British Association for Psychopharmacology updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity


This is an exhaustive review.  Print it out, sit down in a comfy chair and spend some time with it's 40 pages (not counting 14 pages of citations).  Should be required reading for the addiction specialist.  The full text is free at http://jop.sagepub.com/content/early/2012/05/15/0269881112444324.full.pdf+html


Here are some interesting (to me) gems: 

Wernkicke's and thiamine replacement

It  has been suggested that a presumptive diagnosis of WE should be made for any patient with a  history of alcohol dependence who shows one or more of the following: evidence of ophthalmoplegia, ataxia, acute confusion, memory disturbance, unexplained hypotension, hypothermia, coma, or unconsciousness.

Patients commonly deemed ‘at risk’ of developing WE during a hospital admission or a planned detoxification are those whose drinking has exceeded 15 units per day [=8.5 US standard drinks] for a month or more and where there is evidence of recent weight loss or vomiting or diarrhoea or malnutrition or peripheral neuropathy or chronic ill health.

In healthy uncomplicated alcohol-dependent/heavy drinkers (i.e. those at low risk), oral thiamine >300 mg/day should be given during detoxification.If patient is at high risk of WE (e.g. malnourished, unwell) prophylactic parenteral treatment should be given, using 250 mg thiamine i.m. or i.v. once daily for 3–5 days or until no further improvement is seenIf WE is suspected or established, parenteral thiamine (i.m. or i.v.) of >500 mg should be given for 3–5 days, followed by >250 mg once daily for a further 3–5 days depending on response

Enthusiasm for phamacotherapy of alcohol dependence

We endorse the recommendation that pharmacotherapy should be the default position, such that the decision not to prescribe is made actively for those patients presenting with harmful alcohol use or abuse that have not benefited from psychosocial interventions and for everyone with dependence, rather than only thinking of medication for more complex patients. 

QTc in methadone vs buprenorphine

In a study of the prevalence of corrected QT (QTc) interval prolongation during methadone and buprenorphine treatment, 4.6% of subjects on methadone had corrected QT intervals > 500 ms, 15% > 470 ms and 28.9% > 450 ms. All subjects on buprenorphine had QTc < 450 ms. There was a positive dose-dependent association between QTc interval and methadone dose. All eight patients with QTc > 500 ms were prescribed 120 mg or more of methadone

Benzodiazepine taper facilitated by melatonin also valproate, trazodone, paroxetine

Four of the pharmacotherapies showed significant effects on benzodiazepine discontinuation rates in single studies. Garfinkel et al. (1999) reported discontinuation rates of 77% with the addition of melatonin compared with 25% with gradual dose reduction alone. Rickels et al. (1999) added sodium valproate, trazodone or placebo to a benzodiazepine taper. At 5 weeks post-taper, 79% of sodium valproate and 67% of trazodone, but only 31% of placebo patients were benzodiazepine free. These differences were not maintained at 12 weeks post-taper. Adjunctive paroxetine in patients without major depression increased discontinuation rates compared with gradual dose reduction alone (46% vs. 17%) (Nakao et al., 2006) 

Antabuse for cocaine dependence
There is a lot I had forgotten about the role of disulfiram for cocaine dependence and the combination of disulfiram & naltrexone for combined alcohol / cocaine dependence


Buproprion a nicotine blocker?

The atypical antidepressant bupropion has been well studied and is licensed as an aid to smoking cessation. It has dopaminergic and adrenergic actions, and also appears to act as an antagonist at the nicotinic acetylcholinergic receptor

Naltrexone improves mood

Lastly, although it is theoretically possible for naltrexone to worsen mood, this has not been seen clinically. Recent studies in newly abstinent heroin addicts have not found naltrexone induction and/or maintenance to worsen mood, but instead to improve it