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].

Recommendations on advice for people who are dependent on alcohol 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] and guidelines published by the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003].

• Reducing alcohol consumption will help with possible withdrawal symptoms when detoxification takes place, and may even eliminate the need for assisted withdrawal.
• Involving family, friends, and work colleagues will help with the engagement and motivation required to reduce alcohol consumption. If the person has a good social network (who are aware of the problem), potential complications with accidents may be reduced, and safety will be increased for the person and for others.

These recommendations 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], and 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 dependent on alcohol are often malnourished and deficient in vitamins. In particular, thiamine deficiency is common due to poor diet, poor absorption (caused by gastritis), and a high demand for the vitamin (it is a coenzyme in alcohol metabolism).
• Thiamine deficiency can cause Wernicke's encephalopathy, a condition that is reversible with thiamine supplements. However, if left untreated, Korsakoff's syndrome may develop, causing irreversible brain damage.
• Dose of thiamine
• Most people who are in reasonable health with an adequate diet should receive oral thiamine 200–300 mg per day, taken in divided doses (to aid absorption), while they are undergoing detoxification or during periods when they are drinking very excessively [BNF 59, 2010].
• Lower doses (thiamine 10–25 mg) are recommended by the British National Formulary if there is a suspicion of chronic deficiency during the maintenance stage [BNF 59, 2010]. However, as tablets are most readily available at a dose of 50 mg, and it is very unlikely thiamine will cause harm at higher doses, CKS recommends that 50 mg should be taken daily.
• For the available evidence for the use of thiamine in the treatment of alcohol-dependent people, see Thiamine in alcohol-dependency.

These recommendations are in line with those made by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003]. Assisted withdrawal in primary care is not covered by current guidelines from the National Institute for Health and Clinical Excellence (NICE) concerning alcohol misuse [NICE, 2010a; NICE, 2010c]. However, this issue will be addressed in the forthcoming NICE clinical guideline Alcohol-use disorders: diagnosis and clinical management of harmful drinking and alcohol dependence, due to be published in January 2011 [NICE, 2010e].

• Not all people who are dependent on alcohol require assisted withdrawal with drugs. People with milder symptoms of moderate dependence are less likely to suffer withdrawal symptoms, and these can usually be identified by their pattern of drinking. Complications are rare in this group, with success rates of 80–90%, many of whom do not need medication.
• To provide the best chance of recovery, the person with alcohol dependence not only requires detoxification, but also needs continued psychosocial intervention and support. This care should be provided by trained specialists with input from the person's own primary health care team.

These recommendations are consistent with those made by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003]. With the exception of the use of benzodiazepines in assisted withdrawal, they are largely based on expert and consensus opinion formed from clinical experience with alcohol-dependent people. Assisted withdrawal in primary care is not covered by current guidelines from the National Institute for Health and Clinical Excellence (NICE) concerning alcohol misuse [NICE, 2010a; NICE, 2010c]. However, this issue will be addressed in the forthcoming NICE clinical guideline Alcohol-use disorders: diagnosis and clinical management of harmful drinking and alcohol dependence, due to be published in January 2011 [NICE, 2010e].

• It is important to prepare a person for detoxification by ensuring they have adequate support and giving them advice on what to expect from the process, including dispelling excessively negative expectations so they have the best chance of achieving success [DTB, 2000].
• There is evidence from a large number of randomized controlled trials that benzodiazepines are highly effective in achieving alcohol withdrawal compared with controls [Ntais et al, 2005]. Usually, chlordiazepoxide is the preferred choice (see Choice of benzodiazepine). Drugs other than benzodiazepines are not generally recommended.
• Clomethiazole may be superior to benzodiazepines in preventing alcoholic delirium, but has a greater potential for dependence, and may accumulate to toxic levels if significant hepatic impairment is present. For these reasons it should be reserved for second-line use in an inpatient setting.
• Carbamazepine may be useful if there is a history of withdrawal seizures. However, it prolongs abnormal brain activity and is more likely to lead to relapse, so it is not recommended for routine use.
• Antipsychotic drugs may be indicated if there are coexistent mental problems, but they are not as effective as benzodiazepines in reducing seizures or delirium [Mayo-Smith, 1997] and should not be used routinely.

These recommendations are in line with those made by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003], and are largely based on expert and consensus opinion. Treatment goals are beyond the scope of current guidelines from the National Institute for Health and Clinical Excellence (NICE) concerning alcohol misuse [NICE, 2010a; NICE, 2010c]. However, this issue will be addressed in the forthcoming NICE clinical guideline Alcohol-use disorders: diagnosis and clinical management of harmful drinking and alcohol dependence, due to be published in January 2011 [NICE, 2010e].

• Treatment goals (whether to aim for lifelong abstinence or responsible drinking at non-harmful levels) are contentious, but increasingly in the UK, drinking in moderation is seen as an acceptable target for some alcohol-dependent people.
• The person's acceptance of the goal is an important indicator of how likely it is to be achieved.
• It is preferable for the person who is severely dependent on alcohol to abstain completely. However, if the individual refuses to commit to this, it is better to aim for moderation than nothing at all, even with the risks associated with this approach.
• If the person has a mild dependence on alcohol, they may be deterred by lifelong abstinence. For these individuals, research has shown outcomes are at least as good with moderation as a goal as abstinence.

This recommendation is based on advice from the Driver and Vehicle Licensing Agency (DVLA) [DVLA, 2010].

• Driving with an alcohol problem without informing the DVLA is against the law, and can put the person and others in serious danger.

These recommendations are consistent with those made by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003]. With the exception of the use of acamprosate in reducing alcohol intake, they are largely based on expert and consensus opinion formed from clinical experience with alcohol-dependent people. Ongoing management of dependent drinkers who have undergone withdrawal is beyond the scope of current guidelines from the National Institute for Health and Clinical Excellence (NICE) concerning alcohol misuse [NICE, 2010a; NICE, 2010c]. However, this issue will be addressed in the forthcoming NICE clinical guideline Alcohol-use disorders: diagnosis and clinical management of harmful drinking and alcohol dependence, due to be published in January 2011 [NICE, 2010e].

Follow up and monitoring

• It is important to follow people up immediately after detoxification, as they often find the post-detoxification period difficult. They are often having to address problems that have occurred as a result of their drinking, and may be struggling to meet the expectations of friends and relatives.
• Maintaining contact over the long term with people previously treated by specialist services for alcohol dependence is an important factor in maintaining abstinence.
• Low-intensity monitoring over 1–3 years has been shown to reduce the severity of relapses (possibly through earlier referral to specialist services when needed).
• Depending on the definition used, as many as 70% of people receiving treatment for an alcohol problem will have relapsed at the 6-month follow up. At 12 months, less than 30% of people will still be in contact with a specialist service, but evidence suggests this can be increased to 80% if follow up is given by trained staff [Raistrick et al, 2006].
• The literature suggests that observations at the 3-month follow-up are a good guide to how effective a treatment is for a particular person (changes tend to occur in the first 3 months), and at 12 months it will give you a better guide to the overall benefit of treatment.

Intensive treatments

• Intensive treatments are usually undertaken by specialists and are appropriate for people with moderate to severe alcohol dependence.
• Most of the therapies are based on cognitive behavioural therapy, which is flexible, performance based (the person is given a 'to do list'), and best carried out in the community under specialist supervision.
• For evidence on the effectiveness of intensive treatments relative to each other, see The Mesa Grande project.

Acamprosate

• Acamprosate is an anti-craving drug and is useful for reducing the quantity of alcohol consumed or for maintaining abstinence, and there is evidence from randomized controlled trials that acamprosate is effective for this purpose [Bouza et al, 2004]. It is usually initiated by specialist services within a few days of successful alcohol detoxification, and its use may be continued in primary care.

Self-help manuals

• Self-help manuals have been shown in controlled trials to be effective at reducing alcohol intake (and are ranked joint fourth in the Mesa Grande), but only if the person has a low level of alcohol dependence. They are unlikely to be effective if the person is more severely dependent.

Mutual-aid groups

• The evidence to support the effectiveness of mutual-aid groups is limited by methodological difficulties, in part caused by the need for anonymity of the attendees. Alcoholics Anonymous has claimed a success rate of 65% of people remaining abstinent after 1 year, but this only applies to committed attendees, and does not take into account the high drop-out rate that is observed.

Disulfiram

• Disulfiram (Antabuse^®) is a sensitizing drug, which provokes an unpleasant reaction when alcohol is consumed concomitantly, including tachycardia, headache, flushing, nausea, and vomiting. Knowledge of this reaction deters the person from drinking alcohol. It is important to warn the person about the need for abstinence and the dangers of continuing drinking whilst taking the drug [SIGN, 2003].
• Disulfiram is sometimes indicated as an adjuvant in the treatment of chronic alcohol dependence, but should only be initiated in a hospital or specialized clinic, and by physicians experienced in its use [ABPI Medicines Compendium, 2008].
• Treatment with disulfiram requires commitment from the person receiving it, and an agreement should be undertaken to continue using the drug even when there is ambivalence. To facilitate this, the taking of the drug should be supervised by a spouse, work representative, or healthcare professional [SIGN, 2003].
• The evidence for the efficacy of disulfiram is limited to supervised use. It is effective at reducing the number of drinking days and the quantity of alcohol used in people who are adherent, even if they continue to drink. However, surprisingly, there is a lack of evidence that disulfiram increases the proportion of people who maintain total abstinence [Hughes and Cook, 1997]. It is rated as number 22 in the Mesa Grande comparison of interventions [Raistrick et al, 2006].

Naltrexone

• Naltrexone is an opioid antagonist that acts as an anti-craving drug in people who are dependent on alcohol. There is evidence that it increases the rates of abstinence, and decreases relapse rates in alcohol-dependent people who are in abstinence-orientated programmes [Schaffer and Naranjo, 1998; Garbutt et al, 1999]. In this regard, it compares favourably with acamprosate, and it is rated as number six in the Mesa Grande comparison of alcohol interventions.
• At present, naltrexone is not licensed for the purpose of preventing relapse in alcohol-dependent people, and it should be reserved for use in specialist centres rather than used in primary care [SIGN, 2003].