8. Harm reduction
Source: gov.uk (2025-11-28)

How to deliver interventions to reduce health and social harms associated with a person's alcohol use. This includes assessing, planning and monitoring gradual alcohol reduction, and providing alcohol harm reduction advice across healthcare settings.

8.1 Main points

A harm reduction approach or philosophy frames the aim of alcohol treatment as reducing harms associated with a person’s alcohol use. Harm reduction can be understood as a continuum, with small changes at one end of the continuum and complete abstinence at the other.

A goal of abstinence is generally recommended for people with moderate or severe dependence.

If a person understands the recommendation but is not ready or chooses not to aim for abstinence or where appropriate, low-risk drinking, this should not be a reason to deny them support from the alcohol treatment service. The practitioner can agree a harm reduction approach with the person that focuses on reducing health and social harms associated with harmful drinking and alcohol dependence.

Working with a person to reduce harm can:
- build therapeutic rapport
- help people with more complex needs to engage in treatment
- provide an opportunity for motivational interventions
Assessment, including risk assessment, and treatment and recovery (support) planning are central to care for people working on harm reduction goals. These processes need to be tailored to the needs of each individual and provided flexibly.

Keyworkers should regularly review harm reduction goals with the person and discuss any barriers that prevent them working towards abstinence or where appropriate, low-risk drinking.

Clinicians should review the health of people who continue to drink at harmful or dependent levels.

A harm reduction approach may (although will not always) involve the person reducing their alcohol use. Any safe reduction in alcohol use, even while a person continues to experience alcohol dependence, can reduce alcohol related harm.

For people with alcohol dependence who experience withdrawal symptoms, the recommended intervention is medically assisted withdrawal and the clinician should inform people of this and discuss risks and benefits of the intervention.

If a person with moderate alcohol dependence is recommended medically assisted withdrawal but still wants to reduce their alcohol use rather than abstain, a clinician should assess whether there are any safety considerations that indicate this approach is not appropriate. The clinician should be competent in the diagnosis and assessment of alcohol dependence and withdrawal symptoms.

If the person is assessed as appropriate, the clinician can develop and monitor a plan for gradual reduction with the person and work with the keyworker (if the clinician is not the keyworker) to support the person through the planned reduction.

If a person with severe dependence or high-risk factors for severe complications in withdrawal does not opt for the recommended medically assisted withdrawal but wishes to reduce their alcohol use, this requires a complex clinical decision. An experienced specialist clinician should assess the risks and benefits for the person and there may be some circumstances in which they agree to monitor and support the person in a planned alcohol reduction.

If a clinician assesses that the risks of serious complications in withdrawal cannot be effectively managed, they can advise the person to continue drinking at a steady rate, avoiding sudden reductions or binges, to reduce the risk of serious withdrawal complications. The clinician should continue to encourage the person to consider medically assisted withdrawal.

Clinicians should prescribe oral or intramuscularly administered thiamine (depending on risk levels) to people who continue to drink at harmful or dependent levels to reduce their risk of developing Wernicke-Korsakoff syndrome and other neurological consequences.

Services should help people access screening for alcohol related liver disease using a test that can detect fibrosis or cirrhosis.

Staff in alcohol treatment services and staff working in relevant health and care services should be trained to provide alcohol harm reduction information and advice.

Every person attending an alcohol treatment service should be offered harm reduction information and advice.

Alcohol harm reduction information and advice includes telling people about:
- the risks of stopping drinking suddenly or reducing too fast for people with alcohol dependence
- the decrease in tolerance after a period of abstinence and the risks of drinking at pre-abstinence levels
- risks related to intoxication including alcohol poisoning and risks to safety
- the increased risk of overdose and other harms when drugs (including prescription and over the counter medication) and alcohol are taken together
- stop smoking advice
- specific advice for older people, young people, and women and those who are pregnant or may become pregnant
8.2 A harm reduction approach

8.2.1 Overview

A harm reduction approach or philosophy frames the aim of alcohol treatment as reducing the harms associated with a person’s alcohol use. Abstinence and harm reduction approaches can be seen in an unhelpfully polarised way that makes their goals seem mutually exclusive. Instead, it can be helpful to understand harm reduction on a continuum, with small changes at one end of the continuum and complete abstinence at the other.

People with alcohol dependence or drinking at harmful levels generally experience physical health, mental health or social harms associated with their alcohol use. Assessment, treatment and support to address those harms is vital to effective alcohol treatment and recovery. So, a harm reduction approach is relevant to everyone who engages in alcohol treatment, whatever their alcohol use goal.

In the context of a harm reduction approach to alcohol treatment, there are particular considerations for people with alcohol dependence who are not ready or do not choose a goal of abstinence or where appropriate, low-risk drinking. For this group of people, the main focus of the work is reducing harms related to their alcohol use, although practitioners should review their alcohol use goal with them regularly.

8.2.2 Recommending medically assisted withdrawal

For people with moderate or severe alcohol dependence, the National Institute for Health and Care Excellence (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) recommend assessment for and delivery of medically assisted withdrawal to achieve abstinence.

If the person has a goal of low-risk drinking rather than abstinence, this is often best achieved following a period of abstinence. So, medically assisted withdrawal can also be an appropriate intervention if a person with alcohol dependence is aiming at low-risk drinking.

Based on individual assessment, the clinician assessing the person should generally recommend and offer medically assisted withdrawal for people with moderate or severe dependence. They should discuss the risks and benefits of this intervention for the person, providing accessible (written and verbal) information in a way the person can easily understand.

However, this chapter contains guidance for other approaches that clinicians can consider to achieve harm reduction goals, including planned alcohol reduction without medication.

8.2.3 Assessment and treatment and recovery planning

Assessment and treatment and recovery (support) planning processes, including risk assessment and risk management, are central to the care of a person who is working towards harm reduction goals. A choice of harm reduction as a goal should not mean the person misses out on these essential processes, which should be tailored to their individual needs and may have to be delivered very flexibly.

You should read chapter 4 on assessment and treatment and recovery planning.

Treatment and recovery planning may include agreeing a contingency plan with the person. This would include actions the keyworker will take if the person disengages from treatment, such as making follow up phone calls or contacting a family member and relevant services.

8.2.4 A flexible service approach

Services may need to be flexible in how they provide assessment and treatment and recovery planning and harm reduction interventions. People experiencing multiple disadvantage and other groups of people for example, those who have poor health or are frail, often find it very difficult to attend a service for regular appointments.

Assertive outreach and co-ordinating a multi-agency team around the person are ways to flexibly deliver harm reduction approaches tailored to the needs of those who find it difficult to use structured alcohol treatment services without targeted support. Services may offer flexibility in other ways. For example, they may need to keep cases open even where the person misses several appointments.

You can find guidance on assertive outreach and a multi-agency team around the person in chapter 9.

8.3 Harm reduction goals

8.3.1 Alcohol harm reduction goals

A treatment and recovery plan should include harm reduction goals that address immediate and longer terms harms and risks the person may be experiencing. Chapter 4 describes assessment and treatment and recovery planning for a wide range of needs including physical health, mental health and social factors. A harm reduction plan generally involves actions to reduce harms in some or all those areas tailored to the person’s individual needs.

Even if the person does not reduce their alcohol use at first, if the practitioner and the person can agree a plan that helps reduce the harms and risks related to their alcohol use, and build on their strengths, this is a positive outcome. It can even help to prevent premature death.

Working towards goals that address physical health and mental health, social harms and longer-term recovery (for example, stable housing) can help to build motivation, self-efficacy and engagement with services.

If the person continues to drink at harmful or dependent levels, assessing and reviewing the person’s physical and mental health on an ongoing basis and responding to any indicators of increased risks is an important part of a harm reduction approach.

Goals can include a reduction of risks and harms related to:
- alcohol related brain damage, including Wernicke’s encephalopathy and other neurological consequences of harmful drinking
- alcohol related liver disease
- unplanned acute withdrawal
- reduced tolerance after a period of abstinence
- intoxication, including alcohol poisoning and safety risks related to intoxication
- concurrent alcohol and drug use, including over the counter and prescribed medications
- smoking
See chapter 24 for reducing risk and harm resulting from alcohol exposed pregnancies.

8.3.2 Agreeing alcohol use goals in the context of harm reduction

You can read about agreeing alcohol use goals in section 4.7 in chapter 4 on assessment and treatment and recovery planning.

A goal of abstinence is generally recommended for people with moderate or severe dependence and people with complex needs. However, goals should always be collaboratively agreed with and based on the individual. If a person is not ready or does not opt for a goal of abstinence or where appropriate a goal of low-risk drinking, the practitioner can consider a harm reduction strategy and discuss this option with the person. The discussion should include information tailored to the person’s individual needs, on any significant risks involved with the person’s continued alcohol use, for example risks to their physical or mental health.

A harm reduction strategy involves developing a practical and personalised plan with the person that will include advice and interventions to reduce harm to a person’s safety, and their physical and mental health. It may (although will not necessarily) include a limited reduction in alcohol use as a specific goal. Evidence shows a reduction in health harms when people reduce consumption, even though they may still be drinking at harmful or dependent levels (Witkiewitz and others, 2020).

Establishing a therapeutic alliance and achieving outcomes valued by the person can help to enhance their motivation and they may go on to choose a goal of reduced drinking or abstinence at a later stage.

8.3.3 Reviewing alcohol use goals

While a harm reduction approach may be the most useful way to work with a person initially, practitioners should never assume that a person is unable to achieve abstinence or make significant reductions in their alcohol use.

The practitioner should review alcohol use goals with the person at frequent defined intervals and adjust the plan as appropriate. At an appropriate time based on the person’s individual circumstances, the clinician should encourage the person to consider the benefits and any risks of a goal of abstinence as this will generally have the greatest effect in reducing risks to the person and supporting long term outcomes (Mann and others, 2017).

8.3.4 Motivation

A person’s unwillingness to consider a goal of abstinence or significant reductions in their drinking should not prevent them accessing support from an alcohol treatment service. An individual harm reduction plan is based on tailoring treatment to the person’s level of motivation at the time they are assessed and then is reviewed regularly with the person. A harm reduction approach can be helpful in building therapeutic rapport and engagement with the service. This approach should make use of the principles, processes and communication skills of motivational interviewing. You can find more information on motivational interviewing in section 5.5.6 in chapter 5 on psychosocial interventions.

Training and supervision in motivational interventions and in a trauma-informed approach should help practitioners to understand ambivalence as a natural part of any decision about behaviour change. It will also help practitioners consider how the experience of trauma might contribute to the person’s ambivalence towards making changes in their alcohol use. You can find more information on trauma-informed care in section 2.2.8 in chapter 2 on principles of care.

The person’s life circumstances also affect how achievable changes in alcohol use are. For example, if a person with alcohol dependence is experiencing rough sleeping, it is unlikely they can achieve and maintain abstinence without accessing safe and secure accommodation. A harm reduction approach is likely to be the most beneficial approach while people are experiencing rough sleeping.

Addressing potential barriers to engagement can positively affect the person’s motivation. For example, this can include flexible engagement interventions and support to address practical barriers including:
- housing needs
- financial and debt problems
- support needs around domestic abuse or sexual assault or exploitation
8.4 Reducing alcohol when a person is experiencing alcohol dependence

8.4.1 Risks and benefits of reducing alcohol use when a person is experiencing alcohol dependence

For people who are alcohol dependent, there are benefits and risks involved in cutting down their alcohol use. Any safe reduction in alcohol use can reduce both short and longer harm to health (Witkiewitz and others, 2021). But reducing alcohol use without medication when someone is alcohol dependent, especially when the reduction is sudden, can result in acute withdrawal symptoms and there is a risk of serious complications, including:
- seizures
- delirium tremens
- Wernicke’s encephalopathy (sometimes leading to long term alcohol related brain damage)
For guidance on complications in withdrawal, read section 10.4 in chapter 10 on pharmacological interventions (/guidance/clinical-guidelines-for-alcohol-treatment/10-pharmacological-interventions#prescribing-medication-to-prevent-and-to-manage-specific-complications-of-withdrawal).

8.4.2 Supporting people to reduce alcohol use: overview

If a person with alcohol dependence wishes to reduce their alcohol use, a clinician competent in diagnosis and assessment of alcohol dependence and withdrawal should assess whether the person is suitable for a gradual planned alcohol reduction.

Once the person has been assessed as suitable, the clinician and keyworker (if the clinician is not the keyworker) can arrange to support the person to do this. They should agree the role each will have in monitoring and supporting the person as they reduce their alcohol use (see sections 8.4.3 and 8.4.4 below for an overview of the roles of specialist clinicians and non-clinical keyworkers). They can then help the person make a plan to reduce their alcohol use safely, regularly reviewing progress, recognising achievement, and offering ongoing motivational support.

For further guidance on supporting people to reduce their alcohol use, see section 8.7 on developing and monitoring a gradual alcohol reduction plan and section 8.8 for a step-by-step approach to reducing alcohol consumption below.

8.4.3 The role of the specialist clinician or multidisciplinary team

A clinician competent in diagnosing and assessing alcohol dependence and withdrawal symptoms or a specialist multidisciplinary team (MDT), should be responsible for:
- assessing the suitability of the person for reducing alcohol use without medication
- developing a personalised alcohol reduction plan
- monitoring the impact of the alcohol reduction on the person
8.4.4 The role of the keyworker

In addition to the input from the MDT or specialist clinician, the keyworker (who might not be the clinician) should offer psychosocial support to the person throughout their planned reduction. Keyworkers who support people during a planned alcohol reduction should be trained to do this.

The specialist clinician should continue to monitor the person during the planned reduction to assess whether the person is experiencing withdrawal symptoms or there are any concerns about their health.

The service should have an escalation process so the keyworker can receive advice and supervision from the lead clinician or MDT if they observe any signs of risk to the person’s health while they are offering psychosocial support. Keyworkers should be trained to recognise withdrawal symptoms (shaking, sweating, anxiety, nausea), and particularly symptoms of withdrawal complications that mean the person should be referred to hospital as an emergency. See step 3 in section 8.8 below for a list of these symptoms.

8.5 Assessing the suitability and safety of a gradual reduction in alcohol use

When the clinician assesses the appropriateness of a gradual alcohol reduction plan they should take account of the person’s needs, risks and strengths as outlined in their comprehensive assessment including all relevant health factors.

The clinician should consider indications that it would not be safe for the person to reduce alcohol without medication, due to the high risk of serious complications in withdrawal.

The alcohol guidelines development group recommends that the person should generally be recommended medically assisted withdrawal rather than alcohol reduction if they:
- are assessed as severely alcohol dependent
- have experienced serious complications in withdrawal in the past (such as seizures (fits), hallucinations or delirium tremens, or Wernicke-Korsakoff syndrome)
- have epilepsy
- have significant unstable physical health or mental health
If the clinician has informed the person of the risks involved with a planned reduction in their care and they still want to reduce their alcohol use rather than engage with the recommended medically assisted withdrawal, the clinician has a complex clinical assessment to make. There is guidance on this in section 8.6.2 below.

8.6 Supporting people with different severity of dependence levels

8.6.1 People with moderate alcohol dependence

If a person with moderate dependence is assessed by a competent clinician as appropriate for a planned reduction, the clinician should provide them with accessible information on the risks and benefits of planned alcohol reduction tailored to their individual needs. Information should include advice against stopping or cutting down alcohol too suddenly, information on withdrawal symptoms and the risk of complications in withdrawal.

For information on what a unit of alcohol is, see the NHS page Alcohol units (https://www.nhs.uk/live-well/alcohol-advice/calculating-alcohol-units/).

Most people need help to understand and calculate units. You can use a unit calculator such as the Alcohol Change UK’s unit calculator (https://alcoholchange.org.uk/alcohol-facts/interactive-tools/unit-calculator) to help the person work out how many units they are drinking on a typical day. You can also find information about units for various alcoholic drinks on the ‘Alcohol units page’ on the Alcohol Change UK website (https://alcoholchange.org.uk/alcohol-facts/interactive-tools/check-your-drinking/alcohol-units). For more information on other harm reduction resources, including drink diaries and apps, see section 8.15.

You can use the step-by-step approach in section 8.8 below to support people with moderate dependence to reduce their alcohol use where there are no safety considerations as outlined in section 8.5 above.

8.6.2 People with severe alcohol dependence or higher risks

Assessing risks and benefits of reducing alcohol use for people with severe dependence or other risks

This is a more finely balanced and complex clinical decision to make if a person has severe alcohol dependence, a history of complications in withdrawal or other risks as set out in section 8.5.

The alcohol guidelines development group recommend that people with severe alcohol dependence access medically assisted withdrawal, which is the evidenced based intervention, as there is a higher risk of developing serious complications in withdrawal.

However, there may be circumstances where a person with severe dependence or high risks opts not to follow the medical advice to access medically assisted withdrawal but wishes to make some reduction in their alcohol use. In this circumstance, the clinician should check the person understands their recommendation for medically assisted withdrawal and personalised advice on the risks of cutting down (see section 8.5) and check that the person has mental capacity to make the decision in question.

The clinician needs to weigh the short-term risks of serious complications in withdrawal against the long-term health risks if the person continues to drink at their current level, taking all health factors into account.

Based on an individual assessment of risks and benefits, if the clinician assesses the risk of inducing withdrawal symptoms can be effectively managed, then a gradual limited reduction to an agreed level can be undertaken. Such a reduction would require:
- regular in-person reviews with the clinician
- recording alcohol use in daily drink diaries or using apps
- a suitable support person aware of the reduction and staying with the person
The clinician can return to the recommendation for medically assisted withdrawal at a later stage.

The clinician and the person can agree an individual plan for reduction and how often this should be reviewed. The clinician can follow all the advice given in sections 8.7 and 8.8 for people with moderate dependence. But people with severe dependence should cut down at a slower rate and be very aware of any withdrawal symptoms.

As there are higher risks for people with severe dependence, the specialist clinician or MDT should closely monitor the person as they reduce their alcohol use. If they start to experience uncomfortable withdrawal symptoms (such as sweating, shaking, anxiety and nausea), this means they are cutting down too quickly. In that case, they need to drink a steady amount for a week, then cut down by smaller amounts over a longer period of time.

As the risks are higher for people with severe dependence, it is particularly important to advise the person to have somebody to support them as they cut down. The clinician should make sure the person and the person supporting them understand they should call an ambulance or go immediately to the hospital emergency department if they see signs of serious complications (see step 3 in section 8.8 below on serious complications in withdrawal).

If risks are assessed as too high to manage effectively

Based on an individual assessment of risks and benefits, if the clinician assesses the risk of inducing withdrawal symptoms cannot be effectively managed, they can advise the person to continue to drink at a steady rate, without sudden reductions or heavy drinking episodes. This will reduce the risk of withdrawal symptoms and serious withdrawal complications. They can support the person to work towards drinking at a steady rate and avoid binges using drink diaries or apps and regular meetings to review progress.

The clinician should continue to:
- monitor the person’s health
- encourage the person to consider medically assisted withdrawal
- address any barriers the person may experience in opting for medically assisted withdrawal
8.7 Developing and monitoring a gradual alcohol reduction plan

8.7.1 Developing a plan

The clinician should develop a plan for gradual alcohol reduction with the person. The plan will include:
- monitoring the person’s current level of alcohol use
- the agreed initial level of reduction (how may units they aim to reduce by) and pace of reduction (how many days they aim to remain at each level of consumption)
- arrangements for the clinician to monitor the impact of the reduction
- arrangements for psychosocial support (keyworker)
- arrangements for an appropriate family member or person to offer support
- arrangements for prescribing thiamine (see section 8.9 below)
- when working with parents or carers, arrangements for supporting children or vulnerable adults where appropriate
- planning activities to help distract the person from cravings
- plan for further interventions or support once the person has reduced their alcohol use
8.7.2 Working with parents and carers who are cutting down on drinking

When developing a plan with a parent or carer, you should help them to consider the support that their family or children might need during the period when they are cutting down their alcohol use. For example, where appropriate, whether the children (or any adult the person is caring for) could stay with supportive relatives or friends, or whether professionals can offer support if necessary.

The practitioner should work with professionals involved with the family to co-ordinate care for the person and their family if this is needed. As always, practitioners should work in line with safeguarding legislation and organisational procedures. You can find information on child and adult safeguarding legislation and guidance in annex 1.

Family members and friends may also want to access support through organisations such as Al Anon UK (https://al-anonuk.org.uk/) and Adfam (https://adfam.org.uk/). Alcohol treatment services should provide advice and information for family members who are supporting the person.

8.8 The step-by-step approach to reducing alcohol consumption

The guidance on gradually reducing alcohol use in this section is based on clinical consensus of the alcohol guidelines development group.

This step-by-step approach is for people with moderate dependence on alcohol and have been assessed as suitable for gradual alcohol reduction by a specialist clinician.

If a specialist clinician or MDT has decided to offer planned alcohol reduction to a person with severe alcohol dependence or at higher risk of serious complications, the person should reduce at a slower rate than shown in the plan below and be very aware of any withdrawal symptoms.

Step 1: work out how much the person drinks

Work out how much the person drinks in a day. A drink diary or app can be useful to record this (see section 8.15 for examples of drink diaries and apps). You should ask them to be accurate and explain that minimising their own use can increase risk when deciding on the reduction rate.

Ask the person to write down each drink they have, when they have it and help them to find out how many units the drink has in it. They can work it out with an online or printed unit calculator (see section 8.15 for an example of a unit calculator). Alternatively, the percentage of alcohol on the side of the bottle or can represents the number of units in a litre. If the person agrees, a family member or friend could help with this.

Step 2: make a plan

Once the person knows how much they have been drinking, suggest they keep their drinking at that level for at least 3 days (and up to 7 days), before starting to cut down.

Agree with the person what level of consumption they are aiming to achieve.

Suggest they try to space out their drinks, particularly in the middle of the day. They should measure drinks using the same glass, measuring cup or can, or ask a family member to do this for them. Suggest they record how much they drink each day in a drink diary or on an app.

Offer your support as they cut down and arrange regular meetings and phone calls with the person to monitor their wellbeing and enhance their motivation (see step 5 on cutting down at their own pace below).

Suggest they ask an appropriate family member or friend to support them and encourage them to arrange regular in-person and phone contact with them. Remind them they can use organisations that offer online and telephone support. For example, the Alcoholics Anonymous (https://www.alcoholics-anonymous.org.uk/) helpline or national alcohol helplines (see section 8.15 below for more details on these resources).

With the person’s consent, speak to the family member or friend and provide them with information about the process.

You should also tell the person and the family member that they should call an ambulance if the person seems to be experiencing serious withdrawal complications (see step 3 below).

If the person is a parent or carer, discuss the support needs of their family members (see section 8.7.2 on working with parents and carers above).

Step 3: tell them about serious complications in withdrawal

Advise them to watch out for serious complications, including:
- symptoms worsening to the point of severe shaking and very heavy sweating
- seizures (fits)
- seeing, hearing or feeling things that are not there (hallucinations or delirium tremens)
- feeling confused about where they are, what time it is, who they are with (symptoms of Wernicke’s encephalopathy which can cause brain damage )
- poor co-ordination and unsteadiness on their feet or impaired eye movements (symptoms of Wernicke’s encephalopathy)
If any of these serious complications occur, they or the person providing support should call an ambulance immediately.

Inform them and the person supporting them that changes in mood and volatility can sometimes occur during a reduction programme.

You should provide this information verbally and also in a written format that is easy for the person and their family member or appropriate support person to understand, taking into account their communication, literacy and language needs.

Step 4: provide advice on health and wellbeing during gradual alcohol reduction

Reassure them that although people often describe feeling frightened and alone when they are reducing or stopping drinking, it can help if they let their keyworker, friends and family know how they feel. Tell them they should try to distract themselves with things that they enjoy.

Tell them that sleep may remain a problem for a while, but that they should keep to a routine and be patient.

Prescribe oral thiamine or prescribe and administer thiamine intramuscularly (see section 8.9). If the person is prescribed thiamine orally, remind them to make sure they take it. Advise them to try and eat foods high in thiamine (B1), such as meat, fish, brown bread and rice. You can also suggest they keep well-hydrated by drinking plenty of water.

Advise them on relapse prevention strategies including managing urges and cravings and taking part in distracting and meaningful activities.

Provide advice sheets for the person and their family member or friend. For example, this could include information on:
- serious complications in withdrawal and actions to take if the person experiences these
- diet
- sleep
- cravings
- concentration and mood
- coping strategies
You should include contact numbers for the alcohol treatment service and for other support, such as helplines. Advice sheets should be easy for the person (and the person supporting them) to understand and take into account the person’s language, literacy and communication needs.

Step 5: cut down gradually at their own pace

It’s important to cut down gradually at a pace that suits the person but aim at cutting down by no more than 10% a day. If they are drinking more than 25 units a day, are aged 65 years and over or their general health is not good, they may need to cut down more slowly. For example, this could be no more than 10% every 4 days.

It is important that the person cuts down at a pace that suits them. They may want to reduce by 10% or less and stay at that level for several weeks or months. Help the person, and where relevant the family member or support person, to work out what 10% of their intake is in units and how much of their usual alcoholic drink that would be.

If they start to experience uncomfortable withdrawal symptoms (sweating, shaking, anxiety, nausea), this means they are cutting down too quickly. In that case, they need to drink a steady amount for several days again, then cut down by smaller amounts over a longer period of time.

Step 6: arrange regular and frequent review

Arrange regular and frequent review supported by a clinician to identify any withdrawal symptoms (see step 4 above) or worsening physical or mental health.

How often you review the person should be agreed with the senior clinician or MDT overseeing the reduction and providing the clinical monitoring.

Ask about withdrawal symptoms, any health problems and changes in their mood and volatility.

Escalate to the lead clinician and refer and support the person to access medical help if their physical or mental health worsens.

Offer motivational support and recognise the person’s progress.

If the person is not managing to reduce their drinking, review the plan and amend if appropriate. Offer motivational support and help the person to address barriers to progress.

8.9 Prescribing thiamine to prevent Wernicke’s encephalopathy and other neurological consequences

In people who drink at harmful or dependent levels over a period of time, there is a risk of both short and long term alcohol related brain damage, most often caused by Wernicke’s encephalopathy.

Prescribing oral or intramuscularly administered thiamine can prevent or reduce the risk of Wernicke’s encephalopathy and other neurological consequences, such as peripheral neuropathy.

Thiamine can be prescribed orally or intramuscularly in the community. You should prescribe thiamine based on individual assessment and the type of healthcare setting you are treating the person in. For intramuscular administration, staff should have the appropriate competencies, and the setting should be equipped to respond appropriately in the event of anaphylaxis.

Thiamine is recommended for people undergoing medically assisted withdrawal and also for people who continue to drink at harmful and dependent levels. You should read guidance on risk levels for Wernicke’s encephalopathy and prescribing and administering thiamine in section 10.4.3 in chapter 10 on pharmacological interventions (/guidance/clinical-guidelines-for-alcohol-treatment/10-pharmacological-interventions#preventing-and-managing-wernickes-encephalopathy).

Chapter 20 provides comprehensive guidance on alcohol related brain damage.

8.10 Referral for liver screening test

The Office for National Statistics data set Alcohol-specific deaths in the UK (https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/alcoholspecificdeathsintheuk) shows the majority of deaths from conditions caused solely by alcohol are deaths from alcohol related liver disease. Symptoms of liver disease do not usually appear until the disease is at an advanced stage. Arranging referral for liver screening with a test that can detect fibrosis or cirrhosis can inform people at an earlier stage of the disease when further damage can be prevented. Abstinence is strongly recommended for people with liver disease.

NICE guideline Cirrhosis in over 16s: assessment and management (https://www.nice.org.uk/guidance/ng50) recommends that anyone drinking at harmful (high-risk) levels (35 units or more per week for women, 50 units or more per week for men) for 3 months or more should be referred for transient elastography. Some areas use alternative tests for detecting cirrhosis.

Screening for alcohol related liver disease should include a measure of liver fibrosis (such as transient elastography), in addition to liver function blood tests, because normal liver blood tests do not exclude advanced fibrosis.

There is more detailed guidance on liver screening tests in section 19.5.2 of chapter 19 on co-occurring physical health conditions.

8.11 Managed alcohol programmes

Managed alcohol programmes are comprehensive harm reduction programmes of care that aim to support people with alcohol dependence or drinking at harmful levels to manage their alcohol use and its associated harms. These programmes involve alcohol treatment practitioners distributing an agreed amount of alcohol each day to support people to drink at a steady pace, alongside other forms of support. Drinking at a steady pace is less harmful than very heavy episodic drinking and periods of unplanned withdrawal.

These guidelines do not include guidance on managed alcohol programmes as there is currently little high-quality evidence on their effectiveness to base guidance on (Magwood and others, 2020). There are also few formal managed alcohol programmes in the UK, so few UK clinicians have gained clinical expertise in this area. The alcohol guidelines development group recommend that more research in this area would be useful.

8.12 Driving while under the influence of alcohol

The Driver and Vehicle Licensing Agency (DVLA) has published general information for medical professionals about assessing fitness to drive (https://www.gov.uk/guidance/general-information-assessing-fitness-to-drive) to help healthcare professionals and doctors understand their roles and responsibilities for assessing fitness to drive.

DVLA guidance states that ‘persistent alcohol misuse and dependence’ are conditions that can affect a person’s fitness to drive safely so these should be reported to the DVLA in Great Britain or to the Driver and Vehicle Agency (DVA) in Northern Ireland.

The guidance says that applicants and licence holders have a legal duty to:
- notify DVLA (or DVA) of any injury or illness that would have a likely impact on safe driving ability
- respond fully and accurately to any requests for information from either DVLA (or DVA) or healthcare professionals
- comply with the requirements of the issued licence, including any periodic medical reviews indicated by DVLA (or DVA)
It also says that doctors and other healthcare professionals should:
- advise the person on the impact of their medical condition for safe driving ability
- advise the person on their legal requirement to notify DVLA (or DVA) of any relevant condition
- treat, manage and monitor the person’s condition with ongoing consideration of their fitness to drive
- notify DVLA (or DVA) when fitness to drive requires notification but an individual cannot or will not notify DVLA (or DVA) themselves
The DVLA guidance acknowledges the challenge for healthcare professionals on issues of consent and to the relationship with their patient when notifying DVLA (or DVA) if a person cannot or will not notify DVLA themselves. It directs healthcare professionals to General Medical Council (GMC) guidance Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA (https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality---patients-fitness-to-drive-and-reporting-concerns-to-the-dvla-or-dva).

Healthcare professionals considering notifying the DVLA (or DVA) of the person’s condition should read the GMC guidance before taking this action.

The GMC guidance sets out the steps a doctor should take to inform decisions about disclosing relevant medical information directly to the DVLA or DVA when a person’s failure or refusal to stop driving exposes others to a risk of death or serious harm. The guidance recognises the duty of confidentiality doctors owe to their patients, but also acknowledges their wider duty to protect and promote the health of patients and the public.

The DVLA has also produced specific guidance on assessing fitness to drive in people with drug or alcohol misuse or dependence (https://www.gov.uk/guidance/drug-or-alcohol-misuse-or-dependence-assessing-fitness-to-drive).

This guidance will help clinicians to give appropriate advice to people with alcohol dependence or drinking at harmful levels.

People who drink heavily and daily may not appear or feel intoxicated because they will have developed tolerance to alcohol. Tolerance is the need to drink more alcohol to get the same or desired effect, and it develops in people who drink heavily and regularly. They are likely to be over the legal driving limit on a daily basis and should be advised not to drive and to notify the DVLA (or DVA) of their condition. The practitioner should explain that although they may not feel intoxicated, their functioning and judgment will still be affected.

8.13 Safety and security

Intoxication is associated with several risks to the safety and security of the person and those around them. There is a summary of harm reduction information and advice for reducing risks of intoxication in section 18.4.5.

Some people with complex needs, including older people who are frail, may require more than information. For example, they may require home visits from an outreach team or staff member, or a referral to adult social care so that their care needs and risks in the home can be assessed and a risk reduction plan put in place. If the assessment is carried out by another service like adult social care, the alcohol treatment service may need to advocate for the person and contribute their expertise on risks related to intoxication.

8.14 Harm reduction information and advice

This section on harm reduction information and advice is relevant for practitioners in alcohol treatment services and primary care settings. It is also relevant for staff in a range of other health and social care settings, such as homelessness services, who work with people with problem alcohol use.

8.14.1 How to provide harm reduction information and advice

Wherever possible, services should make available simple, clear, written alcohol harm reduction information and practitioners should understand this information and be able to provide advice verbally. Information should be available in other formats (such as graphic, video or audio) and in translation for people whose first language is not English. You should make this information and advice available so it can be provided at a one-off occasion to support a Making Every Contact Count (https://www.hee.nhs.uk/our-work/population-health/our-resources-hub/making-every-contact-count-mecc) approach. Services should provide harm reduction advice to everyone who comes into treatment for alcohol or for drugs, or for both alcohol and other drugs.

Alcohol treatment practitioners can also provide information and advice over several sessions (either individual or group) using a psychoeducational approach. A psychoeducational approach involves the practitioner providing information and support to the person so they can better understand and make changes in their alcohol use and associated problems. The information may be new to the person, and it can prompt conversation about risks and benefits associated with their alcohol use. This can help the person to make informed choices about ways to manage harms and risks as part of their personalised harm reduction plan.

You should offer to provide harm reduction information to family members or friends supporting the person. Some of the advice, such as actions to take in a medical emergency, will be addressed specifically to family members and friends.

8.14.2 Providing harm reduction information and advice on specific areas

When providing harm reduction information and advice, it is useful to include:
- information and advice for people with alcohol dependence not to stop or reduce drinking suddenly
- information and advice about tolerance and the risks of reduced tolerance following a period of abstinence or low risk drinking
- information and advice about intoxication and related risks
- information and advice about alcohol poisoning
- information and advice about concurrent alcohol use and prescribed medications or illicit drug use
- harm reduction information and advice for specific populations
8.14.3 Advising people with alcohol dependence not to stop drinking or reduce suddenly

People who are moderately or severely alcohol dependent will experience withdrawal symptoms after stopping drinking (as early as between 6 to 8 hours).

If they suddenly stop or substantially reduce their alcohol use, they will experience acute alcohol withdrawal syndrome, which can lead to severe complications and can even be fatal.

There is a comprehensive list of alcohol withdrawal symptoms and complications in annex 3 (/guidance/clinical-guidelines-for-alcohol-treatment/annex-3-alcohol-withdrawal-symptoms).

When advising people with alcohol dependence not to stop drinking or reduce their alcohol use too quickly, the practitioner should:
- describe withdrawal symptoms and explain they are a sign of alcohol dependence
- advise them that they should not suddenly stop drinking or substantially reduce their alcohol use too quickly
- advise them that stopping suddenly or reducing their alcohol use too quickly can lead to severe complications and can even be fatal
- briefly describe severe complications and how to recognise them
- advise them and anyone who supports them to call an ambulance if the person experiences severe withdrawal complications
- inform them that the safest way to stop drinking and the best treatment advice is to have a medically assisted withdrawal (detox)
- inform them you can offer or refer the person for an assessment by an alcohol specialist clinician for medically assisted withdrawal
If the person with alcohol dependence does not want to stop or reduce their drinking, the practitioner should advise them to maintain their drinking at a steady level and space out drinks evenly to help reduce the occurrence of withdrawal symptoms and risk of serious complications in withdrawal.

If the person does not want a medically assisted withdrawal, but they plan to reduce their drinking, see section 8.5 for guidance on assessment for planned gradual reduction.

8.14.4 Reduced tolerance and risks of intoxication including alcohol poisoning

Tolerance is the need to drink more alcohol to get the same or desired effect, and it develops in people who drink heavily and regularly. The effect of blood alcohol content on a person will decrease as tolerance develops. Although, even in people who have developed tolerance, a high level of alcohol use will still impair functioning and judgement. NICE CG115 (full guideline) found that people with very high alcohol tolerance are able to tolerate a high blood alcohol content that would be fatal to a person without tolerance to alcohol.

After a period of abstinence, tolerance is greatly reduced. If a person returns to drinking at their pre-abstinence level, the effects of blood alcohol content will be much greater than they were before they became abstinent. They will experience increased risks related to intoxication and they may even experience fatal alcohol poisoning. People who have had an unplanned period of abstinence, for example during time in custody or in hospital, can be particularly at risk of returning to drinking at pre-abstinence levels.

The practitioner should provide information and advice to the person on tolerance and alcohol poisoning, including:
- what tolerance is and how it develops
- how tolerance is reduced after a period of abstinence
- how the risks of intoxication, including alcohol poisoning, increase after a period of abstinence (see section 8.14.5 below on intoxication and related risks)
- the increased risk of taking other drugs in addition to drinking after a period of abstinence (see section 8.14.7 on concurrent use of prescribed medications or illicit drugs)
8.14.5 Intoxication and related risks

Intoxication from drinking too much and too quickly may involve significant impairments in:
- motor co-ordination
- reaction time
- judgement and decision-making
- impulse control
It can also involve:
- drowsiness
- digestive problems
- dehydration
At higher levels of blood alcohol content there is a risk of alcohol poisoning.

The level of consumption that leads to significant impairment will vary according to factors such as:
- body size
- whether the person has eaten
- tolerance
- health, including liver function
Intoxication can be associated with several risky behaviours and expose people to risks from others (see section on mitigating risky behaviour while intoxicated below).

Intoxication: information and advice

The practitioner should provide information and advice about intoxication that includes:
- a summary of the UK chief medical officers’ alcohol guidelines on lower risk, increasing risk, high risk drinking levels and single occasion drinking
- a summary of common short-term risks, such as injuries (including head injuries), falls, road traffic accidents, accidents with machinery, drownings and burns
- a summary of common increased risky behaviours, such as unsafe sex which can result in unplanned pregnancies or sexually transmitted diseases
- information about a person’s increased risk of violence (as a perpetrator), including domestic violence
- information about a person’s increased vulnerability to domestic abuse (as a victim) and to sexual assault
- information about a person’s increased risk of self-harm (including suicide)
- information about the increased risk of problems at work including absence
Managing alcohol use: information and advice

Information and advice on managing alcohol use can include:
- drinking at a slower pace, including avoiding drinking in a round where there can be pressure to drink at a faster pace
- alternating between alcoholic drinks with soft drinks or water
- drinking lower strength drinks
- eating before drinking
- start drinking later or finishing earlier
- avoiding areas or activities associated with heavy drinking or heavy drinking social networks
- drinking with people who drink at lower risk levels, where possible
- avoiding taking alcohol and drugs together
Mitigating risky behaviour while intoxicated

Information and advice on mitigating risky behaviour while intoxicated should be individually tailored and can form part of a treatment and recovery plan. Examples include advice on:
- avoiding drink driving or operating machinery (see section 8.12 for responsibilities of staff relating to drink driving)
- arranging with a supportive friend or family member to stay together during the evening, and travel home together
- installing smoke detectors and removing trip hazards in the home (for people who are frequently very intoxicated and for older people who are at greater risk of falls)
- information about local sexual health services and what they provide
- discussing contraception and the risks of alcohol exposed pregnancies (see section 8.14.9 on women who are pregnant or could become pregnant)
- specific advice for people who are at risk of domestic abuse (see chapter 22 on domestic abuse)
- specific advice and support on self-harm including suicidal ideation (for guidance on providing information and support for people who self-harm, see the NICE guideline Self-harm: assessment, management and preventing recurrence (https://www.nice.org.uk/guidance/ng225))
8.14.6 Alcohol poisoning

Alcohol poisoning (sometimes known as alcohol overdose) can result when a person drinks a toxic amount of alcohol, particularly if this takes place over a short space of time. This leads to high blood alcohol levels which the liver cannot process. The level of consumption that leads to alcohol poisoning will vary according to factors such as:
- body size
- health, including liver function
- tolerance
However, drinking above 12 units, especially during a short space of time, is a broad indicator of risk of alcohol poisoning.

Alcohol poisoning may be experienced by people who are relatively inexperienced with alcohol use and unaware of its toxic effects. However, people with alcohol dependence can also experience alcohol poisoning and there is an increased risk of this if they drink heavily following a period of abstinence where their tolerance to alcohol has decreased (see section 8.14.4 on reduced tolerance and risks of intoxication including alcohol poisoning).

Alcohol poisoning affects the automatic functions of the body, including breathing, heart rate and gag reflex (which prevents choking), so it puts the person at risk of a coma and of death.

Signs and symptoms of alcohol poisoning

Signs and symptoms of alcohol poisoning may not all be present at the same time. They include:
- confusion
- vomiting
- seizures (fits)
- slow breathing
- pale or bluish skin
- cold and clammy skin
- unconsciousness
Alcohol poisoning: information and advice

As well as describing the signs and symptoms of alcohol poisoning, practitioners should provide information and advice on alcohol poisoning including telling people that:
- they can experience alcohol poisoning if they drink a large amount in a short space of time and that they should pace their alcohol use (see section 8.14.5 on intoxication and related risks)
- a person with suspected alcohol poisoning is a medical emergency and whoever is with them should call an ambulance immediately
- a person with suspected alcohol poisoning should not be left alone
- a person with suspected alcohol poisoning should be helped to stay upright and awake if possible and helped to drink water if possible
- if a person with suspected alcohol poisoning is unconscious, they should be placed on their side with their ear to the ground with a cushion under their head (the recovery position)
- a person with suspected alcohol poisoning should not be made to vomit as there will be a risk of choking (as the gag reflex is not functioning)
- symptoms of alcohol poisoning may worsen even after the person has stopped drinking and is unconscious
8.14.7 Concurrent use of alcohol and prescribed medications or illicit drugs

Identifying a person’s concurrent alcohol and substance use

Advice on concurrent use of alcohol and prescribed medications or illicit drugs (drinking and taking drugs together) will usually be provided by qualified staff at specialist alcohol and drug treatment services. In these services, identifying a person’s concurrent alcohol and substance use should take place at initial assessment and subsequent treatment reviews. There are many different interactions between prescribed medication and illicit drugs, so a clinician should make an individual assessment of the risks to the person and provide them with tailored advice. The British National Formulary provides information on interactions between alcohol and prescribed medicines (https://bnf.nice.org.uk/interactions/alcohol/).

The alcohol or drug treatment practitioner should support the person to reduce risks related to concurrent use of alcohol and prescribed medications and illicit drugs. They may need to agree additional treatment plans focused specifically on drug use. Section 10.6.1 in chapter 10 on pharmacological interventions provides guidance on pharmacological interventions for concurrent alcohol and illicit drugs or prescribed medications. Drug misuse and dependence: UK guidelines on clinical management (https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk-guidelines-on-clinical-management) provides guidance on drug use, including alcohol in drug treatment, in section 6.5.

Staff in other health and social care services should inform a person suspected of concurrent use that taking alcohol and drugs together can increase risks of overdose and other serious health risks. They should also offer the person referral to an alcohol and drug treatment service.

Concurrent use of alcohol and prescribed medications or illicit drugs: information and advice

Information and advice on concurrent use of alcohol and prescribed medications or illicit drugs should include the:
- increased risk of overdose due to reduced tolerance following a break in regular or dependent use of alcohol or an illicit substance or prescribed medication
- risks related to concurrent use of alcohol and specific illicit drugs and prescribed medication
- additional risks when both alcohol and drugs are used together
You can read guidance on risks related to specific illicit drugs and prescribed medications in ‘Drug misuse and dependence: UK guidelines on clinical management’.

Information and advice on additional risks of using alcohol and illicit drugs or prescribed medications should include:
- risk of overdose from using sedative medications and depressant drugs with alcohol (this includes both prescribed drugs and those obtained illicitly, for example pregabalin, gabapentin, benzodiazepines and opioids, including opioid substitute medications methadone and buprenorphine)
- using illicit drugs such as heroin, or drugs sold as having the look of genuine prescribed medications have an additional risk as their strength and effects can vary
- alcohol and opioids (including methadone or buprenorphine) taken together increase the risk of slowing your rate of breathing, which can lead to death
- physical health harms of stimulant drugs, especially cocaine when it is taken with alcohol
Cocaethylene is formed by the liver when cocaine and ethanol coexist in the blood. Some evidence shows that cocaethylene is more cardiotoxic than the sum of the risks associated with cocaine and the risks associated with alcohol if they are used separately. Concurrent cocaine and alcohol use can increase euphoria, increase the heart rate and increase risk of overdose. Long term concurrent cocaine and alcohol use can increase the risk of heart attacks and strokes.

8.14.8 Smoking

There are high rates of smoking among people with problem alcohol use. The combined impact of smoking and drinking to excess increases various health risks. Practitioners in alcohol treatment services should be competent to provide or to support referral to stop smoking interventions.

You can find advice on smoking in section 19.6 in chapter 19 on people with co-occurring physical health conditions.

8.14.9 Specific populations

Practitioners can also provide harm reduction information tailored to specific populations.

Older people

The ageing process makes people more susceptible and at risk of the physical and mental health harms caused by alcohol (RCPsych, 2018).

In addition to general harm reduction information, there are harms that older people are more likely to experience. These harms are described in section 25.8 of chapter 25 on developing inclusive services. Services should have written information tailored to older people and practitioners should be trained to provide this information verbally to older people.

Women and those who are pregnant or think they could become pregnant

The UK chief medical officers’ low-risk drinking guidelines (https://www.gov.uk/government/publications/alcohol-consumption-advice-on-low-risk-drinking) is that it is safest for women who are pregnant or think they could become pregnant to completely avoid alcohol to keep risks to the fetus to a minimum.

Practitioners should provide information on the risks of alcohol use in pregnancy and advise women and those who are pregnant or think they could become pregnant to avoid alcohol. However, midwives, alcohol treatment practitioners and other healthcare professionals should advise women and those who are (or who could be) alcohol dependent not to stop drinking suddenly. This is because withdrawal complications risk harm to the fetus and the mother. They should rapidly refer the woman to specialist alcohol treatment to be assessed for medically assisted withdrawal (so they can stop drinking safely) and to specialist antenatal care if they are not already engaged with this. They will also need to make a safeguarding referral if the unborn child is at risk of significant harm.

You should read section 24.5.2 in chapter 24 on pregnancy and perinatal care on providing advice on avoiding alcohol use in pregnancy.

Young people

Young people and practitioners can find harm reduction information tailored to young people on the FRANK website (https://www.talktofrank.com/).

See also chapter 23 on alcohol treatment and support for young people for more information on harm reduction.

8.15 Harm reduction resources

8.15.1 Helplines and meetings

Alcoholics Anonymous (https://www.alcoholics-anonymous.org.uk/) a free confidential helpline and website with information on local mutual aid meetings for people who need help with their drinking.

Drinkline, a free, confidential helpline for people who are concerned about their drinking, or someone else’s. Call xx-xxxx-xxxx (weekdays 9am to 8pm, weekends 11am to 4pm).

If you are in Scotland, you can contact Drinkline Scotland for free on xx-xxxx-xxxx (weekdays 9am to 9pm, weekends 10am to 4pm).

Wales DAN 24/7 is a bilingual drug and alcohol helpline. Call free on xx-xxxx-xxxx or text DAN to 81066. DAN 24/7 calls will not appear on home itemised call lists.

SMART Recovery holds both face-to-face and online meetings that support people in managing harmful drinking and other behaviours. You can find out about meetings on the SMART Recovery website (https://smartrecovery.org.uk/).

8.15.2 Alcohol unit calculator

There are several interactive tools to help people check how much they’re drinking. This includes Alcohol Change UK’s unit calculator (https://alcoholchange.org.uk/alcohol-facts/interactive-tools/unit-calculator), which allows people to find out how many units are in a particular drink or to check out how much they’re drinking on a weekly basis.

8.15.3 Drink diaries and apps

Encouraging people to self-monitor and record their alcohol use is a useful intervention. It can help with assessment, and it can also help people to have more self-awareness around drinking situations and to understand the consequences of their drinking.

People can record information on paper diary sheets or using digital apps. The diaries can be individually tailored to the person’s treatment needs and the interventions they are receiving, but would typically include:
- the date and time
- a description of the drinking circumstances
- the amount they drank in units or drinks
- the person’s thoughts and feelings
- the consequences of drinking
Alcohol Change UK’s free Try Dry app (https://alcoholchange.org.uk/alcohol-facts/interactive-tools/the-dry-january-app-1) is for people who want to cut down their drinking or who want to work towards abstinence. It helps people to track the units they drink, as well as calories consumed and money saved when they cut down. It helps people see their drinking patterns and provides a space to monitor thoughts, moods and cravings as well as sleep.

8.15 References

Magwood O, Salvalaggio G, Beder M, Kendall C, Kpade V, Daghmach W and others. The effectiveness of substance use interventions for homeless and vulnerably housed persons: a systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.xx-xxxx-xxxx). PLoS ONE 2020: volume 15, issue 1, article e0227298.

Mann K, Aubin HJ and Witkiewitz K. Reduced drinking in alcohol dependence treatment, what is the evidence? (https://www.karger.com/Article/FullText/481348) European Addiction Research 2017: volume 23, issue 5, pages 219 to 230 (registration and subscription required for full article).

Royal College of Psychiatrists. Our invisible addicts (2nd edition), College Report CR211 (https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/college-reports/2018-college-reports/our-invisible-addicts-2nd-edition-cr211-mar-2018). RCPsych, 2018.

Witkiewitz K, Kranzler HR, Hallgren KA and others. Stability of drinking reductions and long-term functioning among patients with alcohol use disorder (https://link.springer.com/article/10.1007/s11606-020-06331-x). Journal of General Internal Medicine 2021: volume 36, pages 404 to 412.