16. Alcohol care in acute hospitals
Source: gov.uk (2025-11-28)

How to care for people with alcohol-use disorders in acute hospitals, covering assessment, providing a multidisciplinary approach, managing withdrawal, treating complications and planning discharge to ensure continuity of care with community alcohol treatment services.

16.1 Main points

People with alcohol-use disorder present to acute hospitals with a wide range of primary diagnoses. The presence of alcohol-use disorder may not always be obvious to the patient or to clinical staff. There will need to be a system in place for alcohol risk screening and assessing the severity of alcohol-use disorder among all inpatients throughout the hospital.

Acute hospitals will need to have resources and staff with the skills to assess patients with alcohol-use disorders and plan care in relation to their alcohol-use disorders and any co-occurring physical and mental health conditions.

Patients admitted to hospital, who are assessed as drinking in a dependent way, may need medically assisted withdrawal during their inpatient stay. Care plans will need to include appropriate pharmacological interventions for medically assisted withdrawal, including:
- baseline testing
- medication regimens
- ongoing monitoring
- psychosocial support
Hospitals will need protocols or guidelines in place for assessing and managing withdrawal treatment.

In most cases, an acute hospital is the most appropriate setting for patients experiencing complications of alcohol withdrawal, and patients may present to emergency care or be referred from community services because they are experiencing or at significant risk of:
- acute alcohol withdrawal
- seizures
- delirium tremens
- Wernicke’s encephalopathy (WE)
These complications can be very serious and require immediate, skilled management to avoid escalation and potentially life-threatening or life-changing outcomes.

Patients with alcohol dependence and co-occurring physical and mental health conditions, and those whose health is deteriorating, will also be referred to acute hospitals, sometimes in crisis. These patients should not be denied care because they are intoxicated. If they are not able to participate in an assessment, they should be regularly reviewed to manage clinical risks until a more detailed psychosocial assessment is possible. These patients require specialist multidisciplinary assessment and care planning.

On discharge from hospital, all patients with alcohol dependence should be offered referral for ongoing treatment and support in mental health, alcohol treatment and other community services as appropriate and, where indicated, specialist secondary care for co-occurring health conditions.

16.2 Introduction

This chapter is about managing alcohol-use disorders and complications of alcohol use in acute hospital settings. It focuses on:
- assessing need and risk
- decisions about admission to hospital
- pharmacotherapy for managing alcohol withdrawal, relapse prevention and the most severe complications of alcohol withdrawal
Alcohol-use disorder (AUD) has a disproportionate impact on emergency department attendances and hospital admissions. Research has estimated that 1 in 5 adults admitted to hospital in England drinks alcohol at harmful levels. As many as 1 in 10 adults admitted to hospital are alcohol dependent (Roberts and others, 2019).

All levels of AUD increase the lifetime risk of alcohol-related conditions, and risk increases with severity of the AUD. There are over 20 wholly alcohol-attributable or ‘alcohol-specific’ conditions in the International Classification of Diseases 11th Revision (https://icd.who.int/en/). These are conditions that are specifically caused by alcohol, for example alcohol poisoning or alcohol-related liver disease (ARLD). There are over 200 partially alcohol-attributable or ‘alcohol-related conditions’, which include all alcohol-specific conditions. They also include conditions where alcohol use is a known cause in some but not all cases, for example high blood pressure, various cancers and falls (Jones and Bellis, 2014; Rehm and others, 2010).

Patients with AUD can present to any team in the hospital, either through the elective route or the emergency route. Patients can arrive at the emergency department with a range of conditions that can lead to alcohol-related emergency admissions. As well as acute alcohol withdrawal, research (Phillips and others, 2019) has shown that these may include (but are not limited to):
- mental health conditions
- poisonings (including overdoses)
- incidents such as near drowning
- head injury
- laceration
- central nervous system conditions
- cardiovascular conditions
- diabetic conditions
- gastrointestinal conditions
- haematological conditions
A sustainable and well-organised hospital-wide system needs to be in place to ensure hospitals can identify and care for patients with AUD.

For detailed guidance on pharmacological interventions used in the treatment of alcohol dependence and complications of alcohol withdrawal, see chapter 10 on pharmacological interventions.

People with alcohol dependence often have complex needs or experience multiple disadvantage and some people will need more flexible approaches to engagement and delivering these interventions. They will also require integrated ongoing care and support on discharge. For example, see chapter 21 on people experiencing homelessness.

16.3 Main elements of alcohol care in acute settings

The main elements of alcohol care in acute hospitals are as follows. Hospitals should:
- screen all inpatients for AUD (see chapter 3 on identification and brief interventions)
- assess the severity of AUD to inform the appropriate intervention (see chapter 4 on assessment and treatment and recovery planning)
- identify need and manage medically assisted withdrawal from alcohol during admission to hospital
- screen for important comorbidities such as ARLD or mental health conditions and arrange access to appropriate treatment
- provide meaningful psychoeducation (learning about their condition and ways to manage it) and support for people being admitted to hospital with alcohol-related conditions
- organise access to community alcohol treatment services, peer support organisations and mutual aid groups
- collaborate with other local commissioning and provider agencies to ensure they have integrated pathways across primary care, secondary care and community care
16.4 Secondary care alcohol specialist teams can improve care

In some hospitals, specialist staff are organised as alcohol specialist teams. There are various terms used to describe secondary care specialist alcohol services in the UK. For example, alcohol liaison services or alcohol care teams (ACTs). There is also variation in how these services are configured.

This guideline uses the term ACTs, meaning multidisciplinary secondary care specialist alcohol services that are broadly in line with the consensus-based ‘core service descriptor’, available on NHS England’s Alcohol care teams in district general hospitals: resources page (https://www.england.nhs.uk/publication/alcohol-care-teams-in-district-general-hospitals-resources/). This includes having the appropriate numbers of specialist staff for the size of the hospital site it covers.

Services that provide only in-reach from community alcohol services are a valuable accompaniment to ACTs, but these work best with an optimally staffed ACT within the hospital. Hospitals with no ACT or specialist alcohol provision as part of mental health liaison services should still try to implement the requirements for managing alcohol dependence in the sections below, within their resources and in line with local need.

16.5 Identifying alcohol-use disorders and alcohol health risk

Patients with AUD often do not recognise the extent of their alcohol use, or that it may be causing them harm, so admission to hospital is an opportunity for intervention for all patients with AUD.

Staff throughout the hospital should be able to:
- routinely screen inpatients for alcohol health risk
- provide brief advice for people who drink at increasing-risk and harmful (higher-risk) levels
- refer people with possible dependence for specialist assessment
Patients who have not approached community alcohol treatment services before may be having their AUD identified for the first time when they present to an acute hospital. Any alcohol use can carry a significant stigma for people across different social groups, cultures and religions. So, hospitals need to work with them sensitively and confidentially to help them recognise risk or ongoing problems, which is vital to help them change behaviour.

Hospitals should promote a culture that destigmatises AUD. They should also provide education and training to medical, nursing and other colleagues across the trust, and work strategically with stakeholders in the hospital system and wider community to monitor the effectiveness of treatment pathways.

The National Institute for Health and Care Excellence (NICE) public health guideline Alcohol-use disorders: prevention (https://www.nice.org.uk/guidance/ph24) (PH24) recommends the ‘alcohol use disorders identification test’ (AUDIT), available on the Alcohol use screening tests page (https://www.gov.uk/government/publications/alcohol-use-screening-tests), to identify risk levels from alcohol use. There are short forms of AUDIT (which were originally developed as pre-screens) if time is limited. Using AUDIT tools is covered in detail in chapter 3 on identification and brief interventions.

When assessing alcohol risk in people aged 17 and under, you should assess their ability to consent to alcohol-related interventions and treatment. Some will require parental or carer involvement. You can find more about assessing alcohol risk in people aged 17 and under in section 23.4.4 of chapter 23 on alcohol treatment and support for young people.

16.6 Managing alcohol dependence in acute hospitals

Acute hospitals can effectively manage the care of patients with alcohol dependence by making sure that:
- they have a strategy and operational systems in place to identify and manage alcohol-use disorders and alcohol-related harms
- they work with commissioners and partner organisations to build effective care pathways throughout the alcohol treatment system
- they have clear alcohol-related policies and procedures, make staff aware of them and provide staff training to apply them
- they have governance structures to monitor hospital data, audit clinical practice and encourage quality improvement
- staff throughout the hospital are trained to identify and manage AUD
Hospitals should also make sure that there are specialist staff with the appropriate competencies (Philips and others, 2020).

If staff have these competencies, they will be able to:
- undertake a comprehensive alcohol assessment and monitor the patient’s progress
- provide the specialist advice and care to enable evidence-based, high-quality treatment across the hospital system
- oversee the identification and management of all aspects of medically assisted withdrawal, and its complications, across a range of clinical presentations
- deliver psychosocial interventions (such as motivational interviewing) to engage patients to address their AUD (see chapter 5 on psychosocial interventions)
- safely discharge the patient, or transfer their care to the community
- oversee training to deliver alcohol brief interventions in the hospital
16.7 Alcohol assessment

You can find detailed guidance on specialist alcohol assessment in chapter 4 of this guideline. In this section, we focus on aspects of assessment that should occur in an acute hospital setting. You will often have to do an initial assessment with patients in emergency care.

There should be clinicians competent to carry out an assessment of:
- immediate alcohol-related risk as well as a specialist diagnosis of alcohol dependence
- severity of dependence
- the potential impact of dependence on a patient’s treatment and recovery
- risk of complications of withdrawal
Research has shown that delirium tremens and WE are under-recognised conditions (Schuckit, 2014; Harper, 1983; Naidoo and others, 1996). Education and awareness of these conditions will help with early recognition, prevention and poor patient outcomes.

Patients should not be refused assessment because they are intoxicated. Clinicians will need to assess the patient’s degree of intoxication and immediate risk. A series of assessments of risk and temporary inpatient admission may be necessary for people who are intoxicated. Where there is a proper reason to think that the patient may lack capacity to make decisions about alcohol consumption, a capacity assessment should be carried out.

16.7.1 Assessment considerations

If a patient’s initial clinical assessment indicates immediate risk or an AUDIT indicates potential alcohol dependence, they should receive further assessment. At all stages, assessment should consider risk from:
- alcohol withdrawal
- alcohol withdrawal seizures (see section xx-xxxx-xxxx on risk of complicated withdrawal)
- delirium tremens (see section xx-xxxx-xxxx on identifying risk and managing delirium tremens)
- WE (see xx-xxxx-xxxx on WE and chapter 20 on people with alcohol-related brain damage (ARBD))
- mental health crisis, self-harm and suicide risk (see section 16.16 on co-occurring mental health crisis)
- co-occurring physical and mental health conditions (see section 16.15 on co-occurring physical health conditions)
16.7.2 Risk of self-harm or abuse

NICE guideline Self-harm: assessment, management and preventing recurrence (https://www.nice.org.uk/guidance/NG225) (NG225) recommends that all healthcare professionals and social care practitioners “consider admission to a general hospital after an episode of self-harm if:
- there are concerns about the safety of the person (for example, the person is at risk of violence, abuse or exploitation) and psychiatric admission is not indicated
- safeguarding planning needs to be completed and psychiatric admission is not indicated
- the person is unable to engage in a psychosocial assessment (for example, because they are too distressed or intoxicated)”
16.7.3 Initial assessment for people who may have alcohol dependence

Initial assessment should focus on assessing a patient’s immediate needs and risks from:
- alcohol withdrawal
- complications of withdrawal
- current mental health crisis, self-harm and suicide risk
- complexities from co-occurring physical and mental health conditions
- other people, such as domestic abuse
Based on the initial assessment, for patients in an emergency setting, clinicians will need to decide whether to admit the patient because of identified risks, or not to admit them. For people who are alcohol dependent but not admitted to hospital, clinicians should tell the patient to avoid a sudden reduction in alcohol intake and refer them to community alcohol treatment. This is because a sudden reduction in alcohol intake can result in severe withdrawal in dependent drinkers.

16.7.4 Further alcohol assessment and monitoring

Patients with alcohol dependence may be admitted by an elective or emergency route for an alcohol-related condition, or for a condition not related to alcohol. They may require medically assisted withdrawal while they are treated for that condition. Patients whose initial assessment or AUDIT indicates potential alcohol dependence should have further assessment for:
- diagnosis of alcohol dependence
- the severity of their dependence
- risk of complications of withdrawal
- co-occurring complexities and social circumstances
- potential impact of their dependence on their ongoing physical and pharmacological treatment and recovery
Staff responsible for assessing and managing medically assisted withdrawal should be clinicians who are competent in diagnosing and assessing alcohol dependence and withdrawal symptoms. They should also be competent in using recommended drug regimens appropriate for a community setting and trained in the use of a validated tool for measuring withdrawal symptoms.

To assess presence or severity of dependence (mild, moderate or severe), you can use structured self-evaluation questionnaires like the severity of alcohol dependence questionnaire (SADQ) or the Leeds dependence questionnaire (LDQ) to support clinical judgement. Structured tools should never take the place of a clinical interview. There is more information on assessment tools in chapter 4 on assessment and treatment and recovery planning.

16.7.5 Assessing intoxicated patients

You should not refuse a patient an assessment because they are intoxicated. You may need to do a series of assessments of risk, for example every 45 minutes.

Severe intoxication can affect breathing and staff should be able to assess patients using early warning scales such as the Royal College of Physicians’ national early warning score (NEWS) 2 (https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2). There should also be procedures in place for escalating any concerns about the patient’s condition and managing them if they start deteriorating.

There are several issues to consider when assessing intoxicated patients.

You should undertake a clinical assessment of intoxication. If there is a proper reason to think that the patient lacks capacity to make the ‘decision in question’ (see glossary), you should carry out a capacity assessment. For example, you may need to assess the patient’s capacity to make decisions about alcohol consumption.

You should not delay psychiatric assessment. However, there is still dynamic risk (risk that changes with time and circumstance) related to intoxication, which means that you should wait until the patient is not clinically intoxicated to undertake a re-assessment to inform onward care. You may need to consider temporary inpatient admission if you feel that the level of risk is too great.

Part of the assessment should involve checking if the patient has an underlying alcohol use-disorder, and if they do, how severe it is.

16.7.6 Assessing the relevant mental capacity

Some patients with severe alcohol dependence can present to acute services with cognitive or behavioural disturbance, due to a confusional state, such as alcohol withdrawal delirium tremens or WE. In some cases, there may be a proper reason to consider that a patient may lack mental capacity to make the decision in question (see glossary) either temporarily or permanently. For example, it may be necessary to assess the patient’s capacity to consent to medical treatment. This can make clinical assessment or managing behaviour more difficult.

Healthcare professionals should treat patients with empathy, dignity and respect, including recognising that withdrawal states and craving can involve significant suffering. A clinician with experience of complex capacity assessment should assess mental capacity to make the decisions in question. This will often be carried out by staff from the ACT in hospitals where they exist.

You can find guidance on assessment of mental capacity on specific decisions for people with ARBD in chapter 20.

You can find information on national legislation and statutory guidance on assessing mental capacity and ability to consent to treatment in annex 1.

You can find further guidance on managing challenging behaviour during treatment in section 16.13 below.

16.7.7 Dealing with acute alcohol withdrawal

Acute hospital emergency departments should have protocols for people presenting in acute withdrawal. Hospitals should admit anyone presenting with acute alcohol withdrawal or who is assessed to be at high risk of developing:
- withdrawal seizures (see section xx-xxxx-xxxx on risk of complicated withdrawal)
- delirium tremens (see section xx-xxxx-xxxx on identifying risk and managing delirium tremens)
- WE (see section xx-xxxx-xxxx on WE)
Patients in acute withdrawal need immediate assessment after admission by a healthcare professional skilled in assessing and managing alcohol withdrawal.

Emergency departments should not indiscriminately admit patients to general hospitals for unplanned medically assisted withdrawal, but they should not refuse managed withdrawal because it is unplanned. Clinicians should assess the need for admission for medically assisted withdrawal based on:
- assessment of risk of withdrawal complications
- co-existing physical or mental health conditions
- social support available to them
- vulnerability or frailty or risk of self-harm
You should consider a lower threshold for admitting people:
- who are lacking in social support, for example people experiencing homelessness
- with significant physical or mental health comorbidities, cognitive impairment or learning disabilities
- who are frail or vulnerable in other ways
Children and young people aged 10 to 17 who need medically assisted withdrawal should be admitted to an age-appropriate inpatient setting with access to specialist expertise for physical and psychosocial assessment.

Patients who are treated for acute withdrawal should be offered a referral to specialist services for ongoing treatment of alcohol dependence after they are discharged from hospital and informed of peer support organisations and mutual aid groups.

People with potential or diagnosed alcohol dependence who are not admitted to hospital should be advised not to stop drinking suddenly as this can lead to dangerous acute withdrawal. It may be appropriate for them to continue to drink at a steady pace (to avoid potential complications), avoiding episodes of increased heavy alcohol use or periods without alcohol, until they can access medically assisted withdrawal.

16.8 Medically assisted alcohol withdrawal

xx-xxxx-xxxx Risk of alcohol withdrawal

Alcohol withdrawal symptoms generally start within 6 to 24 hours after stopping drinking and can last around a week. Patients with a history of alcohol dependence who present to services after weeks of abstinence will not suffer withdrawal symptoms. You should bear in mind that patients self-reporting their drinking may not be accurate, so it will be important to use clinical judgement. They should be asked about withdrawal symptoms after stopping drinking, which include (but are not limited to):
- sweating
- shaking
- palpitations
- headache
- nausea or vomiting
- anxiety or agitation
- insomnia or disturbed sleep
Patients might also have withdrawal complications, such as seizures, delirium tremens and WE.

Hospital staff should look for signs of WE and assess patients where necessary.

The NICE clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (https://www.nice.org.uk/guidance/cg115) (CG115) recommends the clinical institute withdrawal assessment alcohol - revised (CIWA-Ar) to assess withdrawal risks for patients in general hospital settings. The alcohol guidelines development group also recommend using the alcohol withdrawal scale (AWS) or the Glasgow modified alcohol withdrawal scale (GMAWS). The GMAWS is designed specifically for inpatient use.

xx-xxxx-xxxx Managing withdrawal

You should read guidance on medically assisted withdrawal in section 10.3 in chapter 10 alongside this section when prescribing and managing medically assisted withdrawal.

Staff responsible for assessing and managing medically assisted withdrawal should be clinicians who are competent in diagnosing and assessing alcohol dependence and withdrawal symptoms.

It’s very important to discuss patients’ drinking goals, such as low-risk drinking or abstinence, and securing appropriate support after discharge from hospital. ACTs can play an important role in supporting medically assisted withdrawal in hospital, and where they exist, they should be involved as early as possible.

Benzodiazepine reducing regimens are the standard pharmacological treatment of choice to manage withdrawal from alcohol. In all settings, regular skilled monitoring of symptoms and of the effects of medication is an essential component of care (see sections 10.3.3, 10.3.4 and 10.3.5 of chapter 10).

NICE clinical guideline Alcohol-use disorders: diagnosis and management of physical complications (https://www.nice.org.uk/guidance/cg100) (CG100) gives guidance on symptom-triggered medically assisted withdrawal in inpatient settings, which has been associated with lower benzodiazepine requirements and a shorter length of stay. A symptom-triggered approach requires sufficient numbers of appropriately trained staff. In some settings with fewer appropriately trained staff, a fixed dose regimen may be safer, particularly for patients at high risk of severe withdrawal and complexities.

Clinicians responsible for the clinical governance of medically assisted withdrawal provision (such as ACTs), or those responsible for acute clinical team leadership, should assess the nursing staffing levels and the capability and training of nursing and allied staff. This is to decide which approach would be appropriate and safe to use for people at high risk of severe withdrawal. The options are a:
- symptom-triggered medically assisted withdrawal
- fixed dose medically assisted withdrawal
- hybrid approach
Staff across acute wards should receive training to familiarise them with:
- structured withdrawal assessment tools
- the possible consequences of under-treatment
- the need for adequate monitoring of respiratory rate and oxygen saturations
In hospitals where ACTs exist, they should provide this training.

Where high doses of benzodiazepines have affected patients’ balance, they may require mobility assistance.

xx-xxxx-xxxx Using carbamazepine as an alternative to a benzodiazepine to manage withdrawal

Benzodiazepine reducing regimens are the standard pharmacological treatment of choice to manage withdrawal from alcohol.

NICE CG100 recommends carbamazepine as an effective alternative medication for medically assisted withdrawal from alcohol. There are specific (though uncommon) circumstances in which it is a helpful alternative to benzodiazepines. These include using carbamazepine for patients with a:
- history of adverse reaction or allergy to benzodiazepine drugs (although uncommon, this can be fatal)
- respiratory compromise
- preference for carbamazepine (for example, people who have a history of harmful use or dependence on benzodiazepine drugs and who do not want to take them in this context)
Carbamazepine can also be used in inpatient settings to manage concurrent withdrawal from alcohol and benzodiazepine drugs. You can find more information on concurrent withdrawal from alcohol and benzodiazepines in section 10.6.1 of chapter 10 on pharmacological interventions.

Carbamazepine is not licenced for the management of withdrawal. See section 10.2.2 on unlicensed or off-label prescribing in chapter 10 on pharmacological interventions. Also, you should note the Medicines and Healthcare products Regulatory Agency (MHRA) drug safety update about using anti-epileptic drugs in pregnancy (https://www.gov.uk/drug-safety-update/antiepileptic-drugs-in-pregnancy-updated-advice-following-comprehensive-safety-review) and section 10.6.4 on medically assisted withdrawal in pregnancy in chapter 10 on pharmacological interventions.

xx-xxxx-xxxx Medically assisted withdrawal admission for children and young people

You should admit children and young people aged 10 to 17 who need assisted withdrawal to an age-appropriate setting with access to specialist expertise for physical and psychosocial assessment, as well as medically assisted withdrawal. Children and young people should not be treated in an adult setting.

Many medications for alcohol dependence will be off-label for children and young people aged 17 and under.

Prescribers should be aware of their responsibilities when prescribing unlicensed or off-label medications, outlined in the MHRA guidance Off-label or unlicensed use of medicines: prescribers’ responsibilities (https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribers-responsibilities#examples-of-off-lbel-use-of-medicines).

Children and young people respond differently to medications than adults and younger children respond differently than older children. So, clinicians need to show detailed care and attention when making prescribing decisions for children and young people.

For those children and young people who require medically assisted withdrawal, clinicians can use benzodiazepines (chlordiazepoxide or diazepam) with doses adjusted based on their:
- age
- height
- weight
- stage of development
Clinicians should consult the British National Formulary for Children and the product specification.

It is important that any child or young person offered medically assisted withdrawal is closely monitored by competent specialist staff. What this looks like in practice will be based on clinical judgement determined on a case by case basis, but prescribing should be regularly reviewed.

There is more guidance in section 23.14 on pharmacological interventions for children and young people in chapter 23 on specialist alcohol interventions for children and young people.

xx-xxxx-xxxx Managing alcohol withdrawal in people with alcohol-related liver disease

You should read guidance on medically assisted withdrawal for people with ARLD in section 10.6.6 in chapter 10 on pharmacological interventions and the section on liver disease under co-occurring physical health conditions in section 16.15.1 of this chapter.

xx-xxxx-xxxx Continuing medically assisted withdrawal outside of acute hospitals

Where people have good support networks and no significant physical or mental health complications, it may be beneficial for them to continue and complete medically assisted withdrawal outside the hospital in the community. People with more complex needs might require an alternative setting, such as a specialist inpatient medically assisted withdrawal unit.

Assessing the patient’s suitability to complete medically assisted withdrawal in an alternative setting should only be done by a competent alcohol specialist, after a detailed assessment of the patient’s needs. The assessing specialist must ensure the receiving service can provide appropriate withdrawal management, support and maintain intramuscular thiamine and other nutrition according to the patient’s needs. Transferring the patient should only be done in line with a mutually agreed care pathway with a clear discharge plan agreed between the hospital, the receiving service and the patient.

16.9 Withdrawal complications

Complications of alcohol withdrawal include seizures, delirium tremens and Wernicke’s encephalopathy. These conditions can be very serious and require urgent treatment.

xx-xxxx-xxxx. Risk of complicated withdrawal

You should assess patients with alcohol dependence for risk of complicated withdrawal because this will affect decisions about admitting them to hospital, and it will inform treatment for people admitted for other reasons.

You should offer admission to people who:
- have complicated withdrawal
- are at risk of developing complicated withdrawal
- have signs of WE
Refer to section 10.4 of chapter 10 on pharmacological interventions to prevent and manage specific complications of withdrawal.

xx-xxxx-xxxx Managing seizures

The risk of withdrawal seizures should be minimised by effective medically assisted withdrawal. Where seizures occur, they should be managed using adequate doses of benzodiazepines.

NICE CG100 advocates administering a short-acting benzodiazepine, such as lorazepam, while acknowledging that this is not a licensed indication for the drug. The British National Formulary page on lorazepam (https://bnf.nice.org.uk/drugs/lorazepam/) suggests a dose for treating seizures (although alcohol is not specified as a cause) of 4 milligrams (mg) intravenously into a large vein, followed by another dose of 4mg after 10 minutes, if necessary.

NICE CG100 also states that the anti-epileptic drug phenytoin should not be used to treat alcohol withdrawal seizures. Benzodiazepines are generally favoured (Amato, 2010) over anti-epileptic drugs, and this is also the case with newer anti-epileptic drugs.

Following an alcohol withdrawal seizure, you should monitor patients 1 to 2 hourly for 6 to 14 hours. They should be closely monitored for delirium and the need for intravenous (IV) fluids as electrolyte abnormalities may contribute (as outlined in the American Society of Addiction Medicine (ASAM) alcohol withdrawal management guideline (https://www.asam.org/quality-care/clinical-guidelines/alcohol-withdrawal-management-guideline)).

NICE CG100 recommends that if a patient has an alcohol withdrawal seizure during medically assisted withdrawal, their withdrawal treatment regimen should be reviewed. This is because seizures occurring during medically assisted withdrawal reflect suboptimal dosing.

xx-xxxx-xxxx Identifying risk and managing delirium tremens

Delirium tremens is a severe complication of withdrawal and is preventable by appropriate pharmacological withdrawal management. Patients with delirium tremens should be immediately admitted to a suitably equipped and staffed acute hospital unit.

This section provides guidance on managing delirium tremens in the acute general hospital rather than a specialist detoxification setting with the competence to manage delirium tremens.

Symptoms and risk factors of delirium tremens

Delirium tremens is a preventable complication that research has found to occur in around 3% to 5% of people admitted to hospital for alcohol withdrawal (Schuckit, 2014). It is an agitated delirium that causes:
- disorientation
- agitation
- tachycardia (heart rate of more than 120 beats per minute)
- hypertension (20mmHg (millimetre of mercury) rise in systolic blood pressure)
- fever
- hallucinations (auditory, olfactory and visual)
- marked tremor
- sleeplessness
- paranoid ideation
These symptoms may not always all be present at the same time.

Delirium tremens usually emerges between day 2 and 3 (occasionally up to day 5) of alcohol withdrawal in a person with severe alcohol dependence. Risk factors for delirium tremens can include:
- previous seizures or delirium
- many co-occurring physical health problems
- low potassium
- thiamine deficiency
- systemic disease
- low magnesium
Evidence on the role of magnesium deficiency as a risk factor for delirium tremens is inconclusive and an area of ongoing debate. However, in people with severe alcohol dependence and comorbid malnutrition, consider checking and rectifying magnesium levels as quickly as possible, though this should not delay other treatment. Where magnesium deficiency is identified, you should be mindful of risk and monitor for any signs of the onset of delirium tremens.

As managing delirium tremens differs in important respects from managing other types of delirium, hospitals should have a specific protocol in place for treating delirium tremens as part of their alcohol treatment guidelines.

Guidelines for treating delirium tremens

NICE CG100 covers recommendations on managing and treating delirium tremens. Since the publication of NICE CG100, guidelines have been published in the USA and Australia. These are the:
- ASAM alcohol withdrawal management guideline
- Australian guidelines for the treatment of alcohol problems (https://alcoholtreatmentguidelines.com.au/)
While these more recent guidelines largely reflect expert consensus rather than new evidence, they provide further detail about managing delirium tremens, which clinicians may find helpful.

Managing delirium tremens

The sections below outline the recommendations of the alcohol guidelines development group drawing on the UK, USA and Australian guidelines.

A patient with delirium tremens should:
- be treated in a suitability equipped and staffed acute hospital unit or suitably equipped specialist medically assisted withdrawal unit
- receive one to one nursing care
- receive frequent measurement of their vital signs, respiratory rate and oxygen saturations
The patient should receive a thorough examination and a set of suitable investigations to detect alternative causes of delirium, which you should treat if present. Other causes of delirium can include:
- subdural haematoma
- WE (see section below on the importance of vitamin treatment for potential WE in delirium tremens)
- hepatic encephalopathy
- hypoxia
- sepsis
- metabolic disturbance
- intoxication or withdrawal from drugs
Patients will benefit from a multidisciplinary approach to the management of delirium tremens, with input from:
- an acute medical team
- clinicians with specialist expertise in alcohol dependence and withdrawal complications
- an ACT in hospitals that have them
- a liaison psychiatry team and intensive care unit outreach team, if necessary
Delirium tremens is a disturbance of mind or brain and can in some cases mean that that the person cannot make the decision in question (see glossary). If there is a proper reason to consider that the patient may lack the relevant capacity, the decision-maker should undertake a formal assessment of the patient’s mental capacity to consent to medical treatment. If the patient lacks capacity to consent, the team will need to make a ‘best interests’ decision regarding the treatment. A best interests decision must consider all the relevant circumstances, including having regard to the patient’s wishes and feelings. There should also be consultation with family and carers where practicable and appropriate. You can find more information in the NICE guideline Decision-making and mental capacity (https://www.nice.org.uk/guidance/ng108) (NG108).

Pharmacological intervention for delirium tremens

The goal of pharmacological treatment of delirium tremens is to produce a rousable but sedated state in the patient, similar to a light sleep.

Pharmacological management of delirium tremens is different from other forms of behavioural disturbance because benzodiazepines should be a first-line treatment. You should use adequate doses of benzodiazepines to manage severe alcohol withdrawal before you consider using neuroleptics (antipsychotic medication - see section on neuroleptics below). You should not use neuroleptics as monotherapy (treating the condition with a single drug), other than in exceptional circumstances.

You should review the patient’s withdrawal regimen if they develop delirium tremens (NICE CG100). This is because cases of delirium tremens may arise through untreated, or under-treated withdrawal. To prevent delirium tremens from developing, it is important to:
- identify patients early who are at risk of severe withdrawal
- monitor patients frequently with a validated withdrawal tool
- prescribe patients an appropriate amount of a suitable benzodiazepine, based on their assessed score
Benzodiazepines for treatment of delirium tremens

Benzodiazepines are the mainstay of treatment for delirium tremens (Mayo-Smith and others, 2004).

Benzodiazepines used as a first-line treatment may include:
- oral or intramuscular (IM) lorazepam (NICE recommends oral lorazepam as first-line treatment)
- oral diazepam, as recommended in the Australian guidelines
- oral chlordiazepoxide, which the alcohol guidelines development group agree is appropriate, based on clinical experience
Other benzodiazepines without specific license for treatment of withdrawal are used off-label for this purpose (see section 10.2.2 on off-label and unlicensed prescribing in chapter 10 on pharmacological interventions).

In some circumstances it may be appropriate to give diazepam, which is specifically licensed for alcohol withdrawal (or, if appropriate, another benzodiazepine) parenterally. However, absorption from IM injection of diazepam may be variable, particularly for the gluteal muscles, and so, the IM route of administration of diazepam should only be used if IV administration is not possible.

You should be aware of the MHRA safety alert for the use of benzodiazepines and opioids (https://www.gov.uk/drug-safety-update/benzodiazepines-and-opioids-reminder-of-risk-of-potentially-fatal-respiratory-depression).

Chlordiazepoxide and possible risk of genotoxicity (damage to genetic information)

Chlordiazepoxide should not be used during pregnancy, especially during the first and last trimester unless the clinical condition of the woman requires treatment with chlordiazepoxide. Evidence on the safety of chlordiazepoxide is available on the Electronic Medicines Compendium summary of product characteristics for Librium 5mg capsules (https://www.medicines.org.uk/emc/product/1728/smpc).

Issued in 2020 (and revised in 2023), the European Medicines Agency (EMA) safety working party and non-clinical working party published recommendations on the duration of contraception following the end of treatment with a genotoxic drug (PDF, 1.07MB) (https://www.ema.europa.eu/en/documents/other/safety-working-party-swp-non-clinical-working-party-ncwp-recommendations-duration-contraception-following-end-treatment-genotoxic-drug_en.pdf). Following this advice, the summary of product characteristics for Librium and some generic chlordiazepoxide varied their licence to implement the guidance.

The change is the result of new EMA guidance, rather than new evidence for the genotoxicity of chlordiazepoxide.

MHRA is reviewing the evidence available on chlordiazepoxide to ensure that appropriate and proportional warnings are implemented as required. MHRA advises that healthcare professionals should continue to use current clinical guidelines while this evaluation takes place.

The risks from continued excessive alcohol consumption and complications from alcohol withdrawal, such as seizures and delirium tremens, are likely to significantly outweigh any potential risk of genotoxic effects from the duration and doses of chlordiazepoxide used for medically assisted withdrawal. When prescribing chlordiazepoxide, the clinician should consider the proportionate balance of risk and discuss this with the patient. Both men and women should be advised about contraception following the end of treatment.

Dosage and regimen for benzodiazepines when treating delirium tremens

You should tailor the benzodiazepine dose to the person based on a specific hospital protocol for delirium tremens and specialist advice from clinicians experienced in the treatment of alcohol withdrawal and complications, for example the hospital’s alcohol care team or liaison psychiatry team. While NICE CG100 does not specify a dose for oral or parenteral lorazepam for the treatment of delirium tremens, it is the consensus of the alcohol guideline development group that high doses of whichever benzodiazepine is used may be required to treat delirium tremens adequately. High dose benzodiazepines carry a risk of respiratory depression and so it is essential to frequently monitor the patient, including oxygen saturations and respiratory rate.

When giving benzodiazepines, use either a symptom-triggered regimen (see section 10.3.4 on choice of regimen in chapter 10 on pharmacological interventions) or loading (as recommended by USA and Australian guidance).

Loading is a regimen where specific doses of benzodiazepine are given frequently until light sedation is achieved and then no more given until the following day. As an example of a benzodiazepine loading regimen, the Australian guidelines recommend loading with 20mg diazepam orally given hourly up to 80mg in total over 24 hours (in some cases this may need to be exceeded). Both symptom-triggered and loading regimens aim to achieve rapid control of symptoms and neither of them is a conventional fixed-dose regimen where benzodiazepines are administered 4 times a day.

The choice of regimen will depend on available expertise and resources. Both symptom-triggered and loading approaches require all team members to be trained to ensure that it can be applied consistently and safely.

Managing IV benzodiazepines safely

If a patient is unable to take oral benzodiazepines, you should use parenteral benzodiazepines (NICE CG100). You should not give IV benzodiazepines outside emergency department resuscitation or high dependency settings. This is because of the risk of respiratory depression and the required skills profile of staff. In other settings, you should use an IM route of administration. If you give repeated boluses of IV benzodiazepines to patients, you should be aware of the potential complication of hyponatraemia (low levels of sodium in the blood) and acidosis (high levels of acid in the body).

Neuroleptics

NICE CG100 recommends haloperidol for treatment of delirium tremens as an option where oral lorazepam is declined or symptoms persist. However, the consensus of the alcohol clinical guidelines development group (and clinical guidelines from other countries) is that neuroleptics such as haloperidol should:
- not be given as first-line treatment or monotherapy for delirium tremens
- only be used as an adjunct to benzodiazepine treatment where adequate doses have failed to manage the behavioural disturbance
- not replace adequate doses of benzodiazepines
Risk of Wernicke’s encephalopathy in delirium tremens

Any change in mental status including delirium can be a sign of WE if accompanied by one of the other criteria, which research (Caine and others, 1997) shows are:
- a history of poor nutrition
- ataxia (disorders that affect co-ordination, balance and speech)
- any eye movement abnormality
Clinicians should be aware that WE can be a contributing factor to the delirium and treat as necessary. You can find information on administering thiamine (vitamin B1) to treat WE in section xx-xxxx-xxxx below.

xx-xxxx-xxxx Wernicke’s encephalopathy

You can find detailed guidance on WE in chapter 20 on people with ARBD.

This section deals with administration of thiamine to prevent and treat WE.

Treatment of WE should take place in a hospital setting. Thiamine should be administered parenterally. IV is preferable as the IM route is painful.

Preventing and treating Wernicke’s encephalopathy

WE is a serious complication caused by deficiency of thiamine (vitamin B1), for which the most common cause is alcohol dependence. This can result in lasting brain injury, so preventing this complication is vital.

WE is a potential complication of alcohol withdrawal and thiamine should be prescribed as part of medically assisted withdrawal to prevent WE from developing. However, WE does not occur only when people stop drinking, and people who are malnourished or have decompensated liver disease remain at risk while they continue to drink alcohol.

People with any degree of risk of WE, who choose not to have parenteral (intramuscular or intravenous) thiamine, should be offered oral thiamine.

Vitamin prophylaxis to prevent WE

Many people with alcohol dependence are at risk of developing WE due to thiamine deficiency. They may also have deficiencies in other vitamins. You should provide thiamine supplementation as part of any medically assisted withdrawal. However, it’s essential to offer vitamin prophylaxis in all people who drink harmfully and dependently, whether or not they intend to undergo medically assisted withdrawal.

The risk of anaphylactic reaction from parenteral vitamins has sometimes deterred clinicians from using them, but the risks of failing to correct thiamine deficiency are significant. You should consider the following points.

Absorption of oral thiamine from the intestine is saturated at 5mg to 10mg per dose in healthy people and can be reduced to negligible amounts in people with alcohol dependence, especially those with malnutrition. Oral thiamine will not be adequate to replace depleted thiamine in a significant proportion of these people (Tallaksen and others, 1993; Weber and Kewitz, 1985).

Thiamine stores need to be replaced as quickly as possible and high circulating levels of thiamine are needed for passive diffusion into the central nervous system (based on clinical consensus of the guidelines development group).

For people who need parenteral thiamine, the risk of anaphylaxis is very low: less than 1 in 5,000,000 for IV infusion and lower still for the IM route (Cook and others, 1998; Thomson and Marshall, 2006).

MHRA has published a drug safety update on allergic reactions to parenteral Pabrinex (https://www.gov.uk/drug-safety-update/pabrinex-allergic-reactions) (thiamine and other vitamins).

Pharmacological regimen for vitamin prophylaxis

The appropriate regimen for vitamin prophylaxis will depend on whether the person:
- is considered to be at lower risk
- has no signs of WE but is at high risk of it developing
- is showing signs of WE
Thiamine should be given orally or parenterally as described below.

The lower-risk group comprises people who drink harmfully or dependently but who do not have any of the conditions that put them at high risk. In practice, all people admitted to hospital who drink harmfully or dependently, who do not meet criteria for the high-risk regimen, should be given thiamine 50mg oral 4 times daily.

People in the high-risk group can have a range of conditions, including:
- significant weight loss
- poor diet
- low body mass index (BMI) (less than 18)
- other signs of malnutrition
- memory disturbance
- peripheral neuropathy
- previous history complicated withdrawal including WE
- decompensated liver disease
- long history of harmful drinking and alcohol dependence
- admission to hospital with an acute injury or illness
For people in the high-risk group, offer thiamine 200mg to 300mg IM or IV once per day for 3 to 5 days with daily review and monitoring for signs of WE.

Injections should be given by appropriately skilled, trained and resourced staff.

IM or IV thiamine should be followed by a course of oral thiamine until holistic review of overall recovery indicates it is no longer necessary.

If you have well-founded nutritional concerns, you can also prescribe a suitable nutritional supplement.

Treatment for incipient Wernicke’s encephalopathy

People will require inpatient treatment for WE if they have any of the following additional symptoms:
- impaired eye movements (ophthalmoplegia)
- unsteady walking (ataxia)
- confusion
Pharmacological regimen for treating suspected or established Wernicke’s encephalopathy

If you suspect or diagnose WE, the patient will need the following treatment and monitoring. You should:
- give IV thiamine 300mg to 500mg 3 times a day for 3 to 5 days with daily review
- give IV thiamine 300mg to 500mg once daily for a further 3 to 5 days if the patient is still symptomatic after the first 5 days of treatment - then for as long as clinical improvement continues
- explore other causes for a patient’s confusion
- take appropriate steps to manage the small risk of anaphylaxis by administering thiamine in a setting with facilities for treating anaphylaxis and with appropriately trained staff available during the infusion
- continue to give the full dose of IV thiamine (as set out above) if the patient subsequently develops WE
- follow a course of parenteral thiamine with a course of oral thiamine
- consider checking and re-checking magnesium in all patients with incipient WE and correct it if it’s low
Magnesium is a co-factor for converting thiamine to the active form in the liver (hypomagnesaemia (magnesium deficiency) is a documented cause of WE that does not respond to treatment)

Magnesium deficiency (hypomagnesaemia) can prevent thiamine from working properly in the body (McLean and Manchip, 1999). This means patients may not respond to standard treatment for WE while their magnesium levels are deficient.

Preventing Wernicke’s encephalopathy in people who continue to drink alcohol

For people with a harmful or dependent pattern of drinking, with a lower risk of WE, offer prophylactic oral thiamine, as described above in this section, even if they are likely to continue to drink alcohol.

For people at high risk of WE, offer prophylactic IM or IV thiamine followed by oral thiamine, as described above in this section, even if there are no plans for them to undergo medically assisted withdrawal.

16.10 Psychosocial interventions to support medically assisted withdrawal and ongoing abstinence

During medically assisted withdrawal, all staff should actively listen to and support the patient and give them information on how to manage withdrawal symptoms and where to access help and support. Patients need to understand that they have had a medically assisted withdrawal if they leave hospital after completing one, because they may not realise this.

Trained staff should help the patient explore any ambivalence they have towards treatment of their alcohol dependence and encourage them to access ongoing support to maintain abstinence. The staff can also discuss with the patient about how:
- important they think it is to change their drinking behaviour after they leave hospital
- confident they feel about being able to change their behaviour
If the patient understands the risks and harms from alcohol, especially using their current health problems as a focus, it can help to:
- build motivation for change
- identify goals
- agree initial plans that can be started when they are discharged from hospital
You can find out more about exploring readiness to change and encouraging engagement with further support in chapter 4 on assessment and treatment and recovery planning in section 4.9.3 on motivation, readiness and belief in the ability to change.

16.11 Relapse prevention treatment

Pharmacological interventions for relapse prevention are covered in detail in section 10.5 of chapter 10 on pharmacological interventions.

NICE CG115 recommends initiating relapse prevention medication in hospital following or concurrently with medically assisted withdrawal. It also recommends making appropriate arrangements for psychosocial support and follow-up with repeat prescription.

You should make sure there are clear follow-up procedures, so that the patient is prescribed relapse prevention medications for the appropriate timescale. You should continue to monitor the relapse prevention medication, and ask questions about:
- concordance (interaction and co-operation between patients and healthcare professionals, which addresses patients’ needs)
- concordance strategies
- access to a range of psychosocial interventions, if people want it (you can find more comprehensive guidance on psychosocial interventions in chapter 5)
16.12 Managing deteriorating alcohol dependent patients

As outlined above, alcohol dependent patients may be suffering several concurrent problems, including:
- dehydration
- malnutrition
- electrolyte derangement (or imbalance)
- sepsis
- traumatic injury
Alcohol dependence is associated with needing intensive care for lower respiratory infections and a higher risk of adult respiratory distress syndrome following trauma (Gupta and others, 2019; Kózka and others, 2020; Tignanelli and others, 2019). It is beyond the scope of this guideline to consider treatment for alcohol dependence in intensive care settings, where management is based on physiological principles. However, healthcare professionals who care for patients with alcohol dependence in acute hospital settings should be aware that patients can quickly deteriorate.

Where you identify multimorbidity (2 or more chronic conditions co-occurring), patients are likely to benefit from increased nursing observations and frequent review by the junior medical team. We recommend that there is clear communication between people directly managing the patient, such as emergency department staff, ACT and medical and nursing staff. There should also be early contact between these staff and intensive care outreach or on-call intensive care unit doctors to inform them about the patient and seek advice.

16.13 Managing challenging behaviour

Staff in acute hospitals often have to deal with challenging behaviour from patients admitted for withdrawal or complicated withdrawal. The guidance in this section is based on clinical consensus of the guideline development group.

16.13.1 Reasons for challenging behaviour

Patients with AUD may exhibit challenging behaviour. It is important to understand the reasons why this might occur. Challenging behaviour from patients may be a response to their unmet needs, including compulsion to drink, and may need you to:
- review the patient’s medication and dosages
- understand their priorities
- review the arrangements for them receiving visitors
- address nicotine replacement
- encourage carers’ and families’ involvement to help mitigate against difficult behaviours
Assessing a patient’s capacity to consent to treatment and/or their capacity to make discharge decisions, can be a vital part of managing behavioural challenges. Capacity to make such decisions can fluctuate throughout medically assisted withdrawal, particularly if they are in severe withdrawal, so clinicians need to be aware that that behavioural disturbance can emerge from a confusional state.

16.13.2 Behavioural contracts

If the patient has capacity to consent to medical treatment but has been behaving in a way that makes continued treatment too dangerous (for example, drinking alcohol while being prescribed benzodiazepines for medically assisted withdrawal), you can consider having a behavioural contract with clear expectations and consequences. You should not use a behavioural contract where the patient is incapacitated.

Making decisions about behavioural contracts requires a careful balance of risks and benefits to the patient. Ideally, you should follow a multidisciplinary approach, fully involving the patient.

16.14 Co-occurring physical and mental health conditions

AUD is often accompanied by physical and mental health conditions that may influence the choice of treatment for alcohol dependence and the treatment for physical health conditions in acute hospitals.

When assessing patients, clinicians should understand that it’s possible that the patient might have a co-occurring condition, including:
- a mental health crisis
- alcohol-related liver disease
- alcohol-related hepatitis
- refeeding syndrome if they are malnourished
- experiencing multiple disadvantage
Where you identify 2 or more chronic conditions co-occurring, patients are likely to benefit from increased nursing observations and frequent review by the junior medical team.

This section covers co-occurring physical and mental health conditions. The next 2 sections cover co-occurring physical health conditions, and co-occurring mental health crisis, respectively.

16.15 Co-occurring physical health conditions

16.15.1 Liver disease

Detecting liver disease early

Signs and symptoms of ARLD develop late in the progression of the disease and a high proportion of people with ARLD will have no clinical symptoms nor significant blood test abnormalities.

Eventually, their liver may fail to function sufficiently and will decompensate. This is the stage at which ARLD becomes clinically apparent. The risk of developing liver disease and subsequent decompensation decreases with abstinence (or reduced alcohol consumption). So, it’s important to detect liver disease early and begin interventions.

Screening for liver disease

NICE guideline Cirrhosis in over 16s: assessment and management (https://www.nice.org.uk/guidance/ng50) (NG50) recommends that women drinking more than 35 units per week or men drinking more than 50 units per week for 3 months or more should have their liver stiffness measured by transient elastography (TE, also known as fibroscan) to determine the stage of progression of liver disease.

There are other non-invasive screening methods for liver fibrosis in development, which include the following.

Ultrasound based screening includes:
- acoustic radiation force impulse
- shear wave
Serum fibrosis markers include:
- enhanced liver fibrosis (ELF)
- liver traffic light test
- intelligent liver function test (iLFT)
However, research shows that these tests are currently less well validated for ARLD than TE is (Moreno and others, 2019).

Healthcare professionals who perform and interpret non-invasive fibrosis tests should be trained to do so.

Any screening test should be part of a clear pathway, to make sure the tests are reviewed and acted on.

Scottish Health Action on Alcohol Problems published Alcohol-related liver disease: guidance for good practice (https://www.shaap.org.uk/publication/alcohol-related-liver-disease-guidance-for-good-practice) for healthcare staff in primary and secondary health services and in alcohol treatment services. The content may also be useful for healthcare staff in other UK nations.

Care for people with liver disease

People diagnosed with significant fibrosis or cirrhosis should be followed up by a specialist in liver disease.

Alcohol abstinence is a vital goal for people with ARLD, since abstinence improves outcomes in all stages of ARLD. However, the patient should not be excluded from treatment if they do not accept this goal initially.

There should be effective care pathways between specialist liver services and alcohol treatment services in the hospital and in the community.

Cirrhosis

The European Association for the Study of the Liver (EASL) clinical practice guidelines (https://www.journal-of-hepatology.eu/article/S0168-8278(18)30214-9/fulltext) recommends that if you suspect that a patient has cirrhosis, you should evaluate their liver function and the presence of portal hypertension by measuring:
- serum bilirubin
- albumin
- prothrombin time (PT) or international normalised ratio (INR)
- platelet count
Other liver blood tests may indicate alcohol excess (gamma glutamyl transferase (GGT) and raised aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio). They may also suggest alcohol as the cause of liver disease. But the EASL clinical practice guidelines points out that these tests cannot be used to determine the severity of fibrosis or cirrhosis and test results can be entirely normal, even in people with cirrhosis.

Other causes of liver disease

NICE CG100 recommends evaluating alternative causes of liver disease in people who drink at higher-risk levels with abnormal liver blood test results. In particular, risk factors for the other common liver diseases in the UK (non-alcoholic fatty liver disease and hepatitis C infection) include the metabolic syndrome (obesity and type 2 diabetes mellitus) or injecting drug use.

Ultrasonography helps to exclude other causes of liver disease and may help you to assess advanced disease (for example, splenomegaly and irregular hepatic contour) and its complications (for example, ascites and hepatocellular carcinoma), whatever the causes. However, ultrasonography cannot establish alcohol as the specific cause of a person’s liver disease nor reliably assess hepatic fibrosis.

Decompensated liver disease

Clinical signs of decompensated liver disease include:
- jaundice, shown by yellow discolouration of the skin and sclera (whites of the eyes)
- spider naevi, shown by red star-shaped markings on the face and upper body which blanch when pressed
- easy bruising
- swollen abdomen, caused by ascites (fluid in the abdomen), which patients often mistake for weight gain
- swollen legs
- confusion, such as reversal of day-night waking pattern, drowsiness and poor memory
The patient may also complain of fatigue, itching, abdominal pain and nausea.

The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report Alcohol related liver disease: measuring the units (https://www.ncepod.org.uk/2013arld.html) recommends that people with decompensated cirrhosis should be managed by a specialist with experience in managing patients with liver disease.

Decompensated cirrhosis is a medical emergency with a high mortality. In particular, heavy drinkers presenting with new-onset jaundice, who have suspected alcohol-related hepatitis, can progress rapidly to liver failure and have a significant short-term mortality (30% at 90 days and 56% at one year) (Thursz and others, 2015). Effective early intervention improves outcomes. When you are assessing people who have presented with decompensated cirrhosis, you should determine the precipitating causes and treat the patient appropriately.

A decompensated cirrhosis care bundle (https://www.bsg.org.uk/clinical-resource/bsg-basl-decompensated-cirrhosis-care-bundle-first-24-hours), as recommended by NCEPOD, can help to standardise and optimise the patient’s management in the first 24 hours, when specialist input might not be available. Patients should be reviewed by the gastroenterology or liver team at the earliest opportunity (ideally within 24 hours). You should quickly escalate care for patients with ARLD, who deteriorate acutely and whose background functional status is good. The medical and critical care teams should work closely when making escalation decisions.

Referral for liver transplantation

The UK liver advisory group has produced updated guidelines on liver transplantation for alcohol-related liver disease in the UK (https://www.bsg.org.uk/clinical-resource/liver-transplantation-for-alcohol-related-liver-disease-in-the-uk-revised-uk-liver-advisory-group-recommendations-for-referral/), published by the British Society of Gastroenterology.

Alcohol-related pancreatitis

For guidance on diagnosis and management of alcohol related pancreatitis, see NICE CG100.

Further information and resources

The British Liver Trust (https://britishlivertrust.org.uk/) has developed information guides for liver disease and liver cancer patients and carers.

16.15.2 Nutrition support

Nutritional support for alcohol-related hepatitis

NICE CG100 recommends assessing the nutritional requirements of people with acute alcohol-related hepatitis. This includes offering nutritional support if needed and considering using nasogastric tube feeding (see NICE clinical guideline Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (https://www.nice.org.uk/guidance/cg32) (CG32)).

Assessing nutritional status

Many alcohol-dependent patients have poor nutritional status. When you suspect that they do, refer them to a dietician.

NICE CG32 recommends that all patients admitted to hospital should be:
- assessed to determine their BMI
- screened for unintentional weight loss
- asked if they have eaten little or nothing for the last 5 days
NICE CG32 highlights that patients with decompensated cirrhosis secondary to alcohol, and patients with alcohol dependence who often drink alcohol instead of eating, are at particular risk of malnourishment.

Nutritional assessment is especially important with particular conditions such as alcoholic ketoacidosis, which is associated with periods of complete lack of food. Alcoholic ketoacidosis is a clinical syndrome seen mostly in patients with chronic AUD and often seen in patients who have a pattern of heavy episodic drinking. Typical patients are usually chronic drinkers who are unable to tolerate oral nutrition for a 1 to 3 day period (Howard and Bokhari, 2022).

NICE CG32 recommends providing nutritional assessment and support for people who have:
- a BMI of lower than 18.5
- a BMI of lower than 20 and greater than 5% weight loss in the past 3 to 6 months
- had little food or nutritional supplements in the past 5 days
Poor nutrition is a risk factor for WE, which can cause temporary or permanent brain damage. You should follow the guidance on screening for risk of WE .Guidance on managing WE in acute hospital settings is covered in section 16.6.4 of this chapter.

It’s important to be aware that the metabolic demand produced by acute physical illness in general hospitals will increase the risk of WE.

The NCEPOD report on ARLD also recommends that in the care bundle for decompensated cirrhosis, people who are actively drinking are treated with a treatment regimen of parenteral thiamine and other B vitamins.

Refeeding syndrome

Refeeding is a metabolic disturbance that can occur when nutrition is restored in people who are starved or significantly malnourished. It can happen to people who are admitted to hospital for treatment of alcohol-use disorders, so it’s important to screen people for risk of refeeding syndrome, specifically those who:
- are very underweight (BMI of less than 16) or have lost more than 15% body weight over 3 to 6 months
- have not been eating for the preceding 10 days or more before admission
- have low levels of serum magnesium, phosphate or potassium
- have had severe vomiting or diarrhoea
After identifying people at high risk of refeeding syndrome, you should check their electrolytes, particularly:
- sodium
- potassium
- calcium
- phosphate
- magnesium
Refeeding syndrome should always be managed in an acute hospital setting. Research has shown that alcohol dependent patients are considered at high risk of refeeding syndrome (Mehanna and others, 2008), particularly those with cirrhosis and those with a history of poor nutrition. Refeeding syndrome is characterised by potentially fatal shifts in electrolyte and fluid balance that occur when malnourished patients begin to take in food again. Patients at risk of refeeding syndrome should be reviewed by a dietician within 48 hours. NICE CG32 advises an initial rate of 10 calories per kilogram of body weight per day (kcal/kg/day) in high risk or 5 kcal/kg/day in extreme risk.

Patients should receive regular blood test monitoring of phosphate, magnesium, calcium and potassium, with careful correction of abnormalities. You should not use 5% glucose as a rehydration fluid because it is likely to worsen both WE and electrolyte disturbances.

There are cardiac complications of electrolyte deficiencies, particularly arrhythmias, so the alcohol guidelines development group advise electrocardiogram (ECG) monitoring or telemetry to record severe low electrolyte levels. Electrolytes should be monitored daily for 5 days and then 3 times weekly until stable. You should quickly replace electrolytes when required.

Management of refeeding should be accompanied in all cases by a multivitamin preparation and thiamine replacement immediately before and during the first 10 days of refeeding. This will help prevent neurological complications such as WE.

16.16 Co-occurring mental health crisis

16.16.1 Evidence for co-occurring alcohol and mental health problems

Research shows that people presenting to emergency departments following self-harm and suicidal acts (such as overdose) or acute psychiatric symptoms is associated with intoxication and chronic alcohol-use disorder (Phillips and others, 2019).

Alcohol dependence increases risk of death by suicide by 9.8 times (Ferrari, 2014). Both alcohol dependence and alcohol use at harmful levels are associated with repeated suicidal acts and increased mortality after attending an emergency department (Hawton and others, 2013).

The National Confidential Inquiry into Suicide and Safety in Mental Health Annual report 2024: UK patient and general population data 2011 to 2021 (https://sites.manchester.ac.uk/ncish/reports/annual-report-2024/) found that 47% of people in contact with mental health services who died by suicide used alcohol problematically. However, patients who are intoxicated when they present to hospital following a suicide attempt are more likely to be discharged home than those who are not (Urban and others, 2018; Robins and others, 2021).

Patients who use substances are reported to be stigmatised by health workers because of the perception that they are “violent, manipulative and unmotivated” (Van Boekel, 2013). Qualitative research suggests that alcohol use remains a major barrier to accessing crisis care (Suicide Prevention Consortium, 2022). Stigma like this can create barriers to people accessing mental health services.

16.16.2 Working with people who have co-occurring conditions

The 2 main principles for working with people who have co-occurring mental health conditions and problem alcohol use are:
- Everyone’s job: providers of mental health and alcohol and drug services have a joint responsibility to meet the needs of individuals with co-occurring conditions by working together to reach shared solutions.
- No wrong door: providers of alcohol and drug, mental health and other services have an open-door policy for individuals with co-occurring conditions and make every contact count. Treatment for any of the co-occurring conditions is available through every contact point.
There should also be an agreed and understood care pathway to ensure patients’ needs can be met appropriately.

Patients presenting to emergency departments following a suicidal act, or in suicidal crisis, should receive care in line with NICE guideline Self-harm: assessment, management and preventing recurrence (https://www.nice.org.uk/guidance/NG225) (NG225). The following guidance is taken from NICE NG225 and clinical consensus of the alcohol guidelines development group.

When a person attends the emergency department following an episode of self-harm including a suicide attempt or is at risk of suicide, offer referral to age-appropriate liaison psychiatry services as soon as possible after arrival. For children and young people, this might be a crisis response service (or an equivalent specialist mental health service or a suitably skilled mental health professional). These services will do a psychosocial assessment and provide support alongside any physical healthcare.

After a person attends an emergency department for an episode of self-harm, an age-appropriate liaison psychiatry professional or a suitably skilled mental health professional should see and speak to them.

Do not use breath or blood alcohol concentration to delay assessment.

If the person who has self-harmed, attempted suicide or is in suicidal crisis is intoxicated with alcohol, agree with the person and colleagues what immediate assistance is needed. For example, this could include support and advice about medical assessment and treatment.

Patients presenting with self-harm or suicidal acts should be offered psychosocial assessment at triage. Assessment should include structured and well-documented assessment of the existence and severity of the AUD. In addition, clinicians should do a thorough psychiatric assessment, including:
- taking a psychiatric history
- assessing the relationship between psychiatric symptoms and alcohol use
- performing a mental state examination
Consider admission to the acute hospital after an episode of self-harm including suicidal act or ideation if the person is unable to engage in a psychosocial assessment (for example, because they are too distressed or intoxicated).

If the person is not able to participate in the psychosocial assessment, review their condition frequently in line with local protocols for monitoring people at risk of self-harm or suicide. Complete a psychosocial assessment as soon as possible.

Focus the assessment on the person’s needs and how to support their immediate and long-term psychological and physical safety.

Mental health professionals should undertake a risk formulation as part of every psychosocial assessment.

If a person has self-harmed and presents to services but wants to leave before a full psychosocial assessment has taken place, assess the person’s safety and any mental health problems before they leave. Some people may require an assessment of their capacity to make the decision about discharge or an assessment under the Mental Health Act.

Mental health professionals should discuss with the person harm minimisation strategies that could help to avoid, delay or reduce further episodes of self-harm or suicidal crisis and reduce complications. For example, the impact of alcohol and recreational drugs on the urge to self-harm.

Where possible, the patient and assessor should both agree whether the person is referred for further assessment and treatment or whether they are discharged. A decision to discharge a person without follow-up after an act of self-harm or suicidal ideation should include an assessment of their social and personal problems. These problems may increase risk and the person may respond to therapeutic or social interventions. So, a decision to discharge a person should not be based solely on apparent low risk of repeating self-harm and the absence of a mental illness.

Clinicians should assess how long a person has had suicidal thoughts and whether these are continuous or have reached a crisis. The goal of this kind of assessment should be to provide a risk formulation including a risk management plan (see glossary) and guide onward care, which may include both community alcohol and drug services and primary or secondary mental health services.

When prescribing medicines to someone who has previously self-harmed or who may self-harm in the future, healthcare professionals should take into account factors including the:
- patient’s recreational drug and alcohol use
- risk of harmful alcohol or drug use
- possible interaction with prescribed medicines
16.16.3 Understanding the severity of both alcohol and mental health conditions

It is important to understand the relative severity of both a patient’s AUD and co-occurring mental health disorder to know where the clinical concern should focus. Someone who has recently begun to drink at harmful levels to manage depression will require a different pathway from someone with severe alcohol dependence and depression. You should do a full risk assessment and document it clearly.

16.16.4 Do not exclude people from mental health services because of alcohol use

You should not exclude patients from mental health interventions because of their drinking status. Alcohol and mental health services need to work together to be most beneficial.

NICE NG225 recommends a cognitive behavioural therapy-based approach to prevent repeated self-harm, suicidal thoughts or acts. It states that professionals should not use “substance use or coexisting conditions as reasons to withhold psychological interventions for self-harm”.

All professionals should be aware that repeated episodes of self-harm increase the risk of self-injury death. They should also be aware that self-harm linked to alcohol intoxication is associated with recurring self-harm (Hawton and others, 2013), particularly in patients with alcohol dependence (Robins and others, 2021).

Where ACTs exist, their make-up and skillset varies, but all staff members should be trained in commonly occurring mental disorders and suicide risk assessment. However, patients should not be excluded from formal psychiatric assessment because they are under the care of an ACT.

16.17 People with alcohol use disorders who frequently attend hospital

A study based on 2 London hospitals found that 9% of patients who had 3 or more alcohol-specific admissions accounted for 29% of all alcohol-specific admissions. (Health Innovation Network, South London, 2017).

People experiencing multiple disadvantage including AUD often have multiple admissions or emergency department attendances related to alcohol during a relatively short period (Drummond, 2016; Blackwood and others, 2017; Blackwood and others, 2020; Blackwood and others, 2021).

Patients with AUD with high individual use of secondary care services are more likely to:
- be men
- be aged in their 50s
- live in income deprived areas
- have mental and physical health comorbidities (Blackwood and others, 2017)
While they are likely to attend the emergency department with an alcohol-related condition (Blackwood and others, 2017), they may not think that alcohol dependence is their main problem (Parkman and others, 2017) and say that medical attention for physical injuries and pain is their main reason for attendance. These people require additional attention because a larger proportion of this group is diagnosed with alcohol-related cirrhosis in the following 5 years than those who do not attend frequently (Blackwood thesis, 2019).

Community-based services for people experiencing multiple disadvantage are covered in detail in chapter 9 on alcohol assertive outreach and a multi-agency team around the person.

16.18 Discharge from hospital

16.18.1 Safe discharge and wrap-around support in the community

Patients should be discharged in a planned, safe way with a seamless transition to care in the community that meets all their needs (wrap-around care), including ongoing specialist alcohol treatment. This means that these services need to be planned in an integrated way at a local strategic planning and commissioning level.

Research has shown that alcohol-related readmissions to hospital happen when the patient:
- was discharged against medical advice
- had incomplete withdrawal treatment programmes and clinical complexity (Yedlapati and Stewart, 2018; Blackwood and others, 2020)
- was discharged to live on the streets (Phillips and others, 2025)
Wherever possible, patients should complete medically assisted withdrawal once they have started, either in the hospital or in the community. Decisions about when to discharge people and what care package they need should be based entirely on multidisciplinary assessment and the plan of action that’s most likely to be successful for the patient. You can find guidance on comprehensive, multidisciplinary assessment in chapter 4 on assessment and treatment and recovery planning.

It is essential that discharge planning considers the risks of complicated withdrawal and the patient’s physical or mental health possibly deteriorating in the community, especially for people who are experiencing rough sleeping.

With the patient’s consent, clinicians should support continued abstinence from alcohol after discharge by:
- making direct referral for engagement with community alcohol treatment services and other relevant support services, where agreed with the patient
- encouraging the sharing of goals and plans with carers and relatives
- providing information on mutual aid, peer-support services, care services and helplines
16.18.2 Transfer to specialist mental health services

Patients may require transfer to specialist mental health services. The mental health team should assess all patients who need this transfer. The mental health team should identify and agree the clinical needs of the patient before transfer, in collaboration with the alcohol specialist and the patient. They should write a plan with arrangements for joint working, specifying which service is ‘lead service’ and what strategies they will use if the patient disengages from either service.

16.18.3 Referral to alcohol treatment services

The managing multidisciplinary team or ACT should be responsible for referring patients to the alcohol treatment provider and other providers of their ongoing care package. This means that the ACT or multidisciplinary team will need to understand providers’ capacity, protocols, and inclusion and exclusion criteria. They will also need to share accurate information about the patient and their treatment with the service providers.

When the patient is discharged from hospital, there should be a clear handover of responsibility for the care package to the provider, for example to a community alcohol treatment service keyworker and prescriber.

It is not usually appropriate to discharge patients who need ongoing treatment for their alcohol dependence and expect them to self-refer to a community alcohol treatment service. The guidelines development group’s clinical consensus is that this can introduce an unnecessary barrier to the patient’s continued care, and it’s also inefficient, because of the need to duplicate assessments.

Clinicians should take responsibility for liaising with community alcohol treatment services and handing over important information, including the patient’s risk to self and others. They should also make plans, as necessary, for:
- continuing medically assisted withdrawal in the community
- arranging aftercare following unplanned medically assisted withdrawal
- continuing relapse prevention treatment
Where ACTs exist, they may take responsibility for planning and contacting services to arrange a patient’s ongoing treatment and care. Whether ACTs are in place or not, in-reach provision from community alcohol treatment services is valuable. Where this provision exists, the in-reach worker should meet with the patient before discharge to provide information and orientation about their ongoing care.

16.19 References

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