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4.8 Substance dependence

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained: 

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

Milton Keynes University Hospital NHS Foundation Trust specialist substance misuse provider is Compass Milton Keynes. Compass cover all aspects of drug and alcohol treatment, therefore the patient’s GP is not involved in prescribing opiate substitution therapy (OST) for opiate dependent patients. However, the GP will be aware of the ongoing prescribing of OST and of any changes following medical reviews. 

Their opening hours and contact details for adult patients are as follows:

 

Monday

9.00 am – 5pm

Tuesday

9.00 am – 8pm

Wednesday

12.30 pm - 5pm

Thursday

9.00 am – 8pm

Friday

9.00 am – 5pm

Telephone: 01908 250730; Compass does not provide an on-call service.

Compass have a hospital liaison team whom cover both adult and paediatric patients in hospital. A referral is made by Compass to their under 18 service following triage assessment.

Hospital Liaison Nurse Wayne Pavey: 07515 996919

Hospital Liaison Link Worker Kaye Murray: 07773472665

Hospital Liaison Team Bleep Number: 1860 

 

 

4.8.1 Alcohol dependence

Opioid receptor Antagonists

Naltrexone hydrochloride (Amber 2)

  • Tablets 50mg 

Notes:

 

Nalmefene - Selincro® 

  • Tablets 18mg

Must be initiated under specialist supervision according to:  

  

 

4.8.2 Nicotine dependence 

Guidance for Prescribers:

  • Therapy should only be prescribed to a smoker who commits to a target stop date.
  • The smoker should be offered advice and encouragement to aid smoking cessation.
  • Therapy to aid smoking cessation is chosen according to the smoker’s likely compliance, availability of counselling and support, previous experience of smoking cessation aids, contra-indications and adverse effects of the products and the smoker’s preferences.
  • Counselling, administration, see BNF guidance - NRT preparations doses and administrations 
  • Initial supply of the prescribed smoking-cessation therapy should be sufficient to last only 2 weeks after the target stop date. After 2 weeks a review of the success of therapy must be completed and only if the smoker demonstrates a continuing attempt to stop smoking will a second prescription be issued.
  • If an attempt to stop smoking is unsuccessful then another course of therapy may be provided through the local Stop Smoking Service if the patient is eligible, an assessment will be made at their initial appointment.
  • Nicotine replacement therapy should not be combined with Bupropion treatment.

 

 Indications for Nicotine replacement therapy:

  • To be used as an adjunct in a programme of smoking cessation.

 

 Contra-indications for Nicotine replacement therapy:

  • Severe cardiovascular disease, severe arrhythmias or immediately post-myocardial infarction period.
  • Recent cerebrovascular accident including transient ischaemic attacks 

 

Useful resources

1. NICE Guidance PH10: Smoking Cessation Services (February 2008)

 

2. NICE Guidance PH48: Smoking cessation - acute, maternity and mental health services (November 2013)

 

3. NRT Formulary and Prescribing Guidelines

 

4. NRT Therapeutic Substitution Guidelines

 

5. NRT Patient Information Leaflet  

 

6. Smoking Cessation - Formulary recommendations

 

 

Nicotine Replacement Therapy

Nicotine receptor agonists 

Nicotine

Nicorette®   N

 
  • Chewing gum, sugar-free, nicotine

         2mg, pack of 30, pack of 105, pack of 210;

         4mg, pack of 30, pack of 105, pack of 210. 

         Also available in mint, freshfruit, freshmint, and icy white flavours

 

  • Invisi patches, self-adhesive, nicotine

         ‘10mg’ patch (releasing approx. 10mg/16 hours)

         ‘15mg’ patch (releasing approx. 15mg/16 hours)

          ‘25mg’ patch (releasing approx. 25mg/16 hours)

 
  • Inhalator, nicotine

          10mg/cartridge, 6 cartridge pack, 42 cartridge pack

          15mg/cartridge, 4-cartridge pack, 20-cartridge pack, 36-cartridge pack.

 
  • Lozenges, Nicorette Cools nicotine, mint flavoured

          2mg, pack of 20, pack of 80

          4mg, pack of 80

 
  • Nasal spray, nicotine 500micrograms/metered spray, 200-spray unit.
 
  • Oral spray (Nicorette Quickmist® mouthspray), nicotine 1mg/metered dose,

          1 x 150-dose pack, 2 × 150-dose pack.

 
  • Tablets (sublingual) (Nicorette Microtab®), nicotine 2 mg, starter pack of 2 × 15-tablet discs with dispenser; pack of 100. 

 

Nicotinell®    N

  • TTS Patches, self-adhesive, nicotine,

         ‘10’ patch (releasing approx. 7mg/24 hours)

         ‘20’ patch (releasing approx. 14mg/24 hours)

         ‘30’ patch (releasing approx. 21mg/24 hours)  

 

NiQuitin®    N

  • Lozenges, sugar-free, nicotine

         2mg (mint-flavoured), pack of 36, pack of 72;

         4mg (mint-flavoured), pack of 36 

 

  • Minis Lozenges, nicotine

         1.5mg (cherry- and orange -flavoured), pack of 20, pack of 60

         4mg (mint-flavoured), pack of 20, pack of 60. 

 

  • Chewing Gum, sugar free, mint-flavour, nicotine

         2mg, pack of 12, pack of 24, pack of 96

         4mg, pack of 12, pack of 24, pack of 96

        

  • Patches, self-adhesive, nicotine

        ‘7mg' patch (releasing approx. 7mg/24 hours)

         ‘14mg’ patch (releasing approx. 14mg/24 hours)

         ‘21mg’ patch (releasing approx. 21mg/24 hours) 

 Note: Also available as a clear patch

 

  • Strips (Gel Strips), orodispersible film, mint flavour nicotine

          2.5mg, pack of 15, pack of 60

 

Varenicline

  • Tablets 500micrograms, 1mg, starter pack

Notes:

  • Initiated under primary care specialist supervision according to: NICE TA123: Varenicline for smoking cessation (July 2007) . It should normally be prescribed only as part of a programme of behavioural support. 
  • Patients should be advised to discontinue treatment and seek prompt medical advice if they develop agitation, depressed mood, or suicidal thoughts. Patients with a history of psychiatric illness should be monitored closely while taking varenicline.

 

 

Serotonin and Noradrenaline re-uptake inhibitors

Bupropion hydrochloride

  • Modified Release Tablets f/c 150mg

 CSM advice:

  • Bupropion is contra-indicated in patients with a history of seizures or of eating disorders, a CNS tumour, or who are experiencing acute symptoms of alcohol or benzodiazepine withdrawal.
  • Bupropion should not be prescribed to patients with other risk factors for seizures unless the potential benefit of smoking cessation clearly outweighs the risk.
  • Factors that increase the risk of seizures include concomitant administration of drugs that can lower the seizure threshold (eg. antidepressants, antimalarials (such as mefloquine and chloroquine), antipsychotics, quinolones, sedating antihistamines, systemic corticosteroids, theophylline, tramadol), alcohol abuse, history of head trauma, diabetes, and use of stimulants and anorectics.
  • Initiated under primary care specialist supervision as part of a programme of behavioural support

 


 

4.8.3 Opioid dependence

Opioids

For "Opioid substitution therapy" using methadone or buprenorphine see BNF section 4.10.3

Use as per NICE TA 114: Methadone and buprenorphine for the management of opioid dependence (Jan 2007) 

 

Methadone CD (Amber 2)

  • Oral solution, Sugar Free 1mg/1mL

 

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

 

Return to Chapter: 4. Nervous System

Last updated by: Dupe Fagbenro on 12-03-2019 12:32