Printed on: August 26th, 2025

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Alcohol

Alcohol

About one-quarter of the UK adult population drinks alcohol in a way that is potentially or actually harmful, but few of them access treatment.

The fifth report of the Lancet commission on liver disease was published in 2018 (Lancet 2018;392:2398). The report focused on the public health aspects of liver disease in the UK. There were some stark facts regarding the increasing burden of disease in the UK:

• Hospital admissions with a primary alcohol-related diagnosis have increased by 17% between 2006/07 and 2016/17.
• Alcohol-related deaths are increasing, including an increase in deaths associated with drink driving.
• 31% of men and 16% of women drink more than the recommended weekly limit of alcohol.
• Between 2013/14 and 2017/18, funding for addiction services has been cut by 18%.

Deaths from alcohol-related causes have increased by 60% from before the pandemic (BMJ 2025;359:r681).

In the USA, mortality due to cirrhosis has been increasing since 2009. People aged 25–34y have had the greatest relative increase in mortality, driven entirely by alcohol-related liver disease (BMJ 2018;362:k2817).

This article was updated in July 2025.

You may also be interested in our separate article, Liver disease: alcohol-related liver disease.

Alcohol is a major contributor to global disease and disability. It is associated with over 200 health conditions, including liver disease, several cancers, cardiovascular disease, mental health problems and injuries from violence or accidents. Harms can result from both acute intoxication and chronic heavy drinking (BMJ Open 2024;14:e080657).

Risk factors for alcohol-use disorder include genetic vulnerability (heritability estimated at around 50%), coexisting mental health conditions, early-life trauma and widespread availability of low-cost alcohol. Despite strong evidence for its neurobiological and psychosocial basis, stigma and misconceptions about its causes remain common.

Coexisting conditions are widespread, and span mental, physical and social domains, including:

• Mental health problems such as anxiety, depression, ADHD and increased suicide risk.
• Other forms of substance use, including smoking.
• Physical comorbidities such as overweight, hypertension, nutrient deficiencies (e.g. thiamine, zinc), electrolyte disturbances and osteopenia (especially in women).
• Cognitive impairment may stem from trauma, Wernicke–Korsakoff syndrome or the sedative effects of alcohol.

(N Engl J Med 2025;392:258)

Alcohol use is closely linked to social disadvantage. It can both lead to and result from issues such as unemployment, unstable housing, relationship breakdown, legal problems and work-related risks. These social challenges are often made worse by alcohol use and can make recovery more difficult.

There are also significant health inequalities associated with alcohol. People living in deprived areas are less likely to have alcohol problems identified and treated, especially in primary care. The alcohol harm paradox highlights that although people in these areas often drink less than those in more affluent communities, they suffer more alcohol-related harm and face more barriers to getting help.

A qualitative study in Liverpool – one of the most deprived areas in England, with high levels of alcohol-related harm – found that access to support in primary care was often reactive, with people only receiving help after a physical or mental health crisis (PLoS ONE 2023;18:e0292220). Barriers making it harder to access effective care included:

• Stigma – both internalised and from others, including health professionals.
• Narrow definitions of ‘readiness to change’.
• Limited access to mental health support.
• Inflexible, standardised treatment pathways that didn’t meet individual needs.
• Limited follow-up, with poor signposting, minimal aftercare and underuse of peer support.
• GP reluctance to prescribe medication without specialist input.

Access improved when care was proactive, consistent and tailored to the individual. Patients especially valued peer support, describing it as non-judgemental and motivating. The authors stressed the need for better training in primary care, clearer referral pathways and more integrated, person-centred care, including outreach services, to reduce health inequalities, improve access to treatment and prevent avoidable alcohol-related hospital admissions.

(PLoS ONE 2023;18:e0292220; N Engl J Med 2025;392:258).

How much alcohol is in that drink?

• One unit = 8g of alcohol. That’s not very helpful, is it?
• The number of units in a drink = (volume (ml) x alcohol (% ABV)) / 1000. That doesn’t help much either!

Here’s our easy ‘ready reckoner’: because the % ABV is the number of units in 1 litre, the number of units in 250ml is a quarter of this – that’s roughly equivalent to half a pint. Based on this:

• A large (250ml) glass of wine (ABV 14%) = approximately 3.5 units.
• Half a pint of beer (ABV 4%) = approximately 1 unit.
• A single shot (25ml) of ABV 40% spirits = 1 unit.

There is now robust evidence that even low levels of alcohol consumption carry health risks (NEJM 2025;392:1721). The core messages are clear:

• No level of drinking can be seen as ‘safe’.
• Any amount of alcohol increases the risk of developing a range of health conditions.

The guidelines from the UK Chief Medical Officer, based on a review of all evidence published since 1995, were updated in 2016 (DOH August 2016):

• Guidance is now the same for men and women.
• A 14 units/week limit for regular drinkers was thought to be simpler to understand and more useful than daily limits.
• If drinking 14 units/week, it is best to spread this evenly over 3d or more. Having 1 or 2 heavy drinking sessions increases the risk of death from long-term illness, accidents and injuries.
• A good way to cut down on alcohol is to have several drink-free days each week.

The guidelines should help people make informed decisions about their alcohol consumption to keep risks at what they think is an appropriate level. The guidelines give specific guidance for 3 situations:

• It was previously thought that low levels of alcohol consumption had cardioprotective benefits.
• However, the latest evidence shows that net cardioprotective effects from drinking alcohol are limited to women >55y drinking around 5 units/week, and these effects are offset if they have other risk factors, e.g. being overweight.
• Any cardioprotective effects are cancelled out by heavy drinking sessions (>7.5 units at least monthly).

A BMJ paper quantified the risks:

• Non-drinking (compared with drinking within UK guidance) slightly increased the risk of CVD (by roughly 1.3x).
• Heavy drinking (exceeding UK guidance) increased the risk of most CVD (also by around 1.3x), but reduced the risk of MI and stable angina (BMJ 2017;356:j909).

Alcohol-use disorders encompass a spectrum of mental health conditions, ranging from hazardous and harmful drinking to alcohol dependence. NICE defines these key terms as follows (NICE 2011 (updated 2014), CG115):

• Hazardous drinking: a pattern of alcohol use that increases the risk of physical, mental or social harm. It is not a clinical diagnosis, but indicates a higher risk of adverse outcomes. Typically involves 15–34 units/week for women and 15–49 units/week or more for men.
• Harmful (high-risk) drinking: alcohol consumption that is already causing physical or psychological harm. This usually refers to drinking 35 units/week or more for women and 50 units/week or more for men.
• Alcohol dependence: a diagnosable condition involving a strong desire to drink, impaired control and continued drinking despite harm. Often includes withdrawal symptoms and prioritisation of alcohol over responsibilities.

NICE recommends that all staff caring for people who potentially misuse alcohol should be competent to identify both harmful drinking and alcohol dependence (NICE 2011 (updated 2014), CG115).

In primary care, we should carry out alcohol screening as part of routine practice; identify drinkers at increased risk of harm; and provide brief advice (NICE 2010, PH24). Opportunities for screening include:

• New patient registrations.
• Chronic disease reviews, medication reviews or when screening for other conditions.
• Sexual health or antenatal consultations.
• When treating minor injuries.

Targeted screening is especially important for people at higher risk of alcohol-related harm, including those with:

• Alcohol-related physical conditions such as liver or gastrointestinal disorders, or hypertension.
• Mental health problems, including a history of self-harm or suicide attempts.
• Repeated injuries or presentations due to assault or accidents.
• Frequent attendance at sexual health clinics or repeated requests for emergency contraception. 

Blood tests such as LFTs are not normally used to screen for alcohol-use disorders, but an incidental finding of abnormal LFTs should prompt assessment of alcohol use. Don’t be reassured by normal LFTs in those drinking at increasing levels of risk. You may find the GEMS on Liver disease of interest.

The Alcohol Use Disorder Identification Tool (AUDIT) (WHO, 2001) is considered the most accurate questionnaire for assessing the risk of a person’s alcohol consumption. However, because it can take several minutes to complete, shorter versions are often used first to quickly identify who may need further assessment:

• FAST: starts with one key question, followed by up to three more if needed. Scoring is more complex so isn’t included here.
• AUDIT-C: uses the first 3 questions from the full AUDIT tool and is simpler to use. The questions are:
  • How often do you have a drink containing alcohol?
  • How many units of alcohol do you drink on a typical day when you are drinking?
  • How often have you had 6 or more units (female), or 8 or more units (male), on a single occasion in the past year?
  • A score of ≥5 or more is a positive screen (or ≥3 if <18y or >65y).

A positive result for either of these pre-screening tools should prompt completion of the full AUDIT questionnaire.

We discuss assessment and management of alcohol-use disorders in more detail below. However, here is a summary of NICE guidance on how to respond to different levels of alcohol risk based on the full AUDIT score:

NICE says we can use AUDIT in children as young as 10y, although it is most likely to be used in older adolescents aged 16–17y (NICE 2011, CG115). NICE says the threshold for referral and intervention “should be lowered” compared with adults, but doesn’t give specifics. The American National Institute on Alcohol Abuse and Alcoholism youth screening tool is an alternative screening option in children (JAMA 2024;331:1215). It can be used in patients aged 9–18y. Questions are age specific, and risk is determined by levels of drinking in both the child and their friends. The tool also gives a guide for providing brief intervention (link at end of article).

Alcohol-use disorder is an increasing concern in older adults. This group now accounts for a growing proportion of heavy drinkers (defined as >50 units/week for men and >35 units/week for women), with rates increasing from 12% in 2012 to 21% in 2022. Older adults are more vulnerable to alcohol-related harm due to greater sensitivity to alcohol, polypharmacy, falls risk and comorbidities such as cognitive impairment and liver disease (BMJ 2025;359:r681).

Primary care plays a key role in early identification. Clinicians should routinely ask about alcohol use in older patients, particularly those with:

• Recurrent falls or injuries.
• Memory, mood or sleep problems.
• Long-term conditions or multiple medications.

An AUDIT score of ≥20 suggests probable dependence, but clinical judgement is important because features may be present at lower scores. Key features to look for and some useful questions are summarised below:

Here are some practical steps for initial assessment within primary care (NICE 2011 (updated 2014), CG115; NICE 2010, PH24):

For adults, if screening is positive:

• Ask about quantity, frequency and context of alcohol use.
• Explore impact on physical and mental health, work, relationships and daily functioning. 
• Check for alcohol-related health or social problems.
• Screen for signs of dependence. 
• Offer brief advice to support reduction (see below).

For children and young people, take a detailed history, including:

• Patterns of alcohol use and features of dependence.
• Comorbid substance use.
• Mental and physical health problems.
• Peer relationships, and social and family problems.
• Educational performance and attendance.
• History of abuse or trauma.
• Risk to self or others (including safeguarding concerns).
• Readiness to change and confidence in ability to do so.
• Capacity to consent (involve parents/carers where appropriate).

For more on holistic assessment of children and young people, see our article: Assessing mental health problems in young people.

Primary care plays a vital role in identifying and responding to key risks linked to alcohol use. Be alert for:

• Suicide risk: carry out a full risk assessment and refer to psychiatry if concerned.
• Combined substance use: be alert to the increased risks of alcohol use alongside opioids, benzodiazepines or other substances – these can significantly increase the risk of overdose and death.
• Lack of safety or support: consider safeguarding, especially in young people, vulnerable adults or those experiencing domestic abuse.
• Cognitive or functional decline: in older adults, alcohol may contribute to falls, confusion or poor self-care – even at lower levels of intake.
• Driving: always consider the risk of driving in a patient who may be alcohol dependent (see below).

NICE emphasises the importance of using clinical judgement to guide next steps. For some individuals, support, brief advice and ongoing monitoring may be sufficient. Others may require structured counselling or referral for specialist treatment.

Consider referral to specialist alcohol services if there are:

• Signs of moderate or severe alcohol dependence (e.g. AUDIT score >15).
• No improvement after brief and extended interventions, and the person is open to further help.
• Significant alcohol-related impairment or coexisting conditions (e.g. liver disease, mental health issues). See our article on Liver disease: alcohol-related liver disease for more about this.

For children and young people:

• Most specialist addiction services do not accept under-18s.
• Refer to CAMHS or local youth alcohol services if alcohol use is linked to physical, psychological, educational or social problems or other drug use.
• Use adult referral criteria for 16–17-year-olds.
• Always consider safeguarding concerns, and liaise with social services or the local MASH hub where needed.

• Many mental health symptoms improve with reduced alcohol use.
• For anxiety or depression, treat alcohol misuse first and reassess mood after 3–4 weeks.
• Psychological therapies are usually more effective once drinking has reduced or stopped.
• Encourage smoking cessation if relevant.
• Actively treat coexisting drug misuse through specialist services and support.

Brief interventions involve one or two short, structured conversations during routine consultations (typically 5–15 minutes with doctors or 20–30 minutes with nurses), aimed at reducing alcohol consumption (Cochrane 2018; 2:CD004148):

• In primary care, they lead to an average reduction of around 2.5 units per week.
• Their impact on binge drinking, frequency and intensity of use is less clear.
• Extended interventions – involving more sessions and follow-up from the wider team – may help those drinking at increasing risk or harmful levels, although evidence of added benefit is mixed.

Effective interventions are collaborative, non-judgemental and guided by motivational interviewing principles. They focus on raising awareness, supporting change and building confidence. Key elements include:

• Exploring risks or harms related to drinking.
• Creating space for reflection and practical goal-setting.
• Supporting motivation and self-efficacy.
• Building a trusting, non-confrontational rapport.

For more on these techniques, see our article Supporting behaviour change.

The FRAMES model provides a helpful structure to support these conversations:

Not often.

A large cross-sectional survey of over 15 000 people in England found that brief advice for excessive alcohol use is rarely given in GP consultations, especially compared with advice on smoking cessation (BJGP 2016; 66:e1).

The authors suggest several reasons for lower rates of alcohol advice compared with smoking:

• Alcohol advice is not included in QOF, unlike smoking.
• AUDIT-C screening takes longer than simply asking if a patient smokes.
• Motivation to change may be lower in drinkers than smokers.
• Reducing alcohol is a more complex goal than quitting smoking entirely.

A BMJ editorial reviewed the evidence behind using smartphone apps and digital tools to reduce alcohol use (BMJ 2023;382:p1665). It cites a 2017 Cochrane review which found moderate-quality evidence that digital interventions reduced alcohol consumption (Cochrane 2017, CD011479).

A more recent study found a consistent and significant decrease in alcohol use in a group of students provided with a smartphone app designed to address unhealthy alcohol use when compared with a control group of their peers (BMJ 2023;382:e073713). In its 2020 guidance on digital and mobile health interventions, NICE recommends that we ‘consider’ digital interventions as an adjunct to usual care, but comments that effectiveness can be variable (NICE 2020, NG183).

Abstinence is strongly associated with improved outcomes in alcohol-related liver disease, hepatitis and pancreatitis, and is the foundation of treatment for those conditions.

People with less-severe alcohol use may improve with substantial reduction, although abstinence is often recommended to stabilise health. Ongoing follow-up is important to monitor progress and prevent relapse.

Although effective treatments exist, many people with alcohol-use disorders do not receive care. Stigma, including from healthcare providers, and self-reproach often lead to ambivalence about stopping drinking or engaging in treatment (N Engl J Med 2025;392:258).

Treatment for harmful drinking and mild alcohol dependence is typically provided within specialist alcohol services. Interventions may include (NICE 2011 (updated 2014), CG115):

• Psychological therapy focused on alcohol-related thoughts, behaviours and social context, such as CBT.
• Behavioural couples therapy can be considered for those with a regular partner who is willing to participate, unless there are concerns about domestic abuse.
• Drug therapy: acamprosate or oral naltrexone may be offered alongside psychological support, particularly where there is limited progress with therapy alone or where medication is requested.

Clinical decisions for those with moderate to severe dependence are also made within specialist services. For individuals drinking more than 15 units per day and/or scoring AUDIT ≥20 (NICE 2011 (updated 2014), CG115):

• An assessment for community-based medically-assisted withdrawal may be offered.
• If community withdrawal is not appropriate (e.g. due to comorbidities or safety concerns), more intensive management within specialist services may be required.

If a patient is (or may be) dependent on alcohol, clinicians have a legal and professional duty to inform them that they must stop driving and notify the DVLA. This applies even if they are not currently experiencing withdrawal symptoms (DVLA – assessing fitness to drive (a guide for medical professionals).

This can be an uncomfortable conversation, but it is an essential part of a risk assessment when there are any signs or concerns suggesting possible alcohol dependence. Some questions that we could ask in primary care include:

• Do you currently drive? Have you ever driven while under the influence of alcohol?
• Have you had any drink-driving or other driving-related offences?
• What time do you usually stop drinking at night? When do you usually start driving the next day (e.g. for work)?

Finish by clearly advising the patient: If you are or may be dependent on alcohol (even if not confirmed), you are legally required to inform the DVLA and must stop driving until you meet the medical standards for driving again.

Make sure this advice is clearly documented in the medical record.

If the patient refuses or continues to drive despite medical advice, the healthcare professional should contact the DVLA directly.

People with harmful use of alcohol may be deficient in thiamine due to poor diet, malabsorption (from gastritis) or increased demands (thiamine is a co-factor in alcohol metabolism).

Thiamine deficiency can lead to Wernicke’s encephalopathy (see box below).

NICE recommends that we offer prophylactic thiamine to harmful or dependent drinkers if:

• They are malnourished or at risk of malnourishment and/or
• They have decompensated liver disease and/or
• Medically-assisted withdrawal is planned.

The dose is 50–100mg a day in mild deficiency, or 200–300mg a day in severe deficiency (see BNF). 

People who are malnourished or at risk of malnourishment, or who have decompensated liver disease, should be offered parenteral thiamine if undergoing assisted withdrawal in specialist inpatient alcohol services.

Vitamin B complex preparations (such as vitamin B compound strong tablets) are no longer used (lack of evidence of effectiveness/safety) for:

• Prevention of deficiency.
• Maintenance treatment following treatment for deficiency.
• Prevention of Wernicke’s encephalopathy.

In rare cases of medically-diagnosed deficiency or chronic malabsorption, they may be used.

(RMOC Oral vitamin B supplementation in alcoholism, 2019)

Suspect alcohol withdrawal in anyone who is alcohol dependent and has stopped/reduced their drinking within hours or days of presentation (BMJ 2023;381:p951).

Withdrawal is diagnosed clinically. Common symptoms include:

• Anxiety.
• Nausea and vomiting.
• Autonomic dysfunction (sweating, tremor, tachycardia).
• Insomnia.

If untreated, this can progress to severe withdrawal, with seizures or delirium tremens (see box below for a reminder of the features of delirium tremens), both of which are life threatening.

• Offer acute medical admission for urgent benzodiazepine treatment and monitoring if:
  • Seizures or delirium tremens are present, or there is a past history of these.
  • Signs of autonomic dysfunction are present (sweating, tremor, tachycardia).
  • Age <16y.
• Other risk factors for severe withdrawal that should make us consider admission include:
  • Alcohol intake >30 units/d.
  • Fever.
  • High anxiety.
  • Tachycardia.
  • Hypoglycaemia, hypocalcaemia, hypokalaemia.
  • Poor background physical health.
  • Other psychiatric disorders and/or use of psychotropic drugs.
  • Multiple previous medically-assisted withdrawals.
• Admit urgently for parenteral thiamine if there are features of Wernicke’s encephalopathy (reminder of these in the box below).

As well as being high risk in itself, this presentation in primary care is a chance to make a holistic assessment of a vulnerable group which may present to healthcare rarely or chaotically. Things to think about (particularly if you’re not planning admission) include (BMJ 2023;381:p951).

• Other substance misuse +/- screening for HIV and hepatitis B/C.
• Why did they stop drinking? Physical symptoms, e.g. abdo pain? Social reasons, e.g. lack of money?
• Is this definitely alcohol withdrawal or could other diagnoses actually be causing their symptoms? Don’t miss:
  • Sepsis.
  • Head injury (keep in mind that this group is more likely to have a significant bleed after a head injury due to deranged clotting and low platelets).
  • Decompensated liver disease.
  • Gastritis.
  • Pancreatitis.
  • Metabolic derangements.
  • Other drug intoxication or withdrawal.

Unnecessary inpatient management of alcohol withdrawal isn’t just a poor use of resources – it also has very poor outcomes in terms of long-term abstinence. Usually, patients not requiring medical admission will need referral to the community addiction service for medically-assisted withdrawal (more on this in the next section). There is a group with mild symptoms and lower baseline drinking levels which may only need monitoring, not drug treatment, but they are still likely to benefit from the psychological support offered by addiction services.

We should advise people awaiting a medically-assisted withdrawal that they must NOT suddenly stop or suddenly significantly reduce their alcohol intake because they may:

• Experience unpleasant withdrawal symptoms.
• Develop seizures or delirium tremens.

A commonly-quoted rule of thumb is to not reduce alcohol intake by more than 25% every 2 weeks (BMJ 2023;381:951).

Emergency syndromes of alcohol dependence and tolerance:

NICE recommends that we offer assessment for assisted withdrawal for patients who:

• Typically drink >15 units/d or
• Score ≥20 on the AUDIT score.

This may be offered in the community (for those with mild to moderate dependence) or as an inpatient, but it is a specialist service. It is not just a case of providing chlordiazepoxide/diazepam; appropriate psychological support, usually including motivational interviewing, group therapy and family/carer support, is required.

This means that, in general, unless we are specialists in drug and alcohol dependence, we will not be offering medically-assisted withdrawal in primary care. If we are asked to prescribe the medication under a shared care protocol, this will usually be instalment prescribing of no more than 2 days at a time.

Alcoholics Anonymous and UK SMART Recovery are alcohol dependency mutual aid groups that provide a source of ongoing support for patients, family and friends. Long-term cohort studies suggest that these are effective.

NICE recommends offering those with harmful drinking or alcohol dependence an ‘alcohol-focused psychological intervention’ (usually via addiction services); this may include CBT, behavioural therapy, social-network-based therapy or behavioural couples therapy (NICE 2011, CG115).

Is my patient likely to be able to access medication to help prevent relapse?

If they want it, the answer should be yes! Either acamprosate or oral naltrexone can be used first line. According to NICE, these drugs should be considered alongside psychological interventions in:

• Anyone recovering from harmful or dependent drinking who specifically requests drug therapy, as well as...
• Those who have severe alcohol dependence.
• Those who have mild to moderate alcohol dependence which hasn’t responded to psychological intervention alone.

Are these medications effective?

A 2023 JAMA meta-analysis found that the NNT to prevent return to any drinking was 11 for acamprosate and 18 for oral naltrexone (JAMA 2023;330:1653). The evidence for the second-line drugs is weaker.

Here’s a closer look at these drugs. Check your local formulary; it’s likely that most of these will be specialist initiation only, and remember that they should only be used alongside structured psychological support:

Emerging evidence suggests that GLP-1 receptor agonists, used for diabetes and obesity, may also reduce alcohol-related harm in people with alcohol-use disorders. A large Swedish cohort study (JAMA Psychiatry 2025;82:94) found that semaglutide and liraglutide were associated with a significant reduction in alcohol-related hospitalisations, with semaglutide showing the greatest effect (adjusted hazard ratio 0.64). In contrast, medications such as naltrexone, disulfiram and acamprosate showed only modest benefits, with naltrexone performing slightly better than the others (adjusted hazard ratio 0.86).

A related study (JAMA Netw Open 2024;7:e2447644) reported reduced alcohol consumption in 45% of individuals after starting GLP-1-based anti-obesity treatment, particularly in those with higher BMI and heavier drinking. These findings support the hypothesis that GLP-1 agonists may act on the neural reward pathways involved in addiction. However, randomised trials are needed to confirm efficacy and guide clinical use.

Carbohydrate deficient transferrin is a test that can be used in alcohol-use disorders where abstinence is the key (so it may be used by the DVLA to look for hazardous drinking in those reapplying for a driving licence after losing it for an alcohol-related offence) (DTB 2017;55:69).

• It is more specific than other tests such as GGT, and is less affected by liver disease, but various things can affect the test (obesity, smoking, pregnancy, sepsis, anorexia, iron overload, primary biliary cirrhosis, and those who have a genetic variant in their transferrin molecule).
• It should not be used in isolation and is not performed by all laboratories, so not one for primary care!
• It correlates well with individuals’ drinking pattern in the preceding 30d, showing a response within 1–2w of heavy drinking.

In 2018, Scotland introduced ‘minimum unit pricing’ on alcohol sales (50p per unit).

Following the introduction of this policy (Lancet 2023;401:1361):

• Alcohol sales fell by 3%.
• Deaths wholly attributable to alcohol fell by 13.4%.
• Hospitalisation wholly attributable to alcohol fell by 4.1%.

The greatest reductions were seen in the lower socioeconomic groups, suggesting that the policy is effectively addressing deprivation-based inequalities in harms of alcohol.

	Alcohol Even low levels of alcohol consumption carry health risks. No level of drinking can be seen as ‘safe’, and the DOH advises that both men and women should drink no more than 14 units/week over 3d or more. We should advise women that it is safest to avoid drinking any alcohol in pregnancy. People in deprived areas face greater alcohol-related harm but are less likely to receive timely support in primary care due to factors including stigma, limited access and inflexible treatment pathways. FAST or AUDIT-C questionnaires can be used as an initial screen for alcohol-use disorders. An AUDIT-C score ≥5 should prompt completion of the full AUDIT questionnaire to assess the risk of the person’s alcohol consumption. In those drinking at higher risk levels, it is important to assess for alcohol dependency. Brief advice should be given to those identified as drinking at hazardous levels. People with features of moderate or severe alcohol dependency (AUDIT score >15), or those with severe alcohol-related problems, should be referred to specialist services. Clinicians must inform alcohol-dependent patients to stop driving and to notify the DVLA, even if they have no current withdrawal symptoms. Offer prophylactic thiamine where there is risk of malnourishment, decompensated liver disease or a plan for medically-assisted withdrawal. Acute alcohol withdrawal can be life threatening. Advise all with harmful or dependent drinking not to stop suddenly, and assess for signs needing admission if withdrawal is suspected. Mutual aid support, alcohol-focused psychological support and medication are all effective at maintaining abstinence or lowering risky drinking.
	Do you known what mutual aid groups (e.g. Alcoholics Anonymous) are available locally and how to access these? How do you assess alcohol use in patients newly registering at your practice, and who acts on the results?
	Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) Elearning for healthcare - alcohol identification and brief advice DVLA – assessing fitness to drive (a guide for health professionals) The National Institute on Alcohol Abuse and Alcoholism - youth screening tool (for children aged 9–18y) Useful resources for patients: Mutual support organisations for patients Alcoholics Anonymous UK SMART Recovery Soberistas Club Soda Apps and websites Drinkaware (information for patients on alcohol, units, tracking alcohol consumption and cutting down) Try Dry Curb Reframe app Books The Unexpected Joy of Being Sober, Katherine Gray (Hachette, 2017) One Year No Beer (book and app) This Naked Mind: control alcohol, Annie Grace (book and podcast) Blackout: remembering the things I drank to forget, Sarah Hepola (John Murray, 2016) The Sober Diaries, Clare Pooley (Coronet, 2017)