Protocol · WHO mhGAP
Harmful alcohol use (mhGAP)
Ask every adult about alcohol, without judging. A short, respectful conversation helps many people cut down. Dependence needs a plan for safe withdrawal, because stopping suddenly can cause fits and delirium. Thiamine protects the brain; diazepam treats withdrawal; follow-up and support prevent relapse.
- Based on WHO mhGAP
- For doctors, clinical officers, nurses and trained community workers
- Reviewed October 2026
1Who / when
- Ask every adult about tobacco and alcohol, whatever the reason for the visit.
- Look harder with: smell of alcohol, slurred speech, injuries, liver disease (jaundice, enlarged tender liver, swollen abdomen, spider naevi), unsteady walking, high MCV or low platelets, problems at home or work.
2Red flags: refer now
- Severe intoxication: drowsy or unresponsive, slow breathing. Check airway, breathing and glucose; lay on side; nothing by mouth; consider opioids or head injury.
- Withdrawal with seizures or delirium (confusion, hallucinations, agitation), usually within a week of the last drink.
- Wernicke encephalopathy: confusion with abnormal eye movements or unsteadiness after heavy drinking.
- Gastrointestinal bleeding, liver failure (confusion, jaundice), or head injury.
- Suicidal thoughts during or after intoxication or withdrawal.
Seizures, delirium or Wernicke: treat and transferGive diazepam 10 to 20 mg (by mouth, IV or rectally) for seizures or delirium, give thiamine, and transfer to hospital. Delirium not settling with diazepam: haloperidol 1 to 2.5 mg by mouth or IM.
3Assess
- How often do you drink, and how much on a typical day?
- Harm: injuries, accidents, drink-driving, violence, relationship, money or legal problems, risky sex, poor work or parenting.
- Dependence features: difficulty controlling drinking despite harm; tolerance; withdrawal when stopping; frequent heavy use; strong craving. A pattern of more than 6 standard drinks at a time, every day, suggests dependence.
- Withdrawal risk if stopping: past severe withdrawal, fits or delirium; withdrawal starting within 6 hours of the last drink; other serious illness; failed attempts at home; no social support.
- Mental health: depression, anxiety, suicide risk. Physical health: liver, BP, TB risk, injuries.
4Classify
| Picture | Classify as | Action |
|---|---|---|
| Fits, delirium, Wernicke signs, bleeding, very drowsy | Alcohol emergency | Treat and transfer |
| Tremor, sweating, vomiting, fast pulse, high BP after stopping | Alcohol withdrawal | Diazepam and thiamine; transfer if severe or high risk |
| Features of dependence | Alcohol dependence | Planned withdrawal; relapse prevention |
| Drinking is causing harm, no dependence | Harmful use | Brief intervention; follow up in 1 month |
| No harm, no dependence | Lower-risk use | Brief advice on health benefits of not drinking |
5Treat
Harmful use: brief intervention (motivational interviewing)
- Give personal feedback on the harm their drinking is causing.
- Ask how concerned they are, and their reasons for drinking; avoid arguing or lecturing.
- Advise stopping or cutting to a non-harmful level; ask if they are ready, and offer support.
- Plan: identify triggers and emotional cues, do not keep alcohol at home; address food, housing and work needs.
Dependence
- Thiamine 100 mg by mouth daily for everyone with chronic heavy drinking. Give thiamine before glucose.
- Planned withdrawal: diazepam up to 40 mg a day by mouth (10 mg four times a day or 20 mg twice a day) for 3 to 7 days, reducing as symptoms settle. Liver disease or older people: start with a single 5 to 10 mg dose. Inpatient withdrawal if risk is high.
- Keep hydrated; quiet, well-lit surroundings; watch for depression and suicide risk.
- Combine psychosocial support (structured programmes, mutual-help groups such as Alcoholics Anonymous) with medicine where possible.
- Relapse prevention: acamprosate, naltrexone or disulfiram (mhGAP-IG); baclofen after detoxification (WHO 2023), best started by a specialist. Dose per national formulary.
PregnancyAvoid alcohol completely in pregnancy and when breastfeeding; even small amounts early in pregnancy can harm the baby. Offer extra support to mothers with young children.
6Follow-up
- Harmful use: review in 1 month, then as needed.
- Dependence: several times a week for the first 2 weeks, then weekly for the first month, then monthly.
- Each visit: amount and frequency, mental and physical health, supports; positive feedback for any progress.
7Counsel
- Not drinking is the healthiest choice; cutting down still helps.
- Do not stop suddenly if you drink heavily every day: plan it with the clinic, because withdrawal can cause fits.
- Do not drive after drinking. Eat regularly.
- Families can get support too; tell them where help is available.
From what you have told me, alcohol is starting to harm your health. What do you think about cutting down? I can help you make a plan.
8When to refer
- Same day: any red flag; severe withdrawal; withdrawal with other serious illness.
- Planned withdrawal with high-risk features (past fits or delirium, early withdrawal, no support): inpatient detoxification.
- Not responding to brief interventions; needs a structured treatment programme.
- Pregnant women with dependence; adolescents.
9Sources
- World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016 (ISBN 9789241549790). Substance use module (SUB emergency, SUB 1 to 3), alcohol withdrawal protocol and relapse-prevention table.
- World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023 (ISBN 9789240084278). Recommendations ALC1 to ALC4.
- World Health Organization. WHO Model List of Essential Medicines. 2025.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.