Overview of management of disorders of alcohol use

Overview of substance use and addictive behaviours explains key principles of care for a patient with a disorder of substance use. Many patients with alcohol dependence have denied their drinking or feared the consequences of confronting it for years; most present late. Establishing a therapeutic relationship that engages the person (and ideally those close to them) is central to the management of substance dependence. Develop an agreement for the first steps (eg to undertake short-term planned withdrawal or to reduce intake gradually ) and review the plan as soon as possible.

Note: The most important element of treatment for substance use is a therapeutic relationship.

Specialist advice on any aspects of care for patients with alcohol and other substance dependence is available and contact is encouraged; see Contact details for substance use clinical advisory services for clinicians.

Note: Specialist advice is available by phone on any aspect of the management of substance use; contact is encouraged.

Alcohol use can pose risk of acute harms to the person (such as self-harm, falls and other accidents, suicide) and those around them (through impacts on driving, childcare, fitness to work and acute behavioural disturbances). In any presentation, ensuring the safety of the person and those around them is a priority, especially if the person is highly agitated. Profound disinhibition in highly intoxicated people (eg young men who have a prior history of aggressive behaviour) can lead to serious acts of violence; most perpetrators and victims of fatal ‘king hit’ injuries (single blows to the head causing loss of consciousness, also called ‘coward punches’ or ‘one-punch attacks’) are highly intoxicatedPilgrim, 2014. For advice on assessment and management of acute alcohol intoxication, see the Toxicology and Toxinology guidelines. Alcohol use is also associated with a broad range of acute medical conditions that may require stabilisation (eg liver failure, pancreatitis, gastrointestinal bleeding, head trauma, seizures, Wernicke encephalopathy, aspiration, sepsis).

Further management options for disorders of alcohol use include:

  • brief interventions
  • short-term withdrawal management
  • gradual reduction of alcohol use
  • harm reduction strategies
  • long-term management of alcohol dependence, including drug therapies.

Consider offering a brief intervention for anyone with excessive alcohol use. Brief interventions produce small reductions in hazardous use in research settings compared to standard treatment. The benefits in harmful or dependent alcohol use are less clear than in hazardous use, but motivational interviewing should be considered as part of a stepped approach to aid the development of a treatment planHaber, 2021.

Some patients require or choose to undergo intervention early, such as a planned withdrawal or a gradual reduction, possibly with a view to abstinence.

Some patients will not be willing to engage with these options but will consider harm reduction strategies, which should be offered to all patients.

All patients should also be offered long-term management as part of a chronic illness management plan. Many aspects of long-term management involve cognitive behavioural therapy. In addition, for those who are abstinent, maintenance drug therapy can be considered for relapse prevention. Other supports include residential rehabilitation, peer supports and self-help. Encourage social contact, as isolation increases the risk of poor outcomes.

Certain populations may benefit from specific consideration in the management of substance use—see discussion in Overview of substance use and addictive behaviours. Management advice specific to alcohol use in pregnancy and alcohol use while breastfeeding is included in this topic.