ELMMB logo
Facebook logo Twitter logo
Menu
4.10 Drugs used in substance dependence

4.10 Drugs used in substance dependence

Alcohol dependence

Acamprosate should only be initiated following advice from the drug and alcohol team, or other specialist.
AMBER        Acamprosate tablets e/c 333mg 
 
Nalmefene NICE TAG325
To be supplied via a locally commissioned specialist service in conjunction with continuos psychosocial support. 
RED             Nalmefene  tablets f/c 18mg 
 
Disulfiram is used as an adjunct in the treatment of alcohol dependence  (under specialist supervision)
AMBER       Disulfiram tablets 200mg  
 
Chlordiazepoxide is used in treatment of alcohol withdrawal by Specialist Service only 
RED            Chlordiazepoxide capsules 5mg, 10mg 
 
 
Nicotine Replacement Therapy (NRT) 
NRT should not be prescribed by GPs. 
 
Individuals  wishing to stop smoking should be referred to a local stop smoking service.
Click here to access the Position Statement on GP Prescribing of NRT 
RED              Nicotine replacement therapy 
 
Bupropion 
Bupropion (Zyban®) is contra-indicated in patients with a history of seizures or of eating disorders, or who are experiencing acute
withdrawal from alcohol or benzodiazepines. Refer to prescribing information for full contra-indications and interactions. Use in
line with NICE guidance. 
GREEN      Bupropion tablets m/r 150mg 
 
Varenicline 
Varenicline should only be prescribed on the direct advice of a smoking cessation adviser.  
 
       >      Patients presenting to their GP requesting varenicline should be referred to a smoking cessation adviser to help the 
               patient choose  the most appropriate smoking cessation product. This may not be varenicline.
       >      Varenicline should be used where the use of nicotine replacement therapy (NRT)  is not tolerated, ineffective or 
               inappropriate. Varenicline has not been  compared with NRT, although it has been shown to be superior to bupropion 
               (Zyban®).
       >      Smoking cessation, with or without pharmacotherapy, has been associated with the exacerbation of underlying 
               psychiatric illness (e.g. depression). Care should be taken with patients with a history of psychiatric illness and patients 
               should be advised accordingly.
       >      There is no clinical experience with varenicline in patients with epilepsy. Patients should be advised of this, and explicit
               consent should be obtained if they wish to receive varenicline. 
       >      Varenicline should only be used within its licensed indications, and prescribed for smokers who commit to a target stop
               date and who smoke >10 cigarettes (or equivalent) per day.
       >      The smoker should be offered regular follow up and advice to aid smoking cessation at least 2 weekly  intervals through
               the smoking cessation service.
       >      An initial supply should be for 2 weeks using the ‘starter pack’.  This can then be followed up by a second 2 week supply 
               at the full dose.  A third and fourth prescription of 4 weeks supply should be issued only if the smoker demonstrates a 
               continuing attempt to stop smoking. The GP will be contacted at these points to confirm that these further
               prescriptions should be issued and that the patient is still being followed up by the  smoking cessation service.
       >      Patients should only be treated for an initial 12 week course of varenicline until further NICE guidance on the cost-
               effectiveness of an additional 12 weeks treatment is available. In addition, there are no current criteria to select which 
               patients should receive an additional 12 weeks therapy. 
       >      At the end of therapy patients should be advised to taper the dose rather than abruptly stop therapy, as there is some 
               evidence of an increase in smoking rates and withdrawal symptoms following abrupt withdrawal.
       >      For example, instead of the last week of 1mg twice daily dosing, this could be decreased to 0.5mg twice daily for two 
               weeks, then stop. [This regime is not based on trial data, but on pharmacokinetics]
       >      The concomitant use of varenicline and NRT after the quit date is not recommended. 
 
 
MHRA Advice for healthcare professionals:
       >      Patients and their family or care-givers should be made aware of the possibility that trying to stop smoking might cause 
               symptoms of depression.
       >      Patients who are taking varenicline who develop suicidal thoughts or behaviour should stop their treatment and contact 
               their doctor immediately.
       >      Varenicline should be discontinued immediately if agitation, depressed mood, or changes in behaviour are observed that
               are of concern for the doctor, patient, family or care-giver.
       >      Patients with serious psychiatric illness did not participate in the premarketing studies of varenicline, and the safety and 
               efficacy of varenicline in such patients has not been established. Care should be taken when prescribing varenicline to 
               patients who have a history of psychiatric illness.
 
GREEN      Varenicline tablets 0.5mg, 1mg and ‘starter pack’

Opioid dependence 
These products should only be initiated following advice from the drug and alcohol team, or other specialist. 
CSM Advice - As a result of reports linking methadone and the risk of QT interval prolongation prescribers are advised
                         to carefully monitor the following patients whilst taking methadone:
 
                         >    Patients with heart or liver disease
                         >    Patients with electrolyte abnormalities
                         >    Patients receiving concomitant treatment with CYP 3A4 inhibitors (eg macrolides,  azole antifungals, diltiazem, 
                               verapamil and some anti-HIV protease inhibitors)
                         >    Concomitant treatment with drugs which cause QT interval prolongation
                         >    Patients requiring more than 100mg methadone per day
AMBER      Methadone (see section 4.7.2 for use in analgesia) 
                   mixture 1mg/mL
                   mixture 1mg/mL S/F (sugar free)
                   oral concentrate 10mg/mL, 20mg/mL (care in prescribing and dispensing due to different  strengths – only 
                   dispense after further diluting with  Methadose® diluent)
RED            Injection 50mg/2ml, 50mg/mL
RED            Tablets  5mg          
 
AMBER      Buprenorphine (see section 4.7.2 for differing product used in analgesia) 
                   sublingual tablets 400microgram, 2mg, 8mg.      
RED            Buprenorphine oral lyophilisate 2mg, 8mg (Specialist Substance Misuse service only)
AMBER      Lofexidine tablets 200 microgram
AMBER      Naltrexone  tablets 50mg 

 
 
 
 
 
 
 
 
 
All material in this section is aimed at health care professionals, but is information currently held in the public domain, members of the 
 public seeking advice on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service.
 Email: info.elmmb@nhs.net
 Copyright© 2016 East Lancashire Medicines Management Board  
 All rights reserved.  Disclaimer/Terms and conditions