4.10.1 Alcohol dependence

Drugs used in alcohol dependence not listed below

Prescribers are referred to local trust's guidelines for information and, the drug's Summary of Product Characteristics (SPC) and the BNF for withdrawal regimens full details concerning the pharmacotherapies listed in this section.

Plymouth guidelines:Prescribing Policy for the Management of Substance Misuse (including alcohol)

Together Drugs and Alcohol Service (South Devon, not Torbay): advice regarding patients with alcohol dependence during the Coronavirus (COVID-19) pandemic can be found here.

Prescribing should be an adjunct to psychological therapy rather than an intervention in its own right. Detoxification from alcohol should not take place in isolation and be supported with a post detoxification care plan.

Chlormethiazole (Heminevrin®) should not be used due to greater risk of respiratory depression if alcohol is drunk, except in in-patient settings and according to the Summary of Product Characteristics (SPC)

Acamprosate
  • Gastro-resistant tablets 333mg (£28.29 = 168 tablets)

Indications

  • Maintaining abstinence in alcohol-dependent patients

Dose

  • 18–65 years, body-weight 60kg and over, 666mg 3 times daily; body-weight less than 60kg, 666mg at breakfast, 333mg at midday, and 333mg at night

Notes

  • Acamprosate is supported by NICE CG115: Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (February 2011) following assisted withdrawal or for harmful drinkers and people with mild alcohol dependence who have requested a pharmacological intervention in combination with an individual psychological intervention.
Disulfiram
  • Tablets 200mg (£170.08 = 50 tablets)

Indications

  • Adjunct in the treatment of alcohol dependence (under specialist supervision)

Dose

  • 200mg daily increased if necessary; usual maximum 500mg daily

Notes

  1. Disulfiram should be prescribed in conjunction with supervision from a family member or carer as the evidence base supports improved efficacy with this arrangement. Patients and family members/carers should also be informed of the Disulfiram-Alcohol Reaction (DAR) prior to starting the pharmacotherapy.

Opioid receptor antagonists

Nalmefene
  • Tablets 18mg (£42.42 = 14 tablets)

Indications

  • Nalmefene should only be initiated by suitably trained clinicians, after appropriate psychosocial support is made available and has commenced.
  • Should be prescribed in line with NICE TA325: Nalmefene for reducing alcohol consumption in people with alcohol dependence (November 2014), where it is recommended for people who are:
    • Drinking more than 7.5 units (men) or 5 units (women) per day and
    • Do not have physical withdrawal symptoms and
    • Do not need to stop drinking immediately or completely
  • The SPC states that nalmefene should only be prescribed
  • In conjunction with psychosocial support focussed on treatment adherence and reducing alcohol consumption and
  • Should only be initiated in patients who continue to have a high drinking risk level two weeks after initial assessment

Dose

  • One tablet, preferably 1-2 hours prior to anticipated time of drinking or as soon as possible after starting.
  • The maximum dose is one tablet per day.

Notes

  1. Nalmefene is contraindicated in the following groups:
    1. patients taking opioid analgesics
    2. current or recent opioid addiction
    3. acute symptoms of opioid withdrawal
    4. where recent opioid use is suspected
    5. severe hepatic impairment
    6. severe renal impairment (eGFR less than 30mL/min per 1.73m2)
    7. patients with a recent history of acute alcohol withdrawal syndrome (including hallucinations, seizures, and delirium tremens)

 

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