Screen with AUDIT-C at every opportunity. Assess withdrawal risk before advising abstinence — sudden cessation in a physically dependent drinker can cause life-threatening withdrawal. Give thiamine before glucose or IV fluids, always.
Screening & risk stratification
- AUDIT-C (3 Qs): positive screen ≥4 (men) / ≥3 (women) → full AUDIT or clinical assessment. Standard drink = 10g alcohol.
- Full AUDIT: 8–15 hazardous (brief intervention) · 16–19 harmful (brief intervention + consider referral) · ≥20 likely dependence.
- NHMRC safe limits: ≤10 standard drinks/week and ≤4 on any one day — no level is entirely without risk.
- Brief intervention (FRAMES): Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy — 5–15 min, repeat at every visit.
Withdrawal risk assessment
- CIWA-Ar: <8 mild · 8–15 moderate · >15 severe — score at each review.
- High risk → inpatient: prior DTs/seizures, poly-substance dependence, significant medical/psychiatric illness, poor social support.
- Baseline bloods: FBC (MCV), GGT, ALT/AST, glucose, electrolytes, Mg, creatinine.
Withdrawal management
Ambulatory if CIWA-Ar <15, good support, no prior complicated withdrawal — daily review for ~5 days with a written contingency plan. Diazepam, symptom-triggered and tapered over 5–7 days, is commonly preferred (lorazepam if hepatic impairment — no active metabolites). Thiamine first, always — oral for routine prophylaxis; use the IV/high-dose regimen urgently if Wernicke's is suspected (confusion + ataxia + ophthalmoplegia).
Pharmacotherapy options
Start after withdrawal is complete.
1Naltrexone (1st-line): opioid antagonist; reduces craving/heavy drinking. Avoid with current opioid use or if ALT/AST >3× ULN; not CI in compensated liver disease.
2Acamprosate (1st-line): reduces craving in abstinent patients; renally excreted, no liver risk; avoid in severe renal impairment and pregnancy; can combine with naltrexone.
3Disulfiram (2nd-line): aversion therapy; not PBS-listed; supervised administration preferred; avoid in CVD, psychosis, pregnancy and significant hepatic disease.
Exact doses & PBS criteria. Naltrexone and acamprosate are PBS-subsidised for dependence within a comprehensive treatment program (authority requirements apply and have changed over time) — confirm current doses, authority method and full prescribing criteria at pbs.gov.au and in the AMH before prescribing.
Psychosocial support (required alongside drug Rx)
- Brief intervention / motivational interviewing at each consult — explore ambivalence, non-confrontational.
- CBT / counselling — triggers, coping strategies, relapse prevention (psychologist or AOD counsellor).
- SMART Recovery or AA — evidence-based peer/self-help support, widely available.
Safety
- Thiamine always before glucose or IV fluids — Wernicke's risk.
- Diazepam: titrate to CIWA-Ar; review if >80mg needed in 24h.
- Naltrexone is contraindicated with current opioid use — precipitates withdrawal.
- Acamprosate contraindicated in severe renal failure (CrCl <30) and pregnancy.
Red flags / refer
- CIWA-Ar ≥15 or deteriorating, or prior DTs/seizures — inpatient detox.
- Complex comorbidities — liver failure, cardiac disease, psychosis, poly-drug use, suicidality.
- Failed two or more outpatient attempts — residential detox / AOD specialist.
- Severe depression, psychosis or suicidality — reassess after 4–6 weeks sobriety before attributing to alcohol.
MH-07 v1.0 · Reviewed Jun 2026 · Review Jun 2027
For health-professional use. Adapted from NHMRC alcohol guidelines, DACAS, and Australian Prescriber. Exact PBS criteria, doses & cautions — confirm at pbs.gov.au and the AMH; this is a summary, not the full PI.
