OBJECTIVE To assess the value of opportunistic screening in Accident and Emergency (A&E) for patients with alcohol-related problems and provision of an intervention. METHODS Screening of A&E attendees for the purpose of recruitment to a randomized trial of a counselling intervention. METHODS A General Hospital A&E department. METHODS All 17,000 adult A&E attendees, during a 6-month period and all nursing staff working within the department. METHODS Patients' self-reported alcohol consumption, responses to the CAGE questionnaire (four questions designed to identify problem drinking) and proportions offered, and taking up offer of help. RESULTS Only 4663 (28%) adult attendees at A&E were actually screened and of these 2% declined and 25% were judged unable to answer. Of the rest, 86% drank alcohol, with 22% drinking in excess of current guidelines or with two or more positive answers to CAGE. Only 41% (264) of those drinking to excess were offered help and 88% of these declined it. This left 13 patients to be included in the trial. CONCLUSIONS There is a significant need for an effective intervention in this area but considerable barriers exist to testing the efficacy of potential screening strategies and interventions.