treatment, and whether relapse-prevention medication may be appropriate.
NICE emphasises that clinicians should build a trusting relationship and work in a supportive, empathic and non-judgemental manner. This is particularly important in emergency care, where patients may present at a point of crisis, embarrassment or vulnerability.
Good care should include privacy, dignity, clear information, avoidance of unexplained clinical jargon, and recognition that alcohol misuse may affect families and carers as well as the individual patient. Where family or carer involvement is appropriate, confidentiality must still be respected.
Assessment should not be limited to units per week. NICE recommends that clinicians consider alcohol misuse, severity of dependence, associated risks, health and social problems, and whether assisted withdrawal is required.
A useful initial assessment should explore:
In the ED, this assessment should identify immediate risk and determine whether referral to alcohol liaison, specialist alcohol services, mental health services, safeguarding teams, or inpatient medical care is required.
NICE recommends formal tools to assess the nature and severity of alcohol misuse. These tools are frequently tested in Final FRCEM-style questions because each tool has a distinct purpose.
Clinical purposeNICE-recommended tool
Identification and routine outcome measurement | AUDIT
Severity of alcohol dependence | SADQ or LDQ
Severity of alcohol withdrawal | CIWA-Ar
Nature and extent of problems arising from alcohol misuse | APQ
This distinction is important. AUDIT identifies alcohol misuse. SADQ and LDQ assess dependence severity. CIWA-Ar assesses withdrawal severity. APQ explores the wider problems caused by alcohol misuse, such as occupational, social, psychological, family or functional consequences.
NICE recommends agreeing the goal of treatment with the service user. Abstinence is the appropriate goal for most people with alcohol dependence and for those with significant psychiatric or physical comorbidity, such as depression or alcohol-related liver disease.
For harmful drinking or mild dependence without significant comorbidity, and where there is adequate social support, a moderate level of drinking may be considered if the patient prefers this and there is no strong reason to advise abstinence.
In severe dependence, or where there is significant comorbidity, abstinence is generally the safer and more appropriate target. If the patient is unwilling to aim for abstinence or engage in structured treatment, a harm-reduction plan may still be appropriate, while continuing to encourage movement towards abstinence.
Not every patient with alcohol misuse requires assisted withdrawal. However, NICE recommends considering assisted withdrawal for patients who typically drink more than 15 units of alcohol per day or score 20 or more on AUDIT.
Community-based assisted withdrawal is usually preferred when safe and appropriate. However, inpatient or residential assisted withdrawal should be considered in higher-risk situations, including very high alcohol intake, severe dependence, previous withdrawal seizures or delirium tremens, concurrent benzodiazepine dependence, significant comorbidity, cognitive impairment, homelessness, older age or poor social support.
The preferred medication for assisted withdrawal is a benzodiazepine, usually chlordiazepoxide or diazepam. In patients with liver impairment, a benzodiazepine requiring limited hepatic metabolism, such as lorazepam, may be more appropriate. Benzodiazepines should be used for withdrawal management, not as long-term treatment for alcohol dependence.
For harmful drinking and mild alcohol dependence, NICE recommends psychological interventions focused specifically on alcohol-related thoughts, behaviour, problems and social networks. These may include cognitive behavioural therapies, behavioural therapies, social network and environment-based therapies, or behavioural couples therapy where appropriate.
All interventions should be delivered by trained and competent staff, with appropriate supervision, outcome monitoring and review. Treatment should not be passive. If there is deterioration or no sign of improvement, the care plan should be reviewed.
For people with moderate or severe alcohol dependence after successful withdrawal, NICE recommends considering acamprosate or oral naltrexone in combination with psychological intervention. These medications are not substitutes for psychological treatment; they support relapse prevention as part of a structured plan.
Before starting acamprosate, oral naltrexone or disulfiram, NICE recommends a comprehensive medical assessment, including baseline urea and electrolytes and liver function tests including GGT, with consideration of contraindications and cautions.
Oral naltrexone is started after assisted withdrawal. NICE recommends starting at 25 mg daily and aiming for a maintenance dose of 50 mg daily. Patients should be warned about its effect on opioid-based analgesics, which is highly relevant in emergency care if they later present with trauma or acute pain.
Acamprosate is usually started as soon as possible after assisted withdrawal. Disulfiram may be considered when the goal is abstinence and acamprosate or oral naltrexone are unsuitable, or when the patient prefers disulfiram and understands the risks.
NICE advises against using antidepressants routinely for alcohol misuse alone. Depression or anxiety may improve after abstinence, and persistent symptoms should be reassessed after a period of abstinence before specific psychiatric treatment decisions are made.
NICE also advises that benzodiazepines should only be used for alcohol withdrawal, not as ongoing treatment for alcohol dependence.
Alcohol misuse in young people requires a cautious and developmentally informed approach. NICE recommends initial brief assessment in children and young people aged 10–17 years when alcohol misuse is identified as a potential problem with physical, psychological, educational or social consequences.
For children and young people aged 10–17 years, the usual treatment goal should be abstinence in the first instance. Individual CBT may be offered where there are limited comorbidities and good social support. Multicomponent programmes, including family-based therapies, may be more appropriate where there are significant comorbidities or limited social support.
Specialists may consider acamprosate or oral naltrexone with CBT in young people aged 16–17 years who have not engaged with or benefited from a multicomponent treatment programme, but only after careful review of risks and benefits.
The ED should not treat alcohol-related presentations as isolated events. A fall while intoxicated may indicate frailty, dependency, safeguarding risk, self-neglect, domestic abuse, mental health crisis, or severe dependence. Repeated attendances should prompt structured assessment and referral.
Key ED priorities include:
AUDIT is used for identification and routine outcome measurement.
SADQ or LDQ is used for severity of dependence.
CIWA-Ar is used for severity of withdrawal.
APQ is used for the nature and extent of problems arising from alcohol misuse.
Assisted withdrawal should be considered when daily alcohol intake is high, dependence is significant, or there is risk of withdrawal complications.
Inpatient or residential withdrawal should be considered for severe dependence, previous withdrawal seizures or delirium tremens, significant comorbidity, cognitive impairment, homelessness, older age or poor support.
After successful withdrawal in moderate or severe dependence, acamprosate or oral naltrexone may be considered with psychological treatment.
Benzodiazepines are for alcohol withdrawal, not long-term alcohol dependence.
For children and young people, abstinence is usually the initial goal, with CBT or multicomponent family-based programmes depending on comorbidity and support.
For 16–17-year-olds who fail to engage with or benefit from multicomponent treatment, specialists may consider acamprosate or oral naltrexone with CBT after careful risk–benefit review.
NICE CG115 provides a practical framework for alcohol-use disorders, moving clinicians beyond simple screening towards structured assessment, risk management, psychological intervention, safe withdrawal planning and relapse prevention. For Emergency Medicine clinicians, the key is early recognition, compassionate assessment, correct use of formal tools, and timely referral into specialist pathways. Alcohol-related attendance should be viewed not only as an acute presentation, but as an opportunity to reduce future harm.