A brief guide to the

Assessment and
Treatment of Alcohol
Dependence
 Suggested citation: Quigley, A., Connolly, C., Palmer, B., & Helfgott, S. (2015) A brief guide to the assessment
and treatment of alcohol dependence (2nd ed.). Perth, Western Australia: Drug and Alcohol Office.
ISBN: 978-1-876684-63-1
© Western Australian Drug and Alcohol Authority 2015
Note – The Drug and Alcohol Office is the business name of the Western Australian Alcohol and Drug
Authority, which is an independent statutory authority established in November 1974. Its functions are set
out in the Alcohol and Drug Authority Act 1974.
This booklet is produced by Next Step Drug and Alcohol Services and Workforce Development Branch,
Drug and Alcohol Office. It may be reproduced in whole or in part for study or training purposes subject
to an inclusion of an acknowledgement of the source and no commercial usage or sale. Reproduction for
purposes other than those above requires the written permission of:
Drug and Alcohol Office, PO Box 126, Mount Lawley WA 6929
Website: www.dao.health.wa.gov.au

Next
Step
DRUG AND ALCOHOL
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ii A brief guide to the Assessment and Treatment of Alcohol Dependence

Contents
Introduction.................................................................................................................................................................2
Assessment..................................................................................................................................................................2
History..........................................................................................................................................................................2
Mental state assessment for the alcohol dependent patient.................................................................................3
Physical examination...................................................................................................................................................3
Blood tests...................................................................................................................................................................4
Other tests for health evaluation...............................................................................................................................4
Screening and monitoring..........................................................................................................................................4
Treating alcohol dependence and withdrawal.........................................................................................................5
Managing alcohol withdrawal....................................................................................................................................7
Medical management of alcohol withdrawal...........................................................................................................8
Thiamine and Wernicke – Korsakoff Syndrome.......................................................................................................9
Relapse prevention pharmacotherapies...................................................................................................................9
Future potential relapse prevention pharmacotherapies.....................................................................................10
Counselling................................................................................................................................................................ 11
Psychology................................................................................................................................................................. 11
Neuropsychology...................................................................................................................................................... 11
Useful resource.......................................................................................................................................................... 11
References................................................................................................................................................................. 12
Appendix 1 MMSE Cognitive examination............................................................................................................ 14
Appendix 2 Next Step version of the Revised Clinical Institute Withdrawal Assessment for
Alcohol Scale (CIWA-Ar) (Reoux & Miller, 2000) ................................................................................................... 17

A brief guide to the Assessment and Treatment of Alcohol Dependence 1

 Introduction • features of dependence (See DSM-V page 5)
– morning withdrawal symptoms
These clinical guidelines have been developed
• health complications from drinking
for use by doctors and nurses when assessing
and treating a patient with alcohol dependence. • other consequences from drinking
They will also be of interest to counsellors seeking • history of other drug use
detailed information about the medical treatment • recent use of other drugs
of alcohol dependence. • current situation: accommodation, relationships,
children, social support, work/study, legal issues,
Assessment other agencies involved in care
• developmental history: family of origin, family
The comprehensive assessment of a patient with
relationships, childhood, education and work
alcohol dependence will enable a case summary
history, relationship history, abuse and other
and formulation to be developed, a diagnosis
trauma history
to be made and an appropriate treatment plan
• current and past mental health problems,
to be implemented. The assessment should
diagnoses and treatment
include a history, systemic enquiry, mental state
examination, physical examination and blood tests. • risk assessment: suicide, self harm, aggression
and violence
• current physical well being and symptoms of
History illness
A comprehensive alcohol and other drug history • past medical and surgical history
can take some time to obtain and may require a
– past concussions or head injuries
number of appointments, especially if the reasons
– past withdrawal seizures or epilepsy
for a person’s drinking are to be explored. The
• current medication
history should enable a calculation to be made of
the number of standard drinks being consumed • allergies.
on the average drinking day. It should also include Number
information about any withdrawal symptoms of
Drinks Guide
experienced and any physical or mental health Standard
complications from alcohol use. A full history should drinks
cover the following: 1 can/stubby of full strength beer 4.8% 1.4
• presenting problems and reasons for 1 can/stubby of mid strength beer 3.5% 1.0
seeking treatment 1 slab of full strength beer 34
• treatment goals and motivation to change 1 glass of wine 100ml 1.0
• past alcohol and other drug treatment history 1 bottle of wine 750ml 7.5
• drinking history timeline:
1 cask of wine 4L 39
– age started drinking, first problems,
1 bottle of spirits 700ml 22
first dependent
Adapted from the National Health and Medical Research Council
– amount drunk in standard drinks in the last (NHMRC) Australian Alcohol Guidelines 2009
24 hours and over the last week
– drinking pattern (type of drink, quantity,
frequency) over last month and last year

1.4 1 34 1 7.5 39 22
375ml 375ml 24 x 375ml 100ml 750ml 4 Litres 700ml
Full Strength Mid Strength Full Strength Standard Serve Bottle of Cask White Wine Bottle of Spirits
4.8% Alc Vol 3.5% Alc Vol 4.8% Alc Vol of White Wine White Wine 12.5% Alc Vol 40% Alc Vol
11.5% Alc Vol 12.5% Alc Vol

2 A brief guide to the Assessment and Treatment of Alcohol Dependence

Mental state assessment for Physical examination
the alcohol dependent patient Patients presenting with alcohol dependence
When assessing mental state, the clinician observes should have a comprehensive physical examination
how the patient presents and functions during the looking for evidence of intoxication or withdrawal,
session and briefly documents these observations. the stigmata of alcohol dependence and signs
Listed below are the areas covered in a mental state of the medical complications of acute or chronic
examination and some of the possible findings in alcohol use.
alcohol dependent patients. Some of these signs If a breathalyser is available, a blood alcohol level is
and symptoms may also be related to underlying recommended prior to a physical examination, as
physical and mental health conditions, therefore it it will set a base line for the physical examination.
is important to undertake a thorough assessment.
e.g. withdrawal signs may not be present because
1. Appearance and behaviour of a high blood alcohol level and intoxication
• flushed face, smells of alcohol, poor hygiene, may not be present because of a high level of
unkempt clothing neuroadaptation.
• hostile, aggressive, sexualised behaviour • Alcoholic facies
(intoxication) – conjunctival injection
• fearful, paranoid (withdrawal) – facial telangiectasia
• restless, tremors, agitation (withdrawal) – rhinophyma
• ataxia (intoxication, Wernicke’s encephalopathy) • Evidence of injury
• Anaemia and bruising
2. Speech • Neurological examination
• slurred (intoxication)
– nystagmus
3. Mood and affect – ophthalmoplegia with 3rd and 6th nerve palsy
• euphoric, depressed, irritable (intoxication) – impaired coordination
• anxious, irritable, suspicious (withdrawal) – truncal ataxia/gait abnormalities
• labile (intoxication or withdrawal) – peripheral neuropathy/proximal muscle
wasting
4. Form of thought • Cardiac enlargement and oedema
• tangential, circumstantial, illogical (intoxication
• Abdominal examination
or delirium tremens (DTs)
– hepatomegaly
5. Content of thought • Evidence for cirrhosis and portal
• confabulation (Korsakoff’s syndrome) hypertension
– palmar erythema
6. Perception
– Dupuytren’s contracture
• hallucinations (DTs)
– spider naevi
7. Cognition (see Mini Mental State – parotid enlargement
Examination – Appendix 1) – gynaecomastia
• clouding of consciousness (intoxication, DTs, – splenomegaly
Wernicke’s, hepatic encephalopathy) – ascites
• disoriented to time, place or person – asterixis
(intoxication, DTs, Wernicke’s or Korsakoff’s)
• poor planning and abstract thinking (brain damage)
• impaired short-term memory (Korsakoff’s)

8. Insight
• poor insight (intoxication, brain damage)

A brief guide to the Assessment and Treatment of Alcohol Dependence 3

 Blood tests Other tests for health
Blood tests for markers that are likely to change evaluation
in the context of heavy drinking can be useful in Other blood tests should be ordered depending
assessing and treating alcohol dependence for upon clinical findings and history. Two that
several reasons: are more commonly ordered in alcohol
• they can be used to corroborate patient dependence are:
provided information
Coagulation profile
• they can provide feedback regarding alcohol
Long-term alcohol dependence and resulting
related organ damage to the patient which can
advanced liver disease can significantly impair
assist motivation for change
blood coagulation.
• they can provide useful information as treatment
progresses. A coagulation profile should be ordered if there
are signs of advanced liver disease on physical
Routine blood tests include full blood count, urea
examination.
and electrolytes and liver function tests.
Blood glucose
Full blood count Used if the patient has a history of pancreatitis
Used to screen for low haemoglobin. This may be which can affect insulin secretion and cause
due to gastro-intestinal blood loss as a result of blood glucose levels to rise (hyperglycaemia).
alcohol induced gastritis/ulceration or nutritional Alcohol impairs gluconeogenesis and may lead
neglect. There may also be red blood cell to hypoglycaemia, especially in the setting of
macrocytosis and a low platelet count from heavy starvation or glood glucose-lowering (diabetic)
regular alcohol use. medication.

Urea and electrolytes

Screening and monitoring
Used to check the level of important electrolytes
A number of tests can be useful alone or in
and renal function. Low potassium as a result
combination for screening and monitoring a
of nutritional neglect or diarrhoea/vomiting is
patient’s progress. They include raised:
common and can require treatment to reverse. Low
• erythrocyte mean cell volume (MCV)
sodium is less common but can occur due to high
fluid intake. Low magnesium is a common finding • gamma-glutamyltransferase (GGT) (not as
in alcohol dependence. sensitive or specific as CDT)
• carbohydrate deficient transferrin (CDT)
Liver function tests (sensitivity 82% specificity 97% for >50gm per
The most commonly used liver function tests are: day of alcohol).
• gamma-glutamyltransferase (GGT)
• aspartate-aminotranferase (AST)
• alanine-aminotransferase (ALT)
• albumin
• bilirubin.
An AST/ALT ratio >1 and significantly raised GGT
are suggestive of alcohol-related liver damage.
Elevated bilirubin and liver enzymes suggest acute
alcoholic hepatitis. Low albumin may result from
reduced liver production in the context of more
severe and longer term liver damage.

4 A brief guide to the Assessment and Treatment of Alcohol Dependence

Treating alcohol dependence b. Alcohol (or a closely related substance,
such as a benzodiazepine) is taken to
and withdrawal relieve or avoid withdrawal symptoms.
Alcohol dependence Physical dependence and
According to the DSM-5 (American Psychiatric alcohol withdrawal
Association, 2013) a diagnosis of alcohol use
The development of physical dependence and
disorder (previously described as dependence) can
withdrawal symptoms depends on consuming
be made when a patient meets 2 or more of the
sufficient alcohol for a sufficient period of time
following criteria within a 12 month period:
for the body to neuroadapt. As a clinically useful
1. Alcohol is often taken in larger amounts or over generalisation a person who is physically dependent
a longer period than was intended. on alcohol will try to maintain their blood alcohol
2. There is a persistent desire or unsuccessful above 0.1% and once they go below this level they
efforts to cut down or control alcohol use. will develop alcohol withdrawal symptoms.
3. A great deal of time is spent in activities
Given that the average rate of alcohol metabolism
necessary to obtain alcohol, use alcohol, or
is one standard drink per hour, this requires the
recover from its effects.
consumption of at least 24 standard drinks per day to
4. Craving, or a strong desire or urge to use
maintain a blood alcohol level above 0.1%. However
alcohol.
a number of factors contribute to dependence and
5. Recurrent alcohol use resulting in a failure to withdrawal risk and the amount of drinking required
fulfill major role obligations at work, school, in an individual case is difficult to determine.
or home. Contributing factors include genetics, age, medical
6. Continued alcohol use despite having co-morbidities (such as hepatic dysfunction),
persistent or recurrent social or interpersonal concomitant medication use, and seizure threshold
problems caused or exacerbated by the effects (Roffman & Stern, 2006). Monitoring for signs of
of alcohol. alcohol withdrawal is recommended for patients with
7. Important social, occupational, or recreational a history of drinking more than 60gm (6 standard
activities are given up or reduced because of drinks) of alcohol per day.
alcohol use.
The features of alcohol withdrawal include:
8. Recurrent alcohol use in situations in which it is
• anxiety and agitation
physically hazardous.
• tremors
9. Alcohol use is continued despite knowledge
• nausea and vomiting
of having a persistent or recurrent physical or
psychological problem that is likely to have • sweating
been caused or exacerbated by alcohol. • increased body temperature
10. Tolerance, as defined by either of the following: • tachycardia
a) A need for markedly increased amounts • hypertension
of alcohol to achieve Intoxication or • insomnia
desired effect. • seizures
b. A markedly diminished effect with • increasing apprehension ranging from fear to
continued use of the same amount of terror or paranoia
alcohol. • delirium tremens – in severe cases of alcohol
11. Withdrawal, as manifested by either of withdrawal.
the following:
Symptoms of withdrawal usually begin 6-24 hours
a. The characteristic withdrawal syndrome for after the last drink and can occur in patients with a
alcohol (see next section). blood alcohol level (BAL) above zero.

A brief guide to the Assessment and Treatment of Alcohol Dependence 5

 Figure 1
Alcohol Withdrawal – Severity of signs and symptoms of alcohol withdrawal over time
Source: NSW Health (2000, p. 41)

Seizures
Severe
withdrawal
Severity of signs and symptoms

marked tremor
vomiting
Mild extreme agitation
withdrawal disorientation
confusion
anxiety paranoia
agitation hyperventilation
tremor delirium tremens
nausea
tachycardia
hypertension
disturbed sleep
raised temperature
HA LLU CI N AT I O NS

1 2 3 4
DAY DAY DAY DAY

Seizures Delirium tremens

Seizures may occur 6-48 hours after last drinking Delirium tremens is a severe form of withdrawal
and are usually generalised tonic–clonic seizures, that involves marked tremor, extreme agitation
although partial seizures also occur. A seizure may and hyperactivity, clouding of consciousness,
occur before or during the early development of disorientation and hallucinations. This will typically
withdrawal features. occur 48 to 96 hours after the last drink, but can
occur earlier (Roffman & Stern, 2006). If untreated,
Seizures become more common with a longer
there is a high mortality. Delirium tremens is more
history of alcohol dependence and repeated
likely to occur with higher alcohol consumption;
detoxifications (Rogawski, 2005). The risk of
a longer history of alcohol dependence; a higher
seizures increases in those with a history of alcohol
BAL when withdrawal symptoms occur; when there
withdrawal seizures, idiopathic epilepsy, head
is a concurrent infectious disease, and also when
injury or concurrent benzodiazepine dependence.
there have been previous seizures or delirium
Patients who experience a seizure should initially tremens (Palmstierna, 2001).
be managed according to a seizure management
Patients who develop delirium tremens will
protocol. Patients who experience a first or atypical
generally require intravenous fluids and IV sedation
seizure should be referred to a hospital emergency
and should be managed in an acute hospital,
department for review and seizure work-up.
preferably in a high dependency unit.

6 A brief guide to the Assessment and Treatment of Alcohol Dependence

Managing alcohol withdrawal Specialist inpatient withdrawal is most
appropriate when:
Prior to commencing withdrawal treatment, the
• alcohol withdrawal symptoms are likely to be
clinician should:
moderate to severe
• provide the patient and their carer with
• there are complicating medical, psychological or
information about what to expect
psychiatric issues
• help the patient to develop a plan to cope with
• there have been previous complicated
withdrawal
withdrawals (DTs, seizures)
• ensure appropriate support
• there is dependence on other drugs in addition
• organise medication and observation as needed
to alcohol
• help the client to plan and commit to follow up
• previous attempts to withdraw as an outpatient
support and treatment.
have been unsuccessful
Setting for alcohol withdrawal • there is a lack of social support
Alcohol withdrawal can occur as an: • the patient is pregnant.
• inpatient (Saunders et al., 2002)
• outpatient with assistance from a home-based
Outpatient withdrawal is most appropriate when:
withdrawal service
• the patient is not severely dependent on alcohol
• outpatient without assistance.
• where previous withdrawals have not been
The course a withdrawal process takes and hence complicated
the appropriate treatment and support needed, • there are no significant complicating medical,
depend upon: psychological or psychiatric issues
• the severity of alcohol dependence • there is no significant use of drugs other
• whether there is dependence on other drugs in than alcohol
addition to alcohol • the person has a stable home environment
• co-existing medical, psychological or psychiatric • a non using carer is present to provide support,
issues monitor progress and control medications
• psychosocial factors such as physical • the patient is strongly motivated for abstinence.
environment, support, expectations and fears
(Saunders et al., 2002)
• the patient’s reasons for withdrawing
• the patient’s motivation for abstinence. As medical assistance is often required for
outpatient withdrawal, patients should be linked
(Saunders, Jenner, Jenner, & Yang, 2002)
with a GP and home withdrawal service whenever
Some women may feel unsafe in an inpatient possible.
environment (Swift & Copeland, 1998), particularly
if they have a history of sexual abuse and may
discharge early.

A brief guide to the Assessment and Treatment of Alcohol Dependence 7

 Monitoring alcohol withdrawal Medical management
Alcohol withdrawal can be life-threatening and all
of alcohol withdrawal
alcohol dependent patients should be carefully
Early treatment with benzodiazepines is important
assessed and monitored for severity of withdrawal
to prevent severe withdrawal symptoms
symptoms. Next Step monitors patients using
developing. Patients at risk of severe withdrawal
the Clinical Institute Withdrawal Assessment for
symptoms should be advised to continue drinking
Alcohol Scale (CIWA-Ar scale, Reoux & Miller,
until they can receive medical assistance.
2000, see Appendix 2). A score of 9 or more
indicates significant withdrawal symptoms and Withdrawal management at Next Step involves the
the need for medication. A score of 15 or more routine prescribing of:
indicates severe withdrawals with impending risk of • diazepam
confusion and seizures – urgent medical attention • a night-time hypnotic such as temazepam
should be provided. • thiamine and multi vitamins.
Most of the features of alcohol withdrawal settle Additional medications (e.g. antiemetics,
over 5-7 days. However a syndrome associated analgesics) are prescribed if symptoms develop.
with protracted abstinence can last several
months and includes insomnia, mild anxiety and Patients who are at increased risk of a seizure
autonomic dysfunction with small elevations during alcohol withdrawal (i.e. patients with a
in blood pressure, pulse and respiratory rate history of seizures, benzodiazepine dependence
(Schuckit, 2009). or high levels of alcohol dependence) should
be immediately commenced on a minimum of
diazepam 10mg qid as a seizure may precede the
development of withdrawal signs. These patients
will usually also require additional diazepam as per
CIWA-Ar scale score.
Outpatient or home withdrawal medication
Drug Dose/frequency
Diazepam 5-10mg oral qid Reduced over 5-7 days
Temazepam 10-20mg oral nocte 3-5 days
Metoclopramide 10mg 6 hourly O/IMI prn
Thiamine 300mg oral daily 5 days

Inpatient withdrawal medication

Drug Dose
Diazepam 10-20mg oral tds or qid Reduced over 5-7 days
Plus
PRN 5-20mg subject to CIWA-Ar score
OR
Diazepam 5-20mg oral 2-4 hourly Up to 120mg in the first 24 hours and
subject to CIWA-Ar score then rapidly reduced
Temazepam 10-20mg oral nocte 3-5 days
Metoclopramide 10mg O/IMI 6 hourly prn
Thiamine 250mg IMI/day 3-5 days
Thiamine 300mg oral daily Duration of admission

In the majority of patients benzodiazepines should be ceased prior to planned discharge as there exists the
potential to develop a dependence on benzodiazepines.

8 A brief guide to the Assessment and Treatment of Alcohol Dependence

Thiamine and Wernicke – • Patients with a diagnosis of acute Wernicke’s are
generally managed at an acute hospital and may
Korsakoff Syndrome be given 500mg TDS IV for 2 days then 500mg/
Thiamine (Vitamin B1) deficiency is common day IV for 5 days. (Lingford-Hughes, Welch &
in heavy drinkers due to poor nutrition, poor Nutt, 2004)
absorption due to impaired intestinal absorption,
possibly decreased stores (liver disease), increased
loss (chronic diarrhoea), impaired utilisation (Mg
Relapse prevention
deficiency). Thiamine deficiency can lead to pharmacotherapies
Wernicke’s encephalopathy. Naltrexone
Signs of Wernicke’s encephalopathy include: Naltrexone is an opioid antagonist that blocks
• confusion the effects of endogenous opiates which are
• ataxia – truncal released during alcohol consumption or during
• oculomotor abnormalities (nystagmus and exposure to alcohol related cues, and is thought
opthalmoplegia – internuclear opthalmoplegia to reduce the reinforcing effects of alcohol
3rd nerve and 6th nerve) (Jupp & Lawrence, 2010).
• coma, hypothermia, hypotension. Most clinical trials find naltrexone reduces cravings
and the amount drunk per drinking episode (Jupp
Many cases can be sub-clinical.
& Lawrence, 2010). It appears to have little effect
Without immediate administration of thiamine on returning to drinking per se, but does appear
there can be irreversible cognitive damage known to reduce the rate at which patients return to
as Korsakoff’s syndrome, due to bilateral lesions in heavy drinking particularly when combined with
the limbic system including the mammilliary bodies counselling (Anton et al., 2006).
of the hypothalamus.
Naltrexone is contraindicated in patients with
Signs of Korsakoff’s syndrome are: current or recent use of opioid medication and is
• anterograde amnesia (inability to form new not suitable for people who have pain disorders
memories) and retrograde amnesia for relatively needing opioid analgesia. Patients who are suffering
recent events from depression should be monitored closely.
• disorientation to time
Naltrexone has shown hepatotoxic potential,
• confabulation (making up stories) particularly at doses above that recommended.
• apathy. Naltrexone should not be used in patients with
Oral thiamine (50-100mg) should be taken daily by acute hepatitis or liver failure, and used with
all alcohol dependent patients. caution in those with active liver disease.

For patients undergoing alcohol withdrawal, the The safety of naltrexone for pregnant or
following thiamine regime is recommended: breastfeeding women has not been established.
• For healthy patients who have adequate dietary The recommended daily dose of naltrexone is
intake, 300mg/day of oral thiamine should be 50mg (1 tablet).
administered for 5 days.
• Patients in poor health with poor dietary intake Acamprosate
will have poor absorption of oral thiamine and Acamprosate is a synthetic GABA analogue that
should therefore be administered 250mg/day reduces glutamatergic hyperactivity and is thought
of thiamine parenterally for 3-5 days, then oral to reduce alcohol withdrawal associated negative
doses of 300mg/day for the duration of their affect and reduce craving and alcohol related
admission. cue induced relapse during abstinence (Jupp &
Lawrence, 2010).

A brief guide to the Assessment and Treatment of Alcohol Dependence 9

 A number of trials have shown that acamprosate Disulfiram has some relatively benign side
increases time to relapse, decreases number effects including metallic taste, sedation, rash
of drinks per drinking day and reduces craving and temporary impotence. Very rare but severe
in alcohol dependent patients (Schuckit, 2009). side effects include neuropathies, depression,
However it has been found to be less effective psychotic symptoms, increased liver function
than naltrexone in terms of reducing craving tests and hepatitis. (Schuckit, 2009). Because
which could be explained by the development of the severe reaction when alcohol is ingested
of tolerance to the drug which has been found with disulfiram, it should not be used for people
in animal studies (Jupp & Lawrence, 2010). In with diabetes, heart disease, stroke or psychosis
addition, US-based clinical trials have not obtained and should be used with caution in patients with
the same positive results as European trials which liver disease. Disulfiram should only be prescribed
may be due to methodological differences but with close medical supervision and cautious
does suggest that further research is needed monitoring of blood counts and liver function tests.
(Jupp & Lawrence, 2010). Acamprosate and
naltrexone treatments can be used in combination, The safety of disulfiram for pregnant or
and although some research has found the breastfeeding women has not been established.
combination more effective than either drug alone, Patients should be fully withdrawn from alcohol
there is uncertainty over whether acamprosate before commencing disulfiram.
adds anything to naltrexone alone (Foy, 2007).
The recommended daily dose of disulfiram is
Acamprosate is reasonably well tolerated (side 200‑400mg (1-2 tablets).
effects include gastro-intestinal upset and
diarrhoea) and without serious harms (Garbutt,
West, Carey, et al., 1999; Mason, 2003). It is
Future potential relapse
considered to be more effective when combined prevention pharmacotherapies
with counselling (Foy, 2007). Various medications are currently being
investigated for their role in the reduction or
Acamprosate is not recommended for women who
cessation of alcohol use and as anti-craving
are pregnant or breastfeeding.
agents. To discuss these medications in any depth
Subject to weight, the recommended daily dose of is beyond the scope of this booklet.
acamprosate for an adult is 1998mg (2 x 333mg tds).
These medications include the following:
Disulfiram • Baclofen
Disulfiram inhibits aldehyde dehydrogenase, • Nalmefene
an enzyme needed to metabilise alcohol. This • Topiramate and other anticonvulsants
causes acetaldehyde to accumulate in the body, • Dopamine agonists
causing uncomfortable and potentially dangerous • Gabapentin
symptoms if alcohol is ingested. These symptoms • Ondansetron
typically include nausea, vomiting, flushing,
• Oxytocin
rapid pulse rate, increased blood pressure and
headache.
There is little evidence that disulfiram enhances
abstinence but there is evidence that it reduces
drinking days (Garbutt et al., 1999). Non-
compliance rates are high and compliance is
enhanced by supervision (Laaksonen, Koski-
Jannes, Salaspuro, Ahtinen, & Alho, 2008), high
patient motivation for abstinence and good non
drinking social support networks.

10 A brief guide to the Assessment and Treatment of Alcohol Dependence

Counselling Further indications for a neuropsychological
assessment include a history of head injury
All patients should be offered counselling and
resulting in loss of consciousness for longer
this can be supplemented by the use of self help
than 30 minutes, or diagnosis of a neurological
resources. Guidelines and resources produced by
condition such as epilepsy or stroke.
the Drug and Alcohol Office include:
A consideration with elderly patients is a
Drug and Alcohol Office. (2014). Self Help Manual. differential diagnosis between alcohol related
Perth, Western Australia: Author. cognitive impairment and a neurodegenerative
Drug and Alcohol Office. (2014). Here’s to your disorder, such as Alzheimer’s disease. In many
health: A guide to reducing alcohol-related risks cases a neuropsychological assessment can assist
and harms. Perth, Western Australia: Author. with the diagnosis of the condition and guide
treatment and patient management.
Marsh, A., O’Toole, S., Dale, A., Willis, L., &
Helfgott, S. (2013). Counselling guidelines:
Alcohol and other drug issues (3rd ed.). Perth, Useful resource
Western Australia: Drug and Alcohol Office. A comprehensive national alcohol treatment
resource has also been produced:
Haber, P., Lintzeris, N., Proude, E., & Lopatko, O.
(2009). Guidelines for the Treatment of Alcohol
Psychology Problems. Barton, Australian Capital Territory:
If patients are experiencing significant mental Department of Health and Ageing.
health issues that do not diminish with reduced
alcohol intake or interfere with reducing alcohol
intake they should be considered for a psychology
referral and/or psychiatric review.

Neuropsychology
All alcohol dependent patients should be
considered for a neuropsychology referral and
assessment. Between 50% – 80% of people
with problematic alcohol use display deficits on
neuropsychological tests (Bates, Bowden & Barry,
2002) and 45% to 70% of clients entering treatment
for problematic alcohol use have impairments
in problem solving, abstract thinking, concept
shifting, psychomotor performance, and memory
tasks (Oscar-Berman, & Marinkovic, 2007). These
impairments are difficult to detect in structured
interviews (Fals-Stewart & Schafer, 1992; Fals-
Stewart & Lucente, 1994) and are usually not
apparent without neuropsychological testing.
Clinicians should consider administering the
Mini-Mental State Examination (Folstein, Folstein,
& McHugh, 1975; Appendix 1) or the Montreal
Cognitive Assessment (MoCA) to patients where
neuropsychological deficits are suspected.

A brief guide to the Assessment and Treatment of Alcohol Dependence 11

 References
American Psychiatric Association (2013). Folstein, M., Folstein, S., & McHugh, P. (1975). ‘Mini-
Diagnostic and Statistical Manual of Mental mental state’. A practical method for grading
Disorders: DSM-5 (5th ed.). Arlington, VA: the cognitive state of patients for the clinician.
American Psychiatric Association. Journal of Psychiatric Research, 12(3), 189–98.
Anton, R., O’Malley, S.S., Ciraulo, D.A., Cisler, R.A. Foy, A. (2007). Circuit breakers for addiction.
Couper, D., Donovan, D.M.,…Zweben, A. (2006). Internal Medicine, 37, 320-325.
Combined pharmacotherapies and behavioural
Garbutt, J., West, S., Carey, T., Lohr, K., & Crews,
interventions for alcohol dependence: The
F. (1999). Pharmacological treatment of alcohol
COMBINE study. A randomised controlled trial.
dependence: A review of the evidence. Journal
Journal of the American Medical Association,
of the American Medical Association, 281(14),
295(17), 2003-2017.
1318-1325.
Bates, M. E., Bowden, S. C., & Barry, D. (2002).
Haber, P., Lintzeris, N., Proude, E., & Lopatko, O.
Neurocognitive impairment associated with
(2009). Guidelines for the Treatment of Alcohol
alcohol use disorders: implications for treatment.
Problems. Barton, Australian Capital Territory:
Experimental & Clinical Psychopharmacology
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A brief guide to the Assessment and Treatment of Alcohol Dependence 13

 Appendix 1 MMSE Cognitive examination
The Mini Mental State Examination (MMSE) was
introduced in 1975 by Folstein et al., (1975). It is
a brief 30-item test that screens for cognitive
impairment. It takes about 10 minutes to
administer. It assesses various functions including
arithmetic, memory and orientation. The test can
be a component of the mental state assessment.
Scores may need to be corrected for educational
attainment and age, and may not be an accurate
reflection of cognitive impairment if the person is
intoxicated or withdrawing.

Scoring the MMSE (at Next Step Drug and

Alcohol Service)
The test is scored out of 30.
27-30: Cognition likely to be intact
23-27: Cognitive impairment possible. Consider
referral for neuropsychological assessment.
<23: Cognitive impairment highly likely. Refer for
neuropsychological assessment.

Alcohol related cognitive impairment and

the MMSE profile
The MMSE is only a screening test and does not
identify all aspects of alcohol related cognitive
impairment. In addition, scores will be negatively
influenced by current alcohol use and recent
heavy alcohol use. A clearer picture of potential
alcohol related cognitive impairment can only be
obtained when the patient has been abstinent for
several weeks.

Montreal Cognitive Assessment (MoCA)

This is a recommended alternative brief screening
instrument to detect mild cognitive impairment.
Further information: www.mocatest.org

14 A brief guide to the Assessment and Treatment of Alcohol Dependence

 Mini Mental State Examination
MENTAL FUNCTION SCORE

DATE___________________ CLINICIAN_____________________________________

ORIENTATION
Score one point for correct answers to each of the following questions.
What is the Time? Day? Date? Month? Year? 5 points ( )
What is the name of This Clinic? This suburb? This city? This state? This
country? 5 points ( )
REGISTRATION
Say: “I’m going to name 3 objects for you and I want you to remember them.
The objects are Car, Dog and Book. Can you repeat them?”
Score 1 point for each object correctly repeated (order not important). Endeavour, by
further attempts and prompting, to have all three repeated, so as to test recall later. 3 points ( )
ATTENTION AND CALCULATION
Ask the client to subtract 7 from 100, and then 7 from the result — repeat this five
times, scoring 1 for each time a correct subtraction is performed. 5 points ( )
RECALL
Ask the client to recall the three objects previously repeated (Car, Dog, Book).
Score 1 for each correctly recalled. 3 points ( )
LANGUAGE
Show the client a pencil and ask them to name it. Show the client a watch and ask
them to name it. Score 1 point for each object correctly named. 2 points ( )
Ask the client to repeat the phrase: “No ifs, ands or buts”. Score 1 point if correctly
repeated. 1 point ( )
Hand the client the MMSE sheet and say: “Take this piece of paper in your right
hand, fold it in half with both hands, and place it on the floor”. Score 1 point for
each stage correctly executed. 3 points ( )
Point to CLOSE YOUR EYES (over page) and ask the client to obey what is written.
Score 1 point if client closes their eyes. 1 point ( )
Ask the client to write a sentence. Score 1 if the sentence is sensible and has a verb
and a subject. 1 point ( )
VISUAL-SPATIAL
Ask the client to copy the diagram over the page. Score 1 point if this is correctly
copied (Two 5-sided figures with the intersection creating a 4-sided figure). 1 point ( )

TOTAL SCORE (=30)

A brief guide to the Assessment and Treatment of Alcohol Dependence 15

 Mini Mental State Examination

CLOSE YOUR EYES

SENTENCE

___________________________________________________________________________

16 A brief guide to the Assessment and Treatment of Alcohol Dependence

Appendix 2 Next Step version of the Revised Clinical Institute
Withdrawal Assessment for Alcohol Scale (CIWA-Ar)
(Reoux & Miller, 2000)

Alcohol Withdrawal Assessment

DATE OF ADMISSION _____/_____/____
Seizure History Yes No

WITHDRAWAL DAY
TIME
BAL

BP 240
230
TEMP 220
TEMP 40º 210
39º 200
38º 190
37º 180
36º 170
35º 160
150
BP PULSE 140
130 130
120 120
110 110
100 100
PULSE 90 90
80 80
70 70
60 60
50 50
40 40

1. Nausea and Vomiting

2. Tremor
3. Paroxymal sweats
4. Anxiety
5. Agitation
6. Tactile Disturbances
7. Auditory Disturbances
8. Visual Disturbances
9. Headache
10. Orientation
TOTAL (Max 67)
DIAZEPAM DOSE (mg)
NURSE INITIALS

Withdrawal Symptoms CIWA-Ar score Diazepam dose CIWA-Ar frequency

Mild 0–8 NIL CIWA-Ar prior to medication 4-6 hourly
Moderate 9–14 5–15mg CIWA-Ar prior to medication 2-4 hourly
Severe 15 or more 20mgs CIWA-Ar repeated in 1 hr – if no reduction in score discuss with doctor.

A brief guide to the Assessment and Treatment of Alcohol Dependence 17

 CIWA-Ar

1. NAUSEA AND VOMITING – Ask “ Do you feel sick to your stomach? 6. TACTILE DISTURBANCES – Ask “Have you any itching, pins and
Have you vomited? Observation. needles sensations, any burning, any numbness, or do you feel bugs
crawling on or under your skin?” Observation.
0 no nausea and no vomiting
1 mild nausea with no vomiting 0 none
2 1 very mild itching, pins and needles, burning or numbness
3 2 mild itching, pins and needles, burning or numbness
4 intermittent nausea with dry heaves 3 moderate itching, pins and needles, burning or numbness
5 4 moderately severe hallucinations
6 5 severe hallucinations
7 constant nausea, frequent dry heaves and vomiting 6 extremely severe hallucinations
7 continuous hallucinations

2. TREMOR – Arms extended and fingers spread apart. Observation. 7. AUDITORY DISTURBANCES – Ask “Are you more aware of sounds
around you? Are they harsh? Do they frighten you? Are you hearing
0 no tremor anything that is disturbing to you? Are you hearing things you know are
not there?” Observation.
1 not visible, but can be felt fingertip to fingertip
2
0 not present
3
1 very mild harshness or ability to frighten
4 moderate, with patient’s arms extended
2 mild harshness or ability to frighten
5
3. moderate harshness or ability to frighten
6
4 moderately severe hallucinations
7 severe, even with arms not extended
5 severe hallucinations
6 extremely severe hallucination
7 continuous hallucinations

3. PAROXYSMAL SWEATS – Observation 8. VISUAL DISTURBANCES – Ask “Does the light appear to be too
bright? Is its colour different? Does it hurt your eyes? Are you seeing
0 no sweat visible anything that is disturbing to you? Are you seeing things you know are
not there?” Observation.
1 barely perceptible sweating, palms moist
2
0 not present
3
1 very mild sensitivity
4 beads of sweat obvious on forehead
2 mild sensitivity
5
3 moderate sensitivity
6
4 moderately severe hallucinations
7 drenching sweats
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations

4. ANXIETY – Ask “Do you feel nervous?“ Observation. 9. HEADACHE, FULLNESS IN HEAD – Ask “Does your head feel
different? Does it feel like there is a band around your head?“
0 no anxiety, at ease Do not rate for dizziness or lightheadedness. Otherwise, rate severity.
1 mildly anxious
2 0 not present
3 1 very mild
4 moderately anxious, or guarded, so anxiety is inferred 2 mild
5 3 moderate
6 4 moderately severe
7 equivalent to acute panic states as seen in severe delirium or acute 5 severe
schizophrenic reactions 6 very severe
7 extremely severe

5. AGITATION – Observation. 10. ORIENTATION AND CLOUDING OF SENSORIUM – Ask

“What day is this? Where are you? Who am I?“
0 normal activity
1 somewhat more than normal activity 0 oriented and can do serial additions
2 1 cannot do serial additions or is uncertain about date
3 2 disoriented for date by no more than 2 calendar days
4 moderately fidgety and restless 3 disoriented for date by more than 2 calendar days
5 4 disoriented for place/or person
6
7 paces back and forth during most of the interview, or constantly
thrashes about

The CIWA-Ar scale measures 10 symptoms. Scores of less than 9 indicate minimal to mild withdrawal.
Scores of 9 to 15 indicate moderate withdrawal (marked autonomic arousal);
and scores of 15 or more indicate severe withdrawal (impending delirium tremens).

The CIWA-Ar alcohol withdrawal assessment tool should be discontinued after 5 to 7 days

18 A brief guide to the Assessment and Treatment of Alcohol Dependence

 Notes

A brief guide to the Assessment and Treatment of Alcohol Dependence 19

 Notes

20 A brief guide to the Assessment and Treatment of Alcohol Dependence

© Drug and Alcohol Office, 2015
DAO 0070