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BNSSG Adult Joint Formulary

4.8 Substance dependence

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)


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



Serotonin and Noradrenaline Re-uptake Inhibitors

Bupropion Hydrochloride

  • For primary care initiation only


4.8.3 Opioid dependence


Recommended: (TLS Green)


  • As part of a shared care substance misuse management scheme

Buprenorphine sublingual


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


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

Diazepam (TLS Green)

  • Benzodiazepine withdrawal


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