Methadone hydrochloride p. 502 or buprenorphine p. 447
withdrawal occurs later, with longer-lasting symptoms.
Methadone hydrochloride and buprenorphine are used as
substitution therapy in opioid dependence. Substitute
medication should be commenced with a short period of
stabilisation, followed by either a withdrawal regimen or by
maintenance treatment. Maintenance treatment enables
patients to achieve stability, reduces drug use and crime, and
improves health; it should be regularly reviewed to ensure
the patient continues to derive benefit. The prescriber
should monitor for signs of toxicity, and the patient should
be told to be aware of warning signs of toxicity on initiation
A withdrawal regimen after stabilisation with methadone
hydrochloride or buprenorphine should be attempted only
after careful consideration. Enforced withdrawal is
ineffective for sustained abstinence, and it increases the risk
of patients relapsing and subsequently overdosing because
of loss of tolerance. Complete withdrawal from opioids
usually takes up to 4 weeks in an inpatient or residential
setting, and up to 12 weeks in a community setting. If
abstinence is not achieved, illicit drug use is resumed, or the
patient cannot tolerate withdrawal, the withdrawal regimen
should be stopped and maintenance therapy should be
resumed at the optimal dose. Following successful
withdrawal treatment, further support and monitoring to
maintain abstinence should be provided for a period of at
Patients who miss 3 days or more of their regular prescribed
dose of opioid maintenance therapy are at risk of overdose
because of loss of tolerance. Consider reducing the dose in
If the patient misses 5 or more days of treatment, an
assessment of illicit drug use is also recommended before
restarting substitution therapy; this is particularly important
for patients taking buprenorphine because of the risk of
Buprenorphine is preferred by some patients because it is
less sedating than methadone hydrochloride; for this reason
it may be more suitable for employed patients or those
undertaking other skilled tasks such as driving.
Buprenorphine is safer than methadone hydrochloride when
used in conjunction with other sedating drugs, and has fewer
drug interactions. Dose reductions may be easier than with
methadone hydrochloride because the withdrawal symptoms
are milder, and patients generally require fewer adjunctive
medications; there is also a lower risk of overdose.
Buprenorphine can be given on alternate days in higher
doses and it requires a shorter drug-free period than
methadone hydrochloride before induction with naltrexone
hydrochloride p. 497 for prevention of relapse.
Patients dependent on high doses of opioids may be at
increased risk of precipitated withdrawal. Precipitated
withdrawal can occur in any patient if buprenorphine is
administered when other opioid agonist drugs are in
circulation. Precipitated opioid withdrawal, if it occurs,
starts within 1–3 hours of the first buprenorphine dose and
peaks at around 6 hours. Non-opioid adjunctive therapy,
such as lofexidine hydrochloride p. 504, may be required if
To reduce the risk of precipitated withdrawal, the first dose
of buprenorphine should be given when the patient is
exhibiting signs of withdrawal, or 6–12 hours after the last
use of heroin (or other short-acting opioid), or 24–48 hours
after the last dose of methadone hydrochloride. It is possible
to titrate the dose of buprenorphine within one week—more
rapidly than with methadone hydrochloride therapy—but
care is still needed to avoid toxicity or precipitated
withdrawal; dividing the dose on the first day may be useful.
A combination preparation containing buprenorphine
with naloxone p. 503 (Suboxone ®) can be prescribed for
patients when there is a risk of dose diversion for parenteral
administration; the naloxone hydrochloride p. 1369
component precipitates withdrawal if the preparation is
injected, but it has little effect when the preparation is taken
Methadone hydrochloride, a long-acting opioid agonist, is
usually administered in a single daily dose as methadone
hydrochloride oral solution 1 mg/mL. Patients with a long
history of opioid misuse, those who typically abuse a variety
of sedative drugs and alcohol, and those who experience
increased anxiety during withdrawal of opioids may prefer
methadone hydrochloride to buprenorphine because it has a
more pronounced sedative effect.
Methadone hydrochloride is initiated at least 8 hours after
the last heroin dose, provided that there is objective
evidence of withdrawal symptoms. A supplementary dose on
the first day may be considered if there is evidence of
persistent opioid withdrawal symptoms. Because of the long
half-life, plasma concentrations progressively rise during
initial treatment even if the patient remains on the same
daily dose (it takes 3–10 days for plasma concentrations to
reach steady-state in patients on a stable dose); a dose
tolerated on the first day of treatment may become a toxic
dose on the third day as cumulative toxicity develops. Thus,
titration to the optimal dose in methadone hydrochloride
maintenance treatment may take several weeks.
Opioid substitution during pregnancy
Acute withdrawal of opioids should be avoided in pregnancy
because it can cause fetal death. Opioid substitution therapy
is recommended during pregnancy because it carries a lower
risk to the fetus than continued use of illicit drugs. If a
woman who is stabilised on methadone hydrochloride or
buprenorphine for treatment of opioid dependence becomes
pregnant, therapy should be continued [buprenorphine is
not licensed for use in pregnancy]. Many pregnant patients
choose a withdrawal regimen, but withdrawal during the first
trimester should be avoided because it is associated with an
increased risk of spontaneous miscarriage. Withdrawal of
methadone hydrochloride or buprenorphine should be
undertaken gradually during the second trimester, with dose
BNF 78 Substance dependence 493
reductions made every 3–5 days. If illicit drug use occurs, the
patient should be re-stabilised at the optimal maintenance
dose and consideration should be given to stopping the
Further withdrawal of methadone hydrochloride or
buprenorphine in the third trimester is not recommended
because maternal withdrawal, even if mild, is associated with
fetal distress, stillbirth, and the risk of neonatal mortality.
Drug metabolism can be increased in the third trimester; it
may be necessary to either increase the dose of methadone
hydrochloride p. 502 or change to twice-daily consumption
(or a combination of both strategies) to prevent withdrawal
The neonate should be monitored for respiratory
depression and signs of withdrawal if the mother is
prescribed high doses of opioid substitute.
Signs of neonatal withdrawal from opioids usually develop
24–72 hours after delivery but symptoms may be delayed for
up to 14 days, so monitoring may be required for several
weeks. Symptoms include a high-pitched cry, rapid
breathing, hungry but ineffective suckling, and excessive
wakefulness; severe, but rare symptoms include
hypertonicity and convulsions.
Opioid substitution during breastfeeding
Doses of methadone and buprenorphine should be kept as
low as possible in breast-feeding mothers. Increased
sleepiness, breathing difficulties, or limpness in breast-fed
babies of mothers taking opioid substitutes should be
reported urgently to a healthcare professional.
Adjunctive therapy and symptomatic treatment
Adjunctive therapy may be required for the management of
opioid withdrawal symptoms. Loperamide hydrochloride
p. 66 may be used for the control of diarrhoea; mebeverine
hydrochloride p. 86 for controlling stomach cramps;
paracetamol p. 444 and non-steroidal anti-inflammatory
drugs for muscular pains and headaches; metoclopramide
hydrochloride p. 432 or prochlorperazine p. 389 may be
useful for nausea or vomiting. Topical rubefacients can be
helpful for relieving muscle pain associated with methadone
hydrochloride withdrawal. If a patient is suffering from
insomnia, short-acting benzodiazepines or zopiclone p. 490
may be prescribed, but because of the potential for abuse,
prescriptions should be limited to a short course of a few
days only. If anxiety or agitation is severe, specialist advice
Lofexidine hydrochloride p. 504 may alleviate some of the
physical symptoms of opioid withdrawal by attenuating the
increase in adrenergic neurotransmission that occurs during
opioid withdrawal. Lofexidine hydrochloride can be
prescribed as an adjuvant to opioid substitution therapy,
initiated either at the same time as the opioid substitute or
during withdrawal of the opioid substitute. Alternatively,
lofexidine hydrochloride may be prescribed instead of an
opioid substitute in patients who have mild or uncertain
dependence (including young people), and those with a short
Patients dependant on opioids can be given a supply of
naloxone hydrochloride p. 1369 to be used in case of
Naltrexone hydrochloride p. 497 precipitates withdrawal
symptoms in opioid-dependent subjects. Because the effects
of opioid-receptor agonists are blocked by naltrexone
hydrochloride, it is prescribed as an aid to prevent relapse in
formerly opioid-dependent patients.
In younger patients (under 18 years), the harmful effects of
drug misuse are more often related to acute intoxication
than to dependence, so substitution therapy is usually
inappropriate. Maintenance treatment with opioid
substitution therapy is therefore controversial in young
people; however, it may be useful for the older adolescent
who has a history of opioid use to undergo a period of
stabilisation with buprenorphine p. 447 or methadone
hydrochloride before starting a withdrawal regimen.
Alcohol dependence 01-Sep-2017
Alcohol dependence is a cluster of behavioural, cognitive
and physiological factors that typically include a strong
desire to drink alcohol, tolerance to its effects, and
consequences, such as physical or mental health problems.
In severely dependent patients who have been drinking
excessively for a prolonged period of time, an abrupt
reduction in alcohol intake may result in the development of
an alcohol withdrawal syndrome, which, in the absence of
medical management, can lead to seizures, delirium
g Patients with mild alcohol dependence usually do not
need assisted alcohol withdrawal. Patients with moderate
dependence can generally be treated in a community setting
unless they are at high risk of developing alcohol withdrawal
seizures or delirium tremens; individuals with severe
dependence should undergo withdrawal in an inpatient
setting. Patients with decompensated liver disease should be
treated under specialist supervision.
A long-acting benzodiazepine, such as chlordiazepoxide
hydrochloride p. 343 or diazepam p. 343, is recommended to
attenuate alcohol withdrawal symptoms; local clinical
In primary care, fixed-dose reducing regimens are used. This
involves using a standard, initial dose (determined by the
severity of alcohol dependence or level of alcohol
consumption), followed by dose reduction to zero, usually
symptom-triggered approach involves tailoring the drug
regimen according to the severity of withdrawal and any
complications in an individual patient; adequate monitoring
facilities should be available. The patient should be
monitored on a regular basis and treatment only continued
as long as there are withdrawal symptoms.
Carbamazepine p. 311 [unlicensed indication] can be used
as an alternative treatment in acute alcohol withdrawal.
Clomethiazole p. 489 may be considered as an alternative
to a benzodiazepine or carbamazepine p. 311. It should only
be used in an inpatient setting and should not be prescribed
if the patient is liable to continue drinking alcohol. hNote:
Alcohol combined with clomethiazole p. 489, particularly in
patients with cirrhosis, can lead to fatal respiratory
depression even with short-term use.
g When managing withdrawal from co-existing
benzodiazepine and alcohol dependence, the dose of
benzodiazepine used for withdrawal should be increased.
The initial daily dose is calculated, based on the
requirements for alcohol withdrawal plus the equivalent
regularly used daily dose of benzodiazepine. A single
benzodiazepine (chlordiazepoxide hydrochloride p. 343 or
diazepam p. 343) should be used rather than multiple
benzodiazepines. Inpatient withdrawal regimens should last
for 2–3 weeks or longer, depending on the severity of
benzodiazepine dependence. When withdrawal is managed
494 Substance dependence BNF 78
in the community, or where there is a high level of
benzodiazepine dependence, or both, the regimen should
last for a minimum of 3 weeks (according to the patient’s
If alcohol withdrawal seizures occur, a fast-acting
benzodiazepine (such as lorazepam p. 339 [unlicensed
indication]) should be prescribed to reduce the likelihood of
further seizures. If alcohol withdrawal seizures develop in a
person during treatment for acute alcohol withdrawal,
review their withdrawal drug regimen. h
g Delirium tremens is a medical emergency that requires
specialist inpatient care. In patients with delirium tremens
(characterised by agitation, confusion, paranoia, and visual
and auditory hallucinations), oral lorazepam p. 339 should
be used as first-line treatment. If symptoms persist or oral
medication is declined, parenteral lorazepam p. 339
[unlicensed], or haloperidol p. 386 [unlicensed] can be given
as adjunctive therapy. If delirium tremens develops during
treatment for acute alcohol withdrawal, the withdrawal drug
regimen should also be reviewed. h
g In harmful drinkers or patients with mild alcohol
dependence, a psychological intervention (such as cognitive
behavioural therapy) should be offered. In those who have
not responded to psychological interventions alone or who
have specifically requested a pharmacological treatment,
acamprosate calcium p. 496 or oral naltrexone hydrochloride
p. 497 can be used in combination with a psychological
Acamprosate calcium p. 496 or oral naltrexone
hydrochloride p. 497 in combination with a psychological
intervention are recommended for relapse prevention in
patients with moderate and severe alcohol dependence, to
start after successful assisted withdrawal. Disulfiram below is
an alternative for patients in whom acamprosate calcium
p. 496 and oral naltrexone hydrochloride p. 497 are not
suitable, or if the patient prefers disulfiram below and
understands the risks of taking the drug.
Nalmefene p. 496 is recommended for the reduction of
alcohol consumption in patients with alcohol dependence
who have a high drinking risk level, without physical
withdrawal symptoms, and who do not require immediate
detoxification (see National funding/access decisions for
Patients with severe alcohol-related hepatitis with a
discriminant function of 32 or more can be given
controlled, and following discussion of the potential benefits
and risks of treatment. Corticosteroid treatment has been
shown to improve survival in the short term (1 month) but
not over a longer term (3 months to 1 year). It has also been
shown to increase the risk of serious infections within the
first 3 months of starting treatment.
Patients with chronic alcohol-related pancreatitis should
be offered nutritional support; those who have symptoms of
steatorrhoea or who have poor nutritional status due to
Exocrine pancreatic insufficiency p. 95 should be prescribed
pancreatic enzyme supplements; supplements are not
indicated when pain is the only symptom. h
g Patients with alcohol dependence are at risk of
developing Wernicke’s encephalopathy; patients at high risk
are those who are malnourished, at risk of malnourishment,
or have decompensated liver disease. Parenteral thiamine
p. 1080, followed by oral thiamine p. 1080, should be given
to patients with suspected Wernicke’s encephalopathy,
those who are malnourished or at risk of malnourishment,
those who have decompensated liver disease or who are
attending hospital for acute treatment. Prophylactic oral
thiamine p. 1080 should also be given to harmful or
dependent drinkers if they are in acute withdrawal, or before
and during assisted alcohol withdrawal. hParenteral
thiamine is available as part of a vitamin B substances with
ascorbic acid p. 1081 preparation.
Alcohol-use disorders: diagnosis, assessment and
management of harmful drinking and alcohol dependence.
National Institute for Health and Care Excellence. Clinical
www.nice.org.uk/guidance/cg115
Alcohol-use disorders: diagnosis and management of
physical complications. National Institute for Health and
Care Excellence. Clinical guideline 100. June 2010 (updated
www.nice.org.uk/guidance/cg100
ALDEHYDE DEHYDROGENASE INHIBITORS
Adjunct in the treatment of alcohol dependence (under
▶ Adult: 200 mg daily, increased if necessary up to
l UNLICENSED USE Disulfiram doses in BNF may differ from
l CONTRA-INDICATIONS Cardiac failure . coronary artery
l CAUTIONS Alcohol challenge not recommended on
routine basis (if considered essential—specialist units only
with resuscitation facilities). avoid in Acute porphyrias
p. 1058 . diabetes mellitus . epilepsy .respiratory disease
l INTERACTIONS → Appendix 1: disulfiram
l PREGNANCY High concentrations of acetaldehyde which
occur in presence of alcohol may be teratogenic; avoid in
l BREAST FEEDING Avoid—no information available.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
l RENAL IMPAIRMENT Use with caution.
l PRE-TREATMENT SCREENING Before initiating disulfiram,
prescribers should evaluate the patient’s suitability for
treatment, because some patient factors, for example
memory impairment or social circumstances, make
compliance to treatment or abstinence from alcohol
l MONITORING REQUIREMENTS During treatment with
disulfiram, patients should be monitored at least every
2 weeks for the first 2 months, then each month for the
following 4 months, and at least every 6 months
l PATIENT AND CARER ADVICE Manufacturer advises
patients and their carers should be counselled on the
disulfiram-alcohol reaction—reactions may occur
following exposure to small amounts of alcohol found in
perfume, aerosol sprays, or low alcohol and "non-alcohol"
arrhythmias, hypotension, respiratory depression, and
coma.g Patients and their carers should be counselled
on the signs of hepatotoxicity—patients should
discontinue treatment and seek immediate medical
attention if they feel unwell or symptoms such as fever or
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 2
▶ Disulfiram (Non-proprietary)
Disulfiram 200 mg Disulfiram 200mg tablets | 50 tablet P £91.73–£120.00 DT = £105.86
GAMMA-AMINOBUTYRIC ACID ANALOGUES
Acamprosate calcium 10-Sep-2018
Maintenance of abstinence in alcohol-dependent patients
▶ Adult 18–65 years (body-weight up to 60 kg): 666 mg once
daily at breakfast and 333 mg twice daily at midday and
▶ Adult 18–65 years (body-weight 60 kg and above): 666 mg
l CAUTIONS Continued alcohol abuse (risk of treatment
l PREGNANCY Manufacturer advises avoid unless potential
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe hepatic failure—no information available.
l RENAL IMPAIRMENT Avoid if serum-creatinine greater
l PRESCRIBING AND DISPENSING INFORMATION
Acamprosate calcium has been used for the maintenance
of abstinence in alcohol dependence in children aged
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 5, 21, 25
ELECTROLYTES: May contain Calcium
▶ Acamprosate calcium (Non-proprietary)
Acamprosate calcium 333 mg Acamprosate 333mg gastro-resistant
tablets | 168 tablet P £33.75 DT = £33.75
▶ Campral EC (Merck Serono Ltd)
Acamprosate calcium 333 mg Campral EC 333mg tablets | 168 tablet P £28.80 DT = £33.75
Reduction of alcohol consumption in patients with alcohol
dependence who have a high drinking risk level without
physical withdrawal symptoms, and who do not require
▶ Adult: 18 mg daily if required, taken on each day there
is a risk of drinking alcohol, preferably taken 1–2 hours
before the anticipated time of drinking, if a dose has
not been taken before drinking alcohol, 1 dose should
be taken as soon as possible; maximum 18 mg per day
l CONTRA-INDICATIONS Recent history of acute alcohol
withdrawal syndrome .recent or current opioid use
seizures). psychiatric illness
l INTERACTIONS → Appendix 1: nalmefene
▶ Frequency not known Dissociation . hallucinations
l PREGNANCY Manufacturer advises avoid—toxicity in
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution in
mild to moderate impairment (risk of increased exposure);
avoid in severe impairment (no information available).
l RENAL IMPAIRMENT Use with caution—avoid in severe
l PRE-TREATMENT SCREENING Before initiating treatment,
prescribers should evaluate the patient’s clinical status,
alcohol dependence, and level of alcohol consumption.
Nalmefene should only be prescribed for patients who
continue to have a high drinking risk level two weeks after
l MONITORING REQUIREMENTS During treatment, patients
should be monitored regularly and the need for continued
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Nalmefene for reducing alcohol consumption in people with
alcohol dependence (November 2014) NICE TA325
Nalmefene is recommended within its marketing
authorisation, as an option for reducing alcohol
consumption, for patients with alcohol dependence:
. who have a high drinking risk level (defined as alcohol
consumption of more than 60 g per day for men and
more than 40 g per day for women, according to the
World Health Organization’s drinking risk levels)
without physical withdrawal symptoms, and
. who do not require immediate detoxification.
The marketing authorisation states that nalmefene
. 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.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 25
Nalmefene (as Nalmefene hydrochloride) 18 mg Selincro 18mg
tablets | 14 tablet P £42.42 DT = £42.42 | 28 tablet P £84.84
496 Substance dependence BNF 78
Naltrexone hydrochloride 17-Aug-2017
l DRUG ACTION Naltrexone is an opioid-receptor
Adjunct to prevent relapse in formerly opioid-dependent
patients (who have remained opioid-free for at least
7–10 days) (initiated under specialist supervision)
▶ Adult: Initially 25 mg daily, then increased to 50 mg
daily, total weekly dose may be divided and given on
3 days of the week for improved compliance (e.g.
100 mg on Monday and Wednesday, and 150 mg on
Friday); maximum 350 mg per week
Adjunct to prevent relapse in formerly alcohol-dependent
patients (initiated under specialist supervision)
▶ Adult: 25 mg once daily on the first day, then increased
l UNLICENSED USE 25 mg dose for adjunct to prevent
relapse in formerly alcohol-dependent patients is an
l CONTRA-INDICATIONS Patients currently dependent on
l CAUTIONS Concomitant use of opioids
▶ Concomitant use of opioids Concomitant use of opioids
should be avoided but increased dose of opioid analgesic
may be required for pain—manufacturer advises to
monitor for opioid intoxication.
l INTERACTIONS → Appendix 1: naltrexone
disorders .tachycardia .thirst. vomiting
▶ Rare or very rare Immune thrombocytopenic purpura . rhabdomyolysis . suicidal tendencies
▶ Frequency not known Withdrawal syndrome
l PREGNANCY Use only if benefit outweighs risk.
l BREAST FEEDING Avoid—potential toxicity.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
mild to moderate impairment; avoid in severe or acute
impairment, acute hepatitis, or hepatic failure.
Dose adjustments Manufacturer advises consider dose
adjustment in mild to moderate impairment.
l RENAL IMPAIRMENT Avoid in severe impairment.
l PRE-TREATMENT SCREENING Test for opioid dependence
with naloxone before treatment.
l MONITORING REQUIREMENTS Liver function tests needed
l PATIENT AND CARER ADVICE Patients should be warned
that an attempt to overcome the blockade of opioid
receptors by overdosing could result in acute opioid
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Naltrexone for the management of opioid dependence
Naltrexone is recommended for the prevention of relapse
in formerly opioid-dependent patients who are motivated
to remain in a supportive care abstinence programme.
Naltrexone should be administered under supervision and
its effectiveness in preventing opioid misuse reviewed
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: capsule, oral
▶ Naltrexone hydrochloride (Non-proprietary)
Naltrexone hydrochloride 50 mg Naltrexone 50mg tablets |
28 tablet P £23.00–£51.21 DT = £47.46
▶ Adepend (AOP Orphan Pharmaceuticals AG)
Naltrexone hydrochloride 50 mg Adepend 50mg tablets | 28 tablet P £47.43 DT = £47.46
Smoking tobacco is the main cause of preventable illness and
premature death in the UK. It is linked to a number of
diseases such as cancer (primarily lung cancer), chronic
obstructive pulmonary disease, and cardiovascular disease,
and can lead to complications during pregnancy. Smoking
cessation reduces the risk of developing or worsening of
smoking-related illnesses, and the benefits begin as soon as
Smoking cessation may be associated with temporary
withdrawal symptoms caused by nicotine dependence,
making it difficult for people to stop. These symptoms
include nicotine cravings, irritability, depression,
restlessness, poor concentration, light-headedness, sleep
disturbances, and increased appetite. Weight gain is a
concern for many people who stop smoking, however it is
less likely to occur when drug treatment is used to aid
g All smokers, including those who smoke e-cigarettes,
should be advised to stop smoking and be offered support to
facilitate smoking cessation. They should also be advised
that stopping in one step (‘abrupt quitting’) offers the best
chance of lasting success, and that a combination of drug
treatment and behavioural support is likely to be the most
effective approach h’Abrupt quitting’ is when a smoker
makes a commitment to stop smoking on or before a
particular date (the quit date), rather than by gradually
g Smokers who wish to stop smoking should be
referred to their local NHS Stop Smoking Services, where
they will be provided with advice, drug treatment, and
behavioural support options such as individual counselling
or group meetings. Smokers who decline to attend their local
NHS Stop Smoking Services should be referred to a suitable
healthcare professional who can also offer drug treatment
Nicotine replacement therapy (NRT), varenicline p. 501, and
bupropion hydrochloride p. 498, are effective drug
treatments to aid smoking cessation.g The choice of
BNF 78 Nicotine dependence 497
drug treatment should take into consideration the smoker’s
likely adherence, preferences, and previous experience of
smoking-cessation aids, as well as contra-indications and
side-effects of each preparation. Varenicline, or a
combination of long-acting NRT (transdermal patch) and
short-acting NRT (lozenges, gum, sublingual tablets,
inhalator, nasal spray and oral spray), are the most effective
treatment options and thus the preferred choices. If these
options are not appropriate, bupropion hydrochloride or
single therapy NRT should be considered instead. h
Nicotine transdermal patches are generally applied for
16 hours, with the patch removed overnight; if smokers
experience strong nicotine cravings upon waking, a 24-hour
patch can be used instead. Short-acting nicotine
preparations are used whenever the urge to smoke occurs or
to prevent cravings; there is no evidence that one form of
NRT is more effective than another.g The use of NRT
combined with varenicline or bupropion hydrochloride is not
recommended, and both varenicline and bupropion
hydrochloride should not be prescribed together.
A quit date should be agreed when drug treatment is
prescribed for smoking cessation, and treatment should be
available before the person stops smoking. Smokers should
be prescribed enough treatment to last 2 weeks after their
agreed quit date and be re-assessed shortly before their
Smokers who are unwilling or not ready to stop smoking
may also benefit from the use of NRT as part of a ’harm
reduction approach’, because the amount of nicotine in NRT
is much lower and less addictive than in smoking tobacco.
Harm reduction approaches include stopping smoking whilst
using NRT to prevent relapse, and smoking reduction or
temporary abstinence with or without the use of NRT. These
smokers should be advised that NRT will make it easier to
reduce how much they smoke and improve their chance of
stopping smoking in the long-term. h
E-cigarettes deliver nicotine without the toxins found in
tobacco smoke. Evidence suggests that e-cigarettes are
substantially less harmful to health than tobacco smoking,
but long-term effects are still largely unknown. Some
smokers have found e-cigarettes useful for smoking
cessation, however they cannot be prescribed or supplied by
are not licensed drugs, they are regulated by the Tobacco and
g Pregnant females should be advised to stop smoking
completely, and be informed about the risks to the unborn
child of smoking during pregnancy, and the harmful effects
of exposure to second-hand smoke for both mother and
baby. All pregnant females who smoke or have stopped
smoking in the last 2 weeks should be referred to their local
NHS Stop Smoking Services, and ongoing support should be
offered during and following pregnancy. Smoking cessation
should also be encouraged for all members of the household.
Pregnant females who smoke should be advised to contact
the NHS Pregnancy Smoking Helpline for further
information (Tel: 0800 169 9169).
NRT should only be used in pregnant females if non-drug
treatment options have failed. Clinical judgement should be
used when deciding whether to prescribe NRT following a
discussion about its risks and benefits. Subsequent
prescriptions should only be given to pregnant females who
have demonstrated they are still not smoking. h
Polycyclic aromatic hydrocarbons found in tobacco smoke
increase the metabolism of some drugs by inducing hepatic
enzymes, often requiring an increase in dose. Information
about drugs interacting with tobacco smoke can be found
under Interactions of the relevant drug monograph.
Stop smoking interventions and services. National Institute
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