Recommendations for referral are based on the clinical guidelines Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010a]. They are consistent with guidelines published by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003].

• People who are moderately or severely dependent on alcohol usually require specialist management in secondary care.
• NICE recommends that a symptom-triggered regimen is used during the medically-assisted withdrawal from alcohol, usually using a benzodiazepine, carbamazepine, or clomethiazole in combination with a recognized validated scoring system such as CIWA-Ar (the Clinical Institute Withdrawal Assessment — Alcohol, revised). This requires a setting where 24-hour assessment and monitoring are available [NICE, 2010a].
• The management of alcohol-related complications, including psychiatric complications [SIGN, 2003], will require levels of expertise not available in primary care [NICE, 2010a].
• The decision on whether to admit for immediate (unplanned) treatment or refer for elective (planned) treatment should be made using clinical judgement, and according to the availability of local services. Ideally, a planned approach is preferred because this is generally considered to be more effective in facilitating long-term abstinence. However, this has to be balanced against the possibility of life-threatening complications developing in people who stop using alcohol abruptly [NICE, 2010a].