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Alcohol misuse

Alcohol misuse is where a person consumes excessive amounts of alcoholic drinks.

Alcohol misuse means drinking excessively - more than the recommended limits of alcohol consumption (see below).

This can lead to a number of harmful physical and psychological effects, such as alcohol poisoning, cirrhosis of the liver, inability to work and socialise and destructive behaviours, such as drink-driving.

Your risk of developing problems increases with the amount of alcohol you drink. The three main risk categories based on how much you drink, that can be used to help judge your own level of risk, are lower-risk, increasing-risk and higher-risk.

Lower-risk drinking

Lower-risk drinking is drinking at a level associated with a low risk of future harm to your health.

For men, lower-risk is drinking no more than 3-4 units of alcohol a day on a  regular basis. For women, it’s lower risk if they drink no more than 2-3 units of alcohol a day on a regular basis.

Sensible' or 'responsible' drinking are sometimes used to mean lower-risk drinking.

Increasing-risk drinking

Increasing-risk drinking is drinking associated with an increased risk of future harm to your health, with the risk increasing the more you drink.

For men, this riskier level of drinking is drinking more than 3-4 units of alcohol a day on a regular basis. For women, it's drinking more than 2-3 units a day on a regular basis.

Higher-risk drinking

Higher-risk drinking is drinking at such a high level that you’re at particularly high risk of harming your health.

For men, higher-risk drinking is regularly drinking over over 50 units a week (eight units of alcohol a day). For women, it’s regularly drinking over 35 units a week (over six units of alcohol a day).

Other categories of alcohol misuse

Binge drinking

The term 'binge drinking' usually refers to an episode of heavy drinking over a short period of time, such as over the course of an evening or over an hour or two. It also refers to an episode of drinking to intoxication or to drunkenness.

Binge drinking can affect your health in a number of ways. For example, it can increase your immediate risk of being in an accident, becoming involved in an argument or fight, or taking part in illegal or risky behaviour, such as drink-driving or unsafe sex.

Different people are affected differently by how much they drink. Alcohol can also affect a person differently at different times. Some people will be at risk of the immediate harms to their health even if they don’t think they’re getting drunk.

Hazardous drinking

Hazardous drinking usually refers to drinking above the recommended lower-risk levels but without, yet, showing evidence of harm to health.

Harmful drinking

Harmful drinking refers to those already experiencing or showing evidence of health harms (but not if just showing evidence of alcohol dependence).

Dependent drinking

Dependent drinking refers to having developed alcohol dependence, which is a specific health harm where the person affected has started to have an excessive desire to drink, or is showing some loss of control over their drinking.

This has usually started to affect the person’s quality of life and relationships, but they may not always find it easy to see this or to accept it.

For someone with severe alcohol dependence who experiences physical alcohol withdrawals when they cut down or stop drinking, suddenly cutting down or stopping can be dangerous without seeking medical advice.

Physical withdrawal symptoms include:

  • hand tremors ('the shakes')
  • sweating
  • nausea
  • visual hallucinations (seeing things that aren’t real)
  • seizures (fits) in the most serious cases

Psychological withdrawal symptoms include:

  • depression
  • anxiety 
  • irritability
  • restlessness
  • insomnia (difficulty sleeping)

Severely dependent drinkers usually experience severe withdrawal symptoms. They often fall into a pattern of 'relief drinking', where they drink to avoid withdrawal symptoms.

Severely dependent drinkers are often able to tolerate very high levels of alcohol, amounts that would incapacitate or even kill some people.

Risks of alcohol misuse

The short-term risks of alcohol misuse include:

  • alcohol poisoning - this may lead to vomiting, seizures (fits) and falling unconscious
  • accidents and injuries requiring hospital treatment, such as a head injury 
  • violent behaviour that might lead to being arrested by police
  • unprotected sex that could potentially lead to unplanned pregnancy or sexually transmitted infections (STIs)
  • loss of personal possessions, such as wallets, keys or mobile phones, leading to stress and anxiety 

Long-term alcohol misuse is a major risk factor for serious conditions including:

As well as causing serious health problems, long-term alcohol misuse can lead to social problems, such as unemployment, divorce, domestic abuse and homelessness.

Read more about the risks of alcohol misuse.

Units of alcohol

Alcohol is measured in units. A unit of alcohol is 10ml of pure alcohol, which is about half a pint of normal strength lager or a single measure (25ml) of spirits. A small glass (125ml) of wine contains about one-and-a-half units of alcohol.

Men should not regularly drink more than 3-4 units of alcohol a day, and women should not regularly drink more than 2-3 units a day. 

'Regularly' means drinking this amount every day or most days of the week.

It's also recommended that both men and women should have at least two alcohol-free days each week. Your health is at risk if you regularly exceed recommended daily limits.

Am I drinking too much alcohol?

You could be misusing alcohol if:

  • you feel you should cut down on your drinking
  • other people have been criticising your drinking
  • you feel guilty or bad about your drinking
  • you need a drink first thing in the morning to steady your nerves or get rid of a hangover

Someone you know may be misusing alcohol if:

  • they regularly exceed the recommended daily limit for alcohol (see above) 
  • they are sometimes unable to remember what happened the night before due to their drinking 
  • they fail to do what was expected of them as a result of their drinking - for example, missing an appointment or work due to being drunk or hungover

Alcohol assessment

If you visit your GP because you're concerned about your drinking, or you receive treatment due to an alcohol-related injury or illness, your alcohol intake may be assessed.

The two most common tests used are the:

  • Alcohol Use Disorders Identification Test (AUDIT)
  • Fast Alcohol Screening Test (FAST)

It's important to be truthful when answering the questions in these tests. The doctor or nurse is asking these questions to ensure you get the best possible advice and treatment.

For example, they might want to start you on a medicine that will either not work properly if you drink, or may even be dangerous to take with alcohol.

Read more about diagnosing alcohol misuse.

Treating alcohol misuse

How alcohol misuse is treated depends on how much alcohol a person is drinking. Treatment options include:

  • detoxification - involves a  nurse or doctor supporting you to safely stop drinking; this can be done by helping you slowly cut down over time or by giving you medicines to prevent you experiencing withdrawal
  • counselling - including self-help groups and talking therapies, such as cognitive behavioural therapy (CBT)
  • medication - there are two main types of medicines to help people stop drinking; the first is to help stop withdrawal symptoms and is given in reducing doses over a short period of time; the most common medicine that’s used in this way is called chlordiazapoxide (Librium); the second is a medication to reduce any urge you may have to drink; the most common medications used for this are acamprosate and naltrexone; these medicines are given at a fixed dose and you'll usually be on them for 6-12 months

Read more about the treatment options for alcohol misuse.

Getting help

If you're concerned about your drinking or someone else's, a good first step is to visit your GP. They will be able to discuss the services and treatments available.

As well as the NHS, there are a number of charities and support groups across the UK that provide support and advice for people with an alcohol misuse problem.

For example, you may want to contact:

Alcohol and pregnancy

The Department of Health recommends pregnant women and women trying to conceive should avoid drinking alcohol. If they do choose to drink, they should not drink more than 1-2 units of alcohol once or twice a week and should avoid getting drunk.

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Alcohol misuse

If you visit your GP because you are concerned about your alcohol consumption, it is likely that they will want to assess the extent and pattern of your drinking.

If you visit your GP because you're concerned about your drinking, or if you are treated for an alcohol-related injury or illness, your alcohol misuse may be assessed.

An alcohol assessment usually involves having a number of screening tests that consist of a series of questions.

It's important that you're truthful when answering the questions, so you can receive the appropriate treatment. Your GP or the healthcare professional carrying out the tests will not judge you.

Three commonly used tests are the:

  • Alcohol Use Disorders Identification Test (AUDIT)
  • Fast Alcohol Screening Test (FAST)
  • Severity of Alcohol Dependence Questionnaire (SADQ)

These tests are described below.

Alcohol Use Disorders Identification Test (AUDIT)

The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization (WHO).

It's a widely used screening test that can help people identify whether they might need to think about changing their drinking habits.

AUDIT involves answering 10 questions about your drinking habits to assess the effects it could have on you. Questions include:

  • How often do you have a drink containing alcohol?
  • How many drinks containing alcohol do you have on a typical day when you are drinking?
  • How often during the last year have you found that you were not able to stop drinking once you had started?
  • How often during the last year have you had a feeling of guilt or remorse after drinking?

The test is usually carried out under the guidance of a healthcare worker.

After you've completed the test your score will be calculated. If the results show that you're drinking hazardously or harmfully, the healthcare worker will advise you about appropriate treatments and services.

Fast Alcohol Screening Test (FAST)

The Fast Alcohol Screening Test (FAST) is a simpler test that you can use to check whether your drinking has reached hazardous levels.

FAST consists of four questions, listed below. The number after each answer is that answer's score.

1. How often do you drink eight or more units (men) or six or more units (women) on one occasion?

  • never (if this is your answer you can stop the test)
  • less than monthly (1)
  • monthly (2)
  • weekly (3)
  • daily or almost daily (4)

2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

  • never (0)
  • less than monthly (1)
  • monthly (2)
  • weekly (3)
  • daily or almost daily (4)

3. How often during the past year have you failed to do what was normally expected of you because you had been drinking?

  • never (0)
  • less than monthly (1)
  • monthly (2)
  • weekly (3)
  • daily or almost daily (4)

4. In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested that you cut down?

  • no (0)
  • yes, on one occasion (1)
  • yes, on more than one occasion (2)

A FAST score of three or more indicates that you're drinking at a hazardous level.

Severity of Alcohol Dependence Questionnaire (SADQ)

As well as helping to identify a person’s dependence on alcohol, the Severity of Alcohol Dependence Questionnaire (SADQ) can also be used to indicate the severity of dependence.

The SADQ is a 20-item questionnaire that has a maximum score of 60. It focuses on five key areas of alcohol dependence. They are:

  • physical withdrawal
  • affective withdrawal
  • withdrawal relief drinking
  • alcohol consumption
  • rapidity of reinstatement

The SADQ is often used by healthcare professionals because it’s very quick and simple to use and it doesn’t require any specialist training to carry out or score.

A person with mild alcohol dependence (SADQ score of 15 or less) will not usually need assisted alcohol withdrawal.

Someone with moderate dependence (SADQ score of 16-30) will usually need assisted alcohol withdrawal, which can often be managed in the community.

Someone who is severely alcohol dependent (SADQ score of more than 30) will need assisted alcohol withdrawal. This will usually be carried out in an inpatient or residential setting.

Read more about how alcohol misuse is treated.

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Alcohol misuse

Alcohol is a powerful chemical that can have a wide range of adverse effects on almost every part of your body.

Alcohol is a powerful chemical that can have a wide range of adverse effects on almost every part of your body, including your brain, bones and heart.

Alcohol and its associated risks can have both short-term and long-term effects

Short-term effects of alcohol consumption

The short-term effects of alcohol consumption are outlined below. This information is based on the assumption that you have a normal tolerance to alcohol. Dependent drinkers with a higher tolerance to alcohol can often drink much more without experiencing any noticeable effects.

1-2 units

After drinking 1-2 units of alcohol, your heart rate speeds up and your blood vessels expand, giving you the warm, sociable and talkative feeling associated with moderate drinking.

4-6 units

After drinking 4-6 units of alcohol, your brain and nervous system starts to be affected. It will begin to affect the part of your brain that's associated with judgement and decision making, causing you to be more reckless and uninhibited.

The alcohol will also impair the cells in your nervous system, making you feel light-headed and adversely affecting your reaction time and co-ordination.

8-9 units

After drinking 8-9 units of alcohol, your reaction times will be much slower, your speech will begin to slur and your vision will begin to lose focus.

Your liver, which filters alcohol out of your body, will be unable to remove all of the alcohol overnight, so it's likely you'll wake with a hangover.

10-12 units

After drinking 10-12 units of alcohol, your co-ordination will be highly impaired, placing you at serious risk of having an accident. The high level of alcohol has a depressant effect on both your mind and body, which makes you drowsy.

This amount of alcohol will begin to reach toxic (poisonous) levels. Your body will attempt to quickly pass out the alcohol in your urine. This will leave you feeling badly dehydrated in the morning, which may cause a severe headache.

The excess amount of alcohol in your system can also upset your digestion, leading to symptoms of nausea, vomiting, diarrhoea and indigestion.

More than 12 units

If you drink more than 12 units of alcohol, you’re at considerable risk of developing alcohol poisoning, particularly if you're drinking lots of units over a short period of time.

It usually takes the liver about an hour to remove one unit of alcohol from the body.

Alcohol poisoning occurs when excessive amounts of alcohol start to interfere with the body's automatic functions such as:

  • breathing
  • heart rate
  • gag reflex, which prevents you choking

Alcohol poisoning can cause a person to fall into a coma and could lead to their death.

Other risks

Some of the other risks associated with alcohol misuse include:

  • accidents and injury - more than 1 in 10 visits to accident and emergency (A&E) departments are due to alcohol-related illnesses
  • violence and antisocial behaviour - each year in England over 1.2 million violent incidents are linked to alcohol misuse
  • unsafe sex - this can lead to unplanned pregnancies and sexually transmitted infections (STIs)
  • loss of personal possessions - many people lose personal possessions, such as their wallet or mobile phone, when they are drunk
  • unplanned time off work or college - this could put your job or education at risk

Long-term effects of alcohol misuse

Drinking hazardous amounts of alcohol for many years will take its toll on many of the body’s organs and may cause organ damage.

Organs known to be damaged by long-term alcohol misuse include the brain and nervous system, heart, liver and pancreas.

Heavy drinking can also increase your blood pressure and blood cholesterol levels, both of which are major risk factors for heart attacks and strokes.

Long-term alcohol misuse can weaken your immune system, making you more vulnerable to serious infections. It can also weaken your bones, placing you at greater risk of fracturing or breaking them.

There are many long-term health risks associated with alcohol misuse. They include:

As well as having a significant impact on your health, alcohol misuse can also have long-term social implications. For example, it can lead to:

  • family break-up and divorce
  • domestic abuse
  • unemployment
  • homelessness
  • financial problems

Kindling

Kindling is a problem that can occur following a number of episodes of withdrawal from alcohol. The severity of a person's withdrawal symptoms may get worse each time they stop drinking, and can cause symptoms such as tremors, agitation and convulsions (seizures).

Alcohol has a suppressing effect on the brain and central nervous system. Research has shown that when alcohol is removed from the body, it activates brain and nerve cells, resulting in excessive excitability (hyperexcitability). This can lead to behavioural symptoms such as seizures.

With each alcohol withdrawal episode, the brain and nervous system becomes more sensitised and the resulting side effects become more pronounced. This kindling effect can also occur following a chemical stimulus to the brain or body, such as an anti-convulsant medication.

Therefore, a person's alcohol withdrawal programme needs to be carefully planned and the effects closely monitored.

Read more about kindling in alcohol withdrawal (PDF, 163kb).

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Alcohol misuse

Treatment options for alcohol misuse depend on whether your drinking is hazardous, harmful or dependent, and whether you're trying to drink less or give up completely.

The treatment options for alcohol misuse depend on whether your drinking is hazardous, harmful or dependent, and whether you're trying to drink less or give up drinking completely.

Increased-risk (hazardous) drinking

If you're drinking hazardous amounts of alcohol, it's likely you'll be referred to a short counselling session, known as a brief intervention. This may be following an alcohol-related accident or injury.  

A brief intervention lasts about 10-15 minutes and covers risks associated with your pattern of drinking, advice about reducing the amount you drink, alcohol support networks available to you and any emotional issues around your drinking.

Keeping a 'drinking diary' may also be recommended so you can record how many units of alcohol you drink a week. You may also be given tips about social drinking, such as alternating soft drinks with alcoholic drinks, when you're out with friends.

Higher-risk (harmful) drinking

If you're drinking harmful amounts of alcohol, you will first need to decide whether you want to reduce your alcohol intake (moderation) or give up drinking alcohol altogether (abstinence).

Harmful drinking is drinking more than the recommended weekly amount of alcohol (21 units for men and 14 units for women) and experiencing health problems directly related to alcohol.

Abstinence will obviously have a greater health benefit, although moderation is often a more realistic goal, or at least a first step on the way to abstinence.

Ultimately, the choice is yours but there are circumstances where abstinence is strongly recommended, including if you:

  • have liver damage, such as liver disease or cirrhosis
  • have other medical problems, such as heart disease, that can be made worse by drinking
  • are taking medication that can react badly with alcohol, such as antipsychotics
  • are pregnant or planning to become pregnant

Abstinence may also be recommended if you have previously tried to achieve moderation and have been unsuccessful.

If you choose moderation, you will probably be asked to attend further counselling sessions so your progress can be assessed and further treatment and advice provided if necessary.

You may also have regular blood tests so the health of your liver can be carefully monitored.

Dependent drinking

If you're dependent on alcohol (you feel unable to function without it), you will also need to choose between moderation and abstinence. Abstinence is usually recommended for people with moderate to severe dependency.

Whatever your level of alcohol dependency, it's recommended you spend time free from alcohol to allow your body to recover from its effects.

Detoxification

How and where you attempt detoxification will be determined by your level of alcohol dependency. In mild cases you should be able to detox at home without the use of medication because your withdrawal symptoms should also be mild.

If your consumption of alcohol is high (over 20 units a day) or you've previously experienced withdrawal symptoms, you may also be able to detox at home with medication to help ease withdrawal symptoms. A tranquiliser called chlordiazepoxide is usually used for this purpose.

If your dependency is severe, you may need to go to a hospital or clinic to detox. This is because the withdrawal symptoms will also be severe and are likely to need specialist treatment.  

Withdrawal symptoms

Your withdrawal symptoms will be at their worst for the first 48 hours. They should gradually start to improve as your body begins to adjust to being without alcohol. This usually takes 3-7 days from the time of your last drink.

You will also find your sleep is disturbed. You may wake up several times during the night or have problems getting to sleep. This is to be expected and your sleep patterns should return to normal within a month.

During detox, make sure you drink plenty of fluids (about three litres a day). However, avoid drinking large amounts of caffeinated drinks, including tea and coffee, because they can make your sleep problems worse and cause feelings of anxiety. Water, squash or fruit juice are better choices.

Try to eat regular meals even if you're not feeling hungry. Your appetite will return gradually.

Avoid driving or operating heavy machinery if you're taking medication to help ease your withdrawal symptoms. This is because it's likely the medication will make you feel drowsy. Make sure you only take your medication as directed.

Detox can be a stressful time. Ways you can try to relieve stress include reading, listening to music, going for a walk and taking a bath. Read more about stress management.

If you're detoxing at home you will regularly see a nurse or another healthcare professional. This might be at home, at your GP practice, or at a specialist NHS service. You'll also be given the relevant contact details for other support services, should you need additional support.

Withdrawal from alcohol is an important first step to overcoming your alcohol-related problems. However, withdrawal is not an effective treatment by itself. You'll need to further treatment and support to help you in the long-term.

Abstinence

Several treatment options are available for abstinence. These often differ in effectiveness depending on the individual, so if you feel that a particular treatment isn't working for you, you can discuss alternatives with your GP or care team.

Medication

A number of medications are recommended by the National Institute for Health and Care Excellence (NICE) to treat alcohol misuse. The three main ones are:

These medications are discussed in more detail below.

Acamprosate

Acamprosate (brand name Campral) is used to help prevent a relapse in people who have successfully achieved abstinence from alcohol. It's usually used in combination with counselling.

Acamprosate works by affecting levels of a chemical in the brain called gamma-amino-butyric acid (GABA). GABA is thought to be partly responsible for inducing a craving for alcohol.

If you're prescribed acamprosate, the course will usually start as soon as you begin withdrawal from alcohol and can last for up to six months.

Disulfiram

Disulfiram (brand name Antabuse) can be used if you're trying to achieve abstinence but are concerned that you may relapse, or if you've had previous relapses.

Disulfiram works by deterring you from drinking by causing unpleasant physical reactions if you drink alcohol. These can include:

  • nausea
  • chest pain
  • vomiting
  • dizziness

As well as alcoholic drinks, it's important to avoid all sources of alcohol because they could also induce an unpleasant reaction. Products that may contain alcohol include:

  • aftershave
  • mouthwash
  • some types of vinegar
  • perfume

You should also try to avoid substances that give off alcoholic fumes, such as paint thinners and solvents.

You will continue to experience unpleasant reactions if you come into contact with alcohol for a week after you finish taking disulfiram, so it's important to maintain your abstinence during this time.

When taking disulfiram you'll be seen by your healthcare team about once every two weeks for the first two months, and then every month for the following four months.

Naltrexone

Like acamprosate, naltrexone can also be used to prevent a relapse or to limit the amount of alcohol someone drinks. It works by blocking the opioid receptors in the body, stopping the effects of alcohol. It's usually used in combination with other medicine or counselling.

If naltrexone is recommended, you should be made aware that it will also stop painkillers that contain opioids, such as morphine and codeine, from working.

If you feel unwell while taking naltrexone, stop the medication immediately and seek advice from your GP or care team.

A course of naltrexone can last up to six months although it may sometimes be longer.

Before being prescribed any type of medication to help treat alcohol misuse you'll have a full medical assessment which will include blood tests.

Counselling

Self-help groups

Many people who have alcohol dependency problems find it useful to attend self-help groups, such as Alcoholics Anonymous (AA).

One of the main beliefs behind AA is that alcoholic dependence is a long-term and progressive condition and that total abstinence is the only solution.

The treatment plan promoted by AA is based on a 12-step programme designed to help you overcome your addiction. It includes the steps listed below.

  • Admitting you're powerless over alcohol and your life has become unmanageable.
  • Recognising you need a power greater than yourself to restore your strength.
  • Examining past errors in your life with the help of a sponsor (an experienced member of the group).
  • Making amends for those errors.
  • Learning to live a new life with a new code of behaviour.
  • Helping others who are also dependent on alcohol.

Read more about alcohol support.

Twelve-step facilitation therapy

Twelve-step facilitation therapy is based on the programme devised by AA (see above). The difference is that you work through the stages on a one-to-one basis with a counsellor rather than in a group.

Twelve-step facilitation therapy may be your preferred treatment option if you feel uneasy or unwilling to discuss your problems in a group setting.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a talking therapy that uses a problem-solving approach to alcohol dependence.

CBT’s approach to alcohol dependence is to identify unhelpful and unrealistic thoughts and beliefs that may be contributing towards your alcohol dependence such as:

  • "I can't relax without alcohol."
  • "My friends would find me boring if I was sober."
  • "Just drinking one pint can’t hurt."

Once such thoughts and beliefs are identified, you'll be encouraged to base your behaviour on more realistic and helpful thoughts such as:

  • "Lots of people have a good time without alcohol and I can be one of them."
  • "My friends like me for my personality, not for my drinking." 
  • "I know I can't stop drinking once I start."

CBT also helps you to identify triggers that can cause you to drink such as:

  • stress
  • social anxiety
  • being in 'high-risk' environments, such pubs, clubs and restaurants

Your CBT therapist will teach you how to avoid certain triggers and how to cope effectively with those that are unavoidable.

Extended brief intervention

Extended brief intervention (EBI) is a one-to-one session with a healthcare professional, usually a doctor, nurse or counsellor. It takes the form of a motivational interviewing technique. The aim is to motivate people to change their behaviour by exploring with them why they drink in the way they do, and help them identify positive reasons for changing.

FRAMES is an acronym that’s often used to describe the components of a brief intervention. It stands for:

  • Feedback - on your risk of having alcohol problems
  • Responsibility - helping you take responsibility for change
  • Advice - providing clear advice when requested
  • Menu - explaining the options for change
  • Empathy - an approach that’s warm, reflective and understanding
  • Self-efficacy - helping you believe in your ability to change

Family therapy

Alcohol dependence doesn't just impact on an individual, it can also affect a whole family. Family therapy provides family members with the opportunity to:

  • learn about the nature of alcohol dependence
  • support the member of the family who is trying to abstain from alcohol

Support is also available for family members in their own right. Living with someone who misuses alcohol can be stressful, so receiving support can often be very helpful.

There are a number of specialist alcohol services that provide help and support for the relatives and friends of people with a dependence on alcohol.

For example, AlAnon is an organisation affiliated to AA and provides relatives and friends with help and support. Their confidential helpline number is 020 7403 0888 (10am-10pm, 365 days a year).

Read more about the different types of talking therapies.

For further information, see the latest NICE guidance about the diagnosis, assessment and management of harmful drinking and alcohol dependence (PDF, 2.72MB).

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