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.

East Lancashire Stop Smoking Service can be contacted on 0800 328 6297 or visit the NHS Quit Squad

Patients can self-refer directly to a stop smoking service provider <click here>

For Blackburn with Darwen contact Blackburn with Darwen Stop Smoking Service.

T: 01254 682037 E: quitsmoking@blackburn.gov.uk

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 Please note: Varenicline (Champix®) 0.5mg and 1mg tablets are unavailable until further notice - see position statement

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’

Prescribing should only be initiated on the direct advice of a smoking cessation adviser and should be linked to specialist

behavioural management support.

Please note: Varenicline (Champix®) 0.5mg and 1mg tablets are unavailable until further notice - see position statement

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