Buprenorphine/naloxone is the definitive partial agonist treatment for opioid use disorder. The combination product is preferred over buprenorphine alone for maintenance because the addition of naloxone lowers its potential for injection abuse. The sublingual film formulation is priced a little higher than the sublingual tablets yet provides very little (if any) meaningful benefit; generic tablets should be used as a cost-saving measure. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Disulfiram is an aversive treatment, causing a buildup of ethanol’s metabolite acetaldehyde in the serum, which in turn causes symptoms such as flushing, dizziness, nausea, and vomiting. Since disulfiram does not reduce cravings and any alcohol ingestion could result in a reaction, noncompliance can be common. Its use should be reserved for selective, highly motivated patients in conjunction with supportive and psychotherapeutic treatment. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Bupropion SR is somewhat less effective in smoking cessation than varenicline, but given the high rate of comorbidity between smoking and depression, it is an attractive option for many patients. It is also a particularly good choice for patients who are not able to set a quit date prior to initiating treatment. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Buprenorphine (Subutex, available now only as generic) is the active ingredient in Suboxone (buprenorphine/ naloxone) and is responsible for the effectiveness of the combination medication in opioid use disorder. In the past, buprenorphine alone was preferred for the initial (induction) phase of treatment, while Suboxone was preferred for maintenance treatment (unsupervised administration). Currently, the combination is favored for both induction and maintenance as it decreases abuse and diversion potential. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Varenicline is the most effective tobacco cessation medication. Psychiatric side effects are usually limited to insomnia or abnormal dreams, but more dramatic reactions are possible, though rare. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Inhaled nicotine is expensive and can cause unpleasant side effects, both of which make this form of nicotine replacement therapy difficult to recommend as a first-line option since no single therapy has been shown to be more effective than another. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

The idea of nasal administration of nicotine is appealing in that it more closely approximates the time course of plasma nicotine levels observed after cigarette smoking than other dosage forms; however, the high cost and unpleasant side effects make this difficult to recommend as a first-line treatment, especially since no one form of nicotine replacement therapy has been shown to be more effective than another. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

First-line intervention for those patients who can stop smoking at initiation of therapy; nicotine in the form of gum or lozenge may act as a substitute oral activity, which may aid in behavior modification. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

While you will not be treating most medical complications of alcohol use, it’s important to ask patients about these things, especially as part of the motivational interviewing strategy. Identifying significant medical sequelae during an interview can be a powerful incentive for patients to consider the negative consequences of drinking. In essence, this comprehensive medical survey will help to “scare them sober.” From Treating Alcohol Use Disorder: A Fact Book (2023).

Phenobarbital is becoming more popular as a strategy for managing alcohol withdrawal syndrome (AWS) as clinicians gain more experience with it. A recent retrospective study compared phenobarbital with lorazepam for AWS and found that patients using phenobarbital had a shorter length of stay (2.8 vs 3.6 days) as well as fewer readmissions and emergency room visits after discharge (Hawa F et al, Cureus 2021;13(2):e13282). From Treating Alcohol Use Disorder: A Fact Book (2023).