Alcohol use disorder: the AU general practice approach

Alcohol use disorder is the most common substance use disorder seen in Australian general practice. Approximately 5% of Australian adults meet criteria for AUD in any 12-month period, and around 25% drink at risky or harmful levels above NHMRC guidelines. Alcohol is responsible for approximately 6,000 deaths and 150,000 hospitalisations in Australia each year, and contributes to around 5% of the total disease burden — through cardiovascular disease, liver disease, seven types of cancer (breast, oral cavity, oropharynx, oesophagus, colon, rectum, and hepatocellular), mental health disorders, injury, and fetal alcohol spectrum disorder.

Despite this burden, AUD is substantially undertreated. Most people with AUD do not receive guideline-concordant pharmacotherapy, and fewer still are offered structured psychological support. General practitioners are positioned to identify risky drinking, deliver brief interventions, and initiate pharmacotherapy — the same role they play in managing hypertension or type 2 diabetes.

The fundamental framing shift: AUD is a chronic relapsing medical condition, not a moral failing. Set-point-like neurobiological adaptations in the dopamine reward pathway and prefrontal cortex drive cravings and impaired control. Acknowledging this with patients reduces shame and improves engagement with treatment.

A. Core clinical — the AU general-practice framework

NHMRC guidelines and standard drink definition

The NHMRC Australian Alcohol Guidelines 2020 define low-risk drinking as no more than 10 standard drinks per week and no more than 4 on any single day. One Australian standard drink = 10 g ethanol — roughly 285 mL full-strength beer (4.8%), 100 mL wine (12.5%), or 30 mL spirits.

The guidelines make clear that no level is safe in pregnancy, breastfeeding, under 18, or when operating machinery or driving. Any amount carries some risk; risk increases with consumption in a dose-response fashion.

Screening

Validated screening tools per the Australian Guidelines for the Treatment of Alcohol Problems (RACP):

• AUDIT-C (3 questions) — quick screen; positive ≥4 in men, ≥3 in women
• AUDIT (10 questions) — full assessment; ≥8 = harmful drinking, ≥15 = likely AUD
• ASSIST — multi-substance screen useful in complex presentations
• CIWA-Ar — quantifies withdrawal severity; ≥10 = moderate, ≥20 = severe

Brief integration of AUDIT-C into standard preventive consultations (health assessments, chronic disease reviews) substantially improves detection rates.

DSM-5 diagnostic criteria

AUD requires ≥2 of 11 criteria over a 12-month period:

1. Drinking more or longer than intended
2. Unsuccessful efforts to cut down or control use
3. Much time spent obtaining, using, or recovering
4. Craving
5. Failure to fulfil major obligations (work, home, study)
6. Continued use despite social or interpersonal problems caused or worsened by alcohol
7. Important activities given up or reduced because of alcohol
8. Use in physically hazardous situations
9. Continued use despite known physical or psychological harm
10. Tolerance (need for markedly more to achieve the same effect)
11. Withdrawal (characteristic syndrome when stopping, or use to avoid withdrawal)

Severity: mild 2–3 criteria, moderate 4–5, severe ≥6.

History and clinical assessment

A thorough history includes: drinking pattern (quantity, frequency, type, setting), duration of problematic use, prior attempts to cut down and what happened, withdrawal history (prior seizures, delirium tremens, prior detoxifications), medical complications (liver disease, pancreatitis, peripheral neuropathy, cardiovascular effects), mental health comorbidity (depression, anxiety, PTSD, bipolar disorder, suicidality), concurrent substance use (benzodiazepines, opioids, cannabis, tobacco — polydrug use changes withdrawal risk and management), social circumstances (employment, housing, relationships, legal history including driving offences), pregnancy and contraception, domestic violence history (alcohol is a factor in approximately 50% of partner violence episodes — routine sensitive inquiry is warranted, with 1800RESPECT as the referral pathway).

Examination should include vital signs (elevated pulse and blood pressure signal early withdrawal in dependent patients), nutritional status, signs of liver disease (jaundice, ascites, hepatomegaly, spider naevi, palmar erythema, Dupuytren’s contracture, gynaecomastia), neurological signs (tremor, peripheral neuropathy, cognitive screen for Korsakoff features), and cardiovascular assessment.

Investigations per eTG Addiction:

• FBC — macrocytosis (MCV >100 fL) is a chronic alcohol marker
• LFTs — AST:ALT ratio >2:1 suggests alcoholic hepatitis; GGT elevated in heavy drinking
• UEC (sodium, potassium — hyponatraemia, hypokalaemia common)
• Coagulation — INR elevated in significant liver disease
• Lipase, glucose
• B12, folate, vitamin D, iron studies — nutritional deficiencies common
• Magnesium and phosphate — important in withdrawal management
• Liver disease screening: ultrasound, FibroScan, APRI or FIB-4, hepatitis B and C serology
• ECG — alcoholic cardiomyopathy; arrhythmias (atrial fibrillation)
• Urine drug screen — concurrent substance use
• Pregnancy test in women of reproductive age

B. Pharmacotherapy for alcohol use disorder

All three first-line agents are available in Australia per AMH and eTG Addiction:

Naltrexone

50 mg daily orally (or 380 mg extended-release injection monthly — not PBS-listed in AU). Mechanism: mu-opioid receptor antagonist — blocks the rewarding and euphoric effects of alcohol, reducing craving and the number of heavy drinking days.

PBS Authority Required for AUD — requires documented DSM-5 AUD diagnosis and patient motivated to reduce or abstain. Monitoring: LFTs at baseline and periodically — hepatotoxicity can occur at high doses; dose reduction if LFTs >3–5× upper limit of normal. Do not use in patients currently taking opioids — will precipitate acute opioid withdrawal.

NPS MedicineWise notes that naltrexone is most effective when combined with psychosocial support rather than used in isolation.

Acamprosate

666 mg three times daily (333 mg TDS if weight under 60 kg). Mechanism: NMDA receptor modulation, reducing excitatory neurotransmission during sustained abstinence — targets withdrawal-related craving particularly in the first weeks to months of abstinence.

PBS Authority Required for AUD. Safe in liver disease (not hepatically metabolised — renally excreted). Common adverse effects: diarrhoea, nausea (usually transient). Acamprosate works best when started soon after withdrawal completion and continued for 12 months or longer.

Disulfiram

200 mg daily orally. Mechanism: inhibits aldehyde dehydrogenase, causing acetaldehyde accumulation when alcohol is consumed — producing flushing, nausea, vomiting, and hypotension. The aversive reaction creates a pharmacological deterrent.

Best reserved for highly motivated patients or when supervised by a spouse or clinic (adherence is the limiting factor). Counsel patients thoroughly about reactions with alcohol-containing products (mouthwash, cooking wine, some medications). Monitor LFTs. Not first-line for patients with cardiovascular disease, psychosis, or severe liver disease.

Off-label options

Baclofen (GABA-B agonist, 30–80 mg/day) — evidence primarily from European specialist settings; particularly useful in patients with cirrhosis or significant liver disease where naltrexone is relatively contraindicated. Sedation at higher doses.

Topiramate (25 mg titrating to ~200 mg/day) — emerging evidence base; reduces heavy drinking days; cognitive and weight-loss side effects limit tolerability.

C. Withdrawal management

Alcohol withdrawal is the primary medical risk in AUD. The physiological mechanism: prolonged heavy drinking upregulates excitatory NMDA receptors and downregulates inhibitory GABA-A receptors; abrupt cessation removes the sedative effect of alcohol, leaving an unbalanced, hyperexcitable CNS.

Timeline: symptoms begin 6–24 hours after last drink; seizures typically 12–48 hours; delirium tremens (DTs) 48–96 hours. Mortality of untreated severe withdrawal or DTs: 5–15%.

Risk stratification for withdrawal setting per Australian Treatment Guidelines:

• Low risk (CIWA-Ar under 10, no prior seizures or DTs, supports available) — outpatient diazepam-assisted withdrawal with daily prescription, daily reviews, and safety-netting
• Moderate-severe risk (CIWA-Ar ≥10, history of withdrawal seizures or DTs, poor supports, significant comorbidities) — inpatient setting with IV fluids, benzodiazepine taper, electrolyte correction, and parenteral thiamine

Thiamine — non-negotiable: parenteral thiamine must be given before any glucose-containing fluid in at-risk patients. Thiamine deficiency (very common in heavy drinkers through inadequate diet and impaired absorption) combined with a glucose load can precipitate Wernicke encephalopathy — ophthalmoplegia, ataxia, and confusion. Most cases present incompletely; if in doubt, give thiamine parenterally. Standard regimen: thiamine 100–300 mg IM or IV daily for 3–5 days, then oral 100 mg TDS.

Outpatient diazepam taper (mild withdrawal) — example per eTG: diazepam 20 mg four times daily on day 1, reducing by 5 mg per dose per day over 4–7 days, titrated to symptom severity. Issue prescriptions daily only — do not provide a week’s supply. SafeScript real-time prescription monitoring applies to diazepam in Victoria and is available in most states. Lorazepam is preferred in severe liver disease (not hepatically metabolised).

Alcohol-related withdrawal seizure — a single uncomplicated seizure during alcohol withdrawal usually does not require ongoing antiepileptic treatment; benzodiazepine loading is the priority. Brain imaging and EEG should be considered to exclude an independent seizure focus.

Delirium tremens — high-dose benzodiazepine, IV fluids and electrolyte correction (particularly magnesium and phosphate), thiamine, close monitoring (ICU level), and psychiatric consult if needed.

D. Australian operations

Brief intervention (5As)

The 5As framework from the Australian Treatment Guidelines applies to all patients with risky or hazardous drinking identified through screening:

1. Ask — assess drinking in standard drinks
2. Assess — compare to NHMRC guidelines; quantify severity
3. Advise — give clear, personalised, non-judgemental advice to reduce or cease
4. Assist — provide self-help resources (DrinkWise, Hello Sunday Morning), initiate pharmacotherapy where appropriate, arrange referral
5. Arrange — schedule follow-up; coordinate with allied health or specialist services

MBS billing pathways

Standard GP consultations (items 23/36/44) — for assessment, brief intervention, and prescribing.

Mental Health Care Plan (MHCP) — items 2715/2717 — for AUD with comorbid depression, anxiety, PTSD, or other mental illness; 10 subsidised psychology sessions per year under Better Access.

GP Chronic Condition Management Plans (GPCCMP) — items 965 and 967 — applicable for AUD as a chronic condition; allied health referral including psychologist, social worker.

Health assessments — Aboriginal and Torres Strait Islander Health Assessment (715), 45–49 health assessment (701), 75+ health assessment (705) — all include alcohol screening.

PBS medications

Naltrexone 50 mg tablets and acamprosate 333 mg tablets are both PBS Authority Required (Streamlined) for AUD with documented DSM-5 diagnosis. Disulfiram 200 mg is general schedule. Diazepam and oxazepam for withdrawal are general schedule with quantity restrictions under SafeScript monitoring. High-potency IV thiamine (Pabrinex) is an S100 hospital medication — not suitable for outpatient prescribing.

State alcohol and drug services

State-funded AOD services provide telephone counselling, outpatient treatment, residential rehabilitation, and supervised withdrawal. Key numbers: DirectLine (Vic) 1800 888 236, ADIS (NSW) 1800 250 015, National AOD Hotline 1800 250 015. The Counselling Online service provides free text and video counselling nationally.

E. Special populations

Pregnancy — there is no safe level of alcohol in pregnancy. Fetal alcohol spectrum disorder (FASD) is entirely preventable through abstinence. Hospital-based supervised withdrawal is preferred in pregnant patients with physical dependence. Naltrexone and acamprosate have limited pregnancy safety data — specialist perinatal addiction input is essential. 1800RESPECT should be offered alongside AUD support if domestic violence is a co-occurring factor.

Older adults — alcohol sensitivity increases with age: smaller body water volume raises blood alcohol concentration, and liver metabolism slows. AUD in older adults is often underpinned by social isolation, bereavement, retirement, or undertreated pain or depression. Withdrawal seizure risk is higher. Pharmacotherapy doses should be reduced; fall risk assessment is essential.

Aboriginal and Torres Strait Islander Australians — AUD disproportionately affects ATSI communities, driven by historical trauma, social disadvantage, and restricted access to culturally safe services. Community-controlled health organisations (ACCHOs) are the preferred and most effective care setting. The 715 ATSI Health Assessment includes alcohol screening. Programs based in country and culturally safe approaches improve engagement.

Comorbid mental health — depression, anxiety disorders, PTSD, and bipolar disorder co-occur with AUD at high rates. Concurrent treatment of both conditions produces better outcomes than sequential treatment. SSRIs (sertraline first-line) are safe with naltrexone and acamprosate. If PTSD is driving alcohol use, trauma-focused therapies alongside AUD treatment outperform AUD treatment alone. Screen carefully for suicidality — AUD substantially elevates suicide risk.

Liver disease — significant liver dysfunction requires modification of management: acamprosate (renally cleared) or baclofen preferred over naltrexone; lorazepam instead of diazepam for withdrawal. Hepatitis B and C vaccination should be offered to non-immune patients with cirrhosis. HCC surveillance with six-monthly ultrasound is appropriate in compensated cirrhosis.

Concurrent benzodiazepine or opioid use — polydrug use substantially increases overdose risk. SafeScript real-time prescription monitoring should be used before prescribing any controlled substance. Motivational interviewing and harm reduction — rather than punitive approaches — are more effective in this group.

When to escalate

Refer or escalate urgently when:

• Signs of impending or active withdrawal in a dependent patient — tremor, sweating, agitation, tachycardia in a patient who has recently stopped or significantly reduced drinking
• Suspected or active delirium tremens — agitation, hallucinations, fever, autonomic instability — call 000
• Wernicke encephalopathy triad: ophthalmoplegia, ataxia, confusion — IV thiamine and emergency referral
• Suspected alcoholic hepatitis (jaundice, elevated bilirubin, Maddrey score ≥32) — gastroenterology urgent
• Active oesophageal variceal haemorrhage or hepatic encephalopathy — emergency department
• Suicidal ideation — crisis intervention; Lifeline 13 11 14
• Severe AUD with complex psychiatric comorbidity — dual-diagnosis service or consultation-liaison psychiatry
• Pregnancy with AUD — perinatal addiction medicine
• Paediatric presentation — child and adolescent mental health services, child protection notification where required

What this article is and is not

This is general health information based on current Australian evidence and guidelines — NHMRC Australian Alcohol Guidelines 2020, Australian Guidelines for the Treatment of Alcohol Problems (RACP), eTG Addiction, and AMH. It is not personal medical advice and does not create a doctor–patient relationship. AUD treatment involves careful clinical assessment of individual circumstances, including physical dependence, comorbidities, and social factors — decisions about specific treatments are made with your own GP and treating clinicians.

For Australian support: Hello Sunday Morning Daybreak app, DrinkWise, Counselling Online, AA Australia, SMART Recovery Australia, HealthDirect — Alcohol.

For crisis: Lifeline 13 11 14, National AOD Hotline 1800 250 015, 000 for acute medical emergency.

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Sources cited

1. Australian Guidelines for the Treatment of Alcohol Problems (RACP)
2. NHMRC Australian Alcohol Guidelines 2020
3. Therapeutic Guidelines (eTG) — Addiction
4. Australian Medicines Handbook
5. NPS MedicineWise
6. Hello Sunday Morning — Daybreak
7. DrinkWise Australia
8. Counselling Online
9. AA Australia
10. SMART Recovery Australia
11. HealthDirect — Alcohol
12. Better Health Channel — Alcohol
13. 1800RESPECT
14. SafeScript — Real-time prescription monitoring