NICE NG248: what to ask, when to refer, what to offer

A patient mentions debt in passing. Another has been relapsing for three months and you did not know, because nobody asked. NG248 is the document that converts both of those moments from clinical instinct into a stated procedure, and it does so without inflating the category it is describing.

The two numbers that set the frame

The guideline's Context chapter opens with figures from the Gambling Survey for Great Britain (2023), and they cut in both directions at once. 2.5% of the population aged 18 and over score 8 or more on the Problem Gambling Severity Index, the threshold NICE treats as problem gambling. A further 12% gamble at what the survey calls elevated risk of harm, scoring 1 to 7. That second band is the one most often misquoted. It is a risk gradient, not a diagnosis, and NG248 does not treat it as one.

The other figures are there to stop the first band being waved away. The Office for Health Improvement and Disparities estimates between 117 and 496 suicides a year in England associated with problem gambling or gambling disorder, and puts the excess cost to the NHS, the wider public sector and society at between £1.05 and £1.77 billion annually at 2021 to 2022 prices. An estimated 7% of the population of Great Britain, some 3.8 million adults, children and young people, are affected others who have personally felt the consequences of someone else's gambling, a figure NICE itself flags as an estimate drawn from studies using varied methods. NHS provision now stands at 15 specialist gambling treatment clinics.

Recommendation 1.1.11 is the one to read twice. Gambling and gambling-related harms can be a dominant risk factor for suicidal ideation and suicide attempts even in the absence of other risk factors. Recommendation 1.1.13 adds that the risk may be highest immediately after a gambling episode.

The treatment ladder, with doses

Section 1.5 is unusually specific for a guideline of this kind. Group CBT is offered first, to reduce gambling severity and frequency, started as soon as possible after diagnosis (1.5.13). Individual CBT is offered if the person does not want a group, if no suitable group can be formed, or if a group is judged unsuitable (1.5.14). The course is defined: usually 8 to 10 sessions for group therapy and 6 to 8 for individual therapy, delivered against evidence-based protocols, always including a relapse-prevention component (1.5.15). Motivational interviewing is a "consider" for people hesitant about starting (1.5.12), and peer support is offered as an integral part of care rather than an afterthought (1.5.11).

Pharmacology sits below psychotherapy, not beside it. Naltrexone is a "consider" only where an adequate course of psychological therapy has not achieved the desired outcome or relapses have repeated (1.5.16), started by or under the supervision of a specialist (1.5.17), with a stated regimen of 25 mg once daily for 3 days then 50 mg once daily for 4 to 6 months, and checks on renal and hepatic function and on concurrent opioid use before starting (1.5.19). NICE records that in January 2025 this was an off-label use.

One recommendation has no clinical dose at all and is arguably the sharpest in the document. Recommendation 1.3.5 states that gambling treatment and support services should be commissioned and provided without influence or involvement from the gambling industry, with no conflicts of interest between commissioners, providers and the industry.

How to use it this week

The cheapest transferable instruction comes in two strengths, and the difference between them matters. Recommendation 1.1.2 says to consider asking about gambling in the same breath as smoking, alcohol and other substances, as part of a routine health check or intake, even where there is no obvious risk factor. Recommendation 1.1.3 is the stronger of the pair and does not hedge: ask. It lists the presentations that make the question obligatory regardless of anything else in the picture: mental health presentations including self-harm and suicidal thoughts, depression, anxiety, psychosis, bipolar disorder, PTSD, personality disorder and ADHD; medicines affecting impulse control such as dopamine agonists in Parkinson's disease or aripiprazole; alcohol or substance dependence, especially cocaine; homelessness; disclosed financial concerns; safeguarding or domestic abuse concerns; a family history of gambling that harms. Recommendation 1.1.6 supplies the wording, and it is deliberately blunt: "Do you gamble?" or "Are you worried about your own or another person's gambling?".

Recommendation 1.1.14 is the practical one to have ready before you need it: blocking software for online gambling, blocking marketing messages, self-exclusion schemes for casinos, arcades and betting shops, bank-level gambling payment blocks, and agreed limits on access to money, including a family member holding finances. These are not UK-specific in principle, even where the named schemes are.

Read the organisational sections with a filter. The NHS triage route, the statutory levy and the 15 clinics describe one country's plumbing. The clinical spine, ask routinely, grade by severity including PGSI score where available, agree an aim that is typically abstinence, offer group CBT of defined length with relapse prevention, escalate to naltrexone only after psychotherapy has been given a fair trial, is portable. Open it this week if you have a patient whose finances, mood and relationship troubles have never been formally connected, and go to sections 1.1 and 1.5 first.