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BNSSG Adult Joint Formulary

4.8 Substance dependence

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Last edited: 11-04-2024

4.8.1 Alcohol dependence

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

Aldehyde Dehydrogenase Inhibitors

Disulfiram (TLS Blue)

Should only be used in patients in whom naltrexone or acamprosate are not suitable
Used as an adjunct in treatment of alcohol dependence under specialist supervision

Gamma-Aminobutyric Acid Analogues and Derivatives

Acamprosate (TLS Blue)

Acamprosate is indicated as therapy to maintain abstinence in alcohol-dependent patients and should be prescribed for up to 6 months with supportive counselling.
Prescribing can be initiated by a GP either as part of a primary care alcohol detox pathway or following the advice of a Specialist. Prescribing should be continued in primary care once initiated by a Specialist. Detailed advice will be provided where appropriate.

Opioid receptor Antagonists

Nalmefene (TLS Red)

South Gloucestershire and North Somerset

Nalmefene (TLS Amber Specialist Recommended) (Prescribing guidance click here)

Bristol
Nalmefene should only be initiated after assessment by a specialist primary care alcohol service
In accordance with NICE TA325, and as an option for patients who:

Are still drinking more than 7.5 units per day (for men) and more than 5 units per day (for women) 2 weeks after an initial assessment and
Do not have physical withdrawal symptoms and
Do not need to either stop drinking straight away or stop drinking completely

Nalmefene should only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption and be initiated only in patients who continue to have a high drinking risk level 2 weeks after initial assessment. A prescription should not be issued without this additional support in place

Naltrexone (TLS Amber 1 month) (SCP click here)

Specialist initiation only
Used in conjunction with the Naltrexone (oral) for Alcohol Shared Care Treatment Pathway (AWP)

Benzodiazepines for Alcohol Withdrawal

See BNSSG Remedy page Alcohol Misuse for further information, including information on Detox in Primary Care

Chlordiazepoxide (TLS Green)

Specific patients:

For patients with renal dysfunction or decompensated liver disease

Lorazepam (TLS Blue)

Oxazepam (TLS Blue)

4.8.2 Nicotine dependence

Nicotine Receptor Agonists

Recommended: (TLS Green)

Nicotine replacement therapy

Please see the Nicotine Replacement Therapy Clinical Guideline

Varenicline

For primary care initiation only
See NICE guidance TA123 - Varenicline for smoking cessation
See NICE guideline NG92

Serotonin and Noradrenaline Re-uptake Inhibitors

Bupropion Hydrochloride

For primary care initiation only

4.8.3 Opioid dependence

Recommended: (TLS Green)

Methadone

As part of a shared care substance misuse management scheme

Buprenorphine sublingual

Espranor^®

NBT - when prescribing methadone or buprenorphine please refer to the pain team for the management of substance misusers

Alternatives:

Lofexidine (TLS Blue)

To support opioid detoxification in specific patients

Naltrexone (TLS Amber 1 month) (SCP Click here)

Used as an adjunct to detox from opiates under specialist supervision
NICE TA115 naltrexone for the management of opioid dependence

Benzodiazepine Dependence

See BNSSG Benzodiazepine and Z-drug Prescribing (including withdrawal) Support Document

Diazepam (TLS Green)

Benzodiazepine withdrawal

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