Submission to Medicines Management Committee
Date of Meeting:
Person presenting at meeting:
Agenda No:
Attachment:
Medicines used for abstinence (naltrexone,
Purpose of Report:
disulfram, acamprosate) or harmful drinking
Support the transfer of prescribing
reduction (nalmefene)
responsibility and care for abstinence
and harmful drinking
Transfer of Prescribing Responsibility
Report Author:
Submitting Team/Organisation:
SWLStG DTC
KCCG Med Mgt team
Contact details: Carl.holvey@nhs.net
Executive Summary: (precise purpose of document)
Describes how medicines for abstinence and reduction of harmful drinking are initiated and
reviewed across South West London which are complicated due to the complex
commissioning arrangements of the services that support their use.
Key sections for particular note (paragraph/page), areas of concern etc:
Note that most DARTs are not currently commissioned to see patients who would qualify for
the use of nalmefene for harmful drinking. They are currently seen by GPs and not referred.
GPs can initiate this medicine and refer directly for psychosocial support to the local recovery
teams. The level of psychosocial support needed for nalmefene to be effective is below the
high level given by NHS support services (as per NICE).
Recommendation(s) for the committee:
Review on discussion with public health commissioners.
Committees which have previously discussed/approved/declined the report and/or
Leads who have been consulted and key outcomes:
Psychiatrists at Sutton, Merton, Richmond and Kingston (CANDI FT) DARTs are in
agreement with the principals of this document.
Wandsworth CCG are in discussions with its providers and public health.
Financial Implications:
Nalmefene 18mg tablets = £42.42 for 14 tabletsi
Other Implications if applicable:
N/a
How will this document be disseminated and to whom?
CANDI DART, SLaM DART, SWLStG DARTs,
CCG MMCs
SWLStG DTC,
SWL Public health teams
Prescribing Guidelines for Medicines used for abstinence
(Naltrexone, Disulfiram, Acamprosate)
or harmful drinking reduction (Nalmefene)
v1.0
Medicines used to help patients sustain abstinence from alcohol



1st line: Acamprosate is by far the most commonly prescribed medicine and is useful for those
experiencing cravings for alcohol.
Disulfram is most useful for stable patients who need a further deterrent as severe side effects
are experienced should someone drink alcohol while being prescribed.
Naltrexone can be used as per NICE along with psychosocial intervention to reduce the risk of
relapse, as support treatment in abstinence and to reduce the craving for alcohol. It is also a
full opiate blocker.
Following detox, medicines for abstinence may be initiated by a Drug and Alcohol Team (DART)
or after inpatient admission (Crawley Hospital or Kingston) in those that are willing and feel they
would benefit. Service users are transferred to the community psychosocial team; there is no
further medical input required from the treatment team at this point. If needed, medical advice and
support can be obtained from DART and the supply is sourced from their GP.
Nalmefene is as a possible treatment for people with alcohol dependence whoii&iii:
o are still drinking more than 7.5 units per day (for men) and more than 5 units per day (for
women) 2 weeks after an initial assessment and
o do not have physical withdrawal symptoms and
o do not need to either stop drinking straight away or stop drinking completely.
o These patients do not necessarily require a detox and do not meet the thresh hold to be
seen by most alcohol treatment teams.
 Those requiring medicines for detox (i.e. chlordiazepoxide) are not initially suitable for
nalmefene.
 This product requires extra monitoring, report adverse effects to the MHRA:
www.yellowcards.gov.uk
 Nalmefene should be taken at a dose of 18mg 1-2hrs before the anticipated time of drinking.
Prescribe 18mg each day, when required, supply 14 doses in 28 days, with a maximum supply
of 6 months to ensure it is reviewed. Should the harmful drinking have not improved at 6
months, nalmefene should be stopped and alternatives considered.
 Those requiring daily administration of nalmefene should be considered for a switch to
naltrexone 50mg daily (unlicensed), which has evidence to support abstinence maintenance
and is a more cost effective alternative.
Psychosocial support
All medicines list above have been shown to be effective and licensed when given in combination
with psychosocial input. Psychosocial input can be from the Substance Misuse Recovery Teams
(SMRTs) and/or Mutual Aids Groups such as Alcoholics Anonymous (AA). The level of
psychosocial support given by SMRTs is to NICE standards which are more in depth then the brief
interventions undertaken in clinical trials with nalmefene. Specialists initiating medicines for
abstinence in initiating medicines for abstinence and harm reduction will refer for psychosocial
support and communicate to GP the care plan (including investigations, recommended monitoring
and review) for continued supply of medicines.
GPs can refer patients for 12 weeks support (as per NICE) directly for those started on
nalmefene by them:




Sutton (CDS), T:020 8773 9393 & E:franco@cdssl.org
Merton (MACS Project), T: 0800 043 2296 (free) or 020 8417 1960/ 0208 417 1975/ 0786 604 5624.
Richmond (CRI), T:020 8891 0161,M:07795 391 187, F:020 8892 3363 & E:richmond.info@cri.org.uk
Kingston (Wellbeing Service) T: 020 8274 3051 or E:kingston.wellbeingservice@nhs.net
The community psychosocial team acknowledges the referral and will continue communicating
with the GP with the progress of the service user under their care. They will inform the GP should
the patient disengages from the programme as nalmefene should be discontinued.
GP monitoring & review requirements
Medicines for abstinence and harm reduction require very little medical review (alcohol
consumption, overall functioning and side-effects). They should be continued for 6 months to 1
year, or indefinitely if the patient continues to derive benefits and remains abstinent from alcohol,
or reduced harmful drinking with nalmefene.


Disulfram cannot be combined with alcohol, acamprosate and naltrexone can be given up
to one month if someone relapses back to alcohol use.
Nalmefene should be discontinued if the patient does not experience a reduction in their
harmful drinking at 4 weeks.
Useful references
Information on medicines for substance misuse (and mental health) may be found on the
information website: http://www.choiceandmedication.org/swlstg-tr/
https://www.nice.org.uk/guidance/ta325 - Nalmefene
www.nice.org.uk/guidance/CG115 - Alcohol use disorders
http://www.medicines.org.uk/emc/ - Summary of Product Characteristics (for Medicines)
Other Clinical Particulars
This table is not exhaustive;
www.emc.medicines.org.uk
see
individual
SmPCs
for
full
prescribing
details.
*Refer back to a specialist or contact Specialist Medicines Information (020 3513 6829) for
review/advice if the medicine(s) if needed.
Management of side-effects
Side-effect
Acamprosate
Diarrhoea,
stomach
flatulence
Opioid
receptor
modulators
(naltrexone
/nalmefene)
Disulfram
Management
nausea Usually self-limiting, supportive advice usually
pain, sufficient: drink plenty of fluids, oral
rehydration salts or take with food for nausea.
Slow titration, reducing the dose temporarily
Headaches
and paracetamol may all help.
Anorgasmia, decreased
Try decreasing the dose or stop*
libido
Allergic reaction: ash,
Stop, refer to physician for treatment.
pruritus, wheeze
Arrhythmias
Switch.*
Nausea,
vomiting, Advise take with largest meal of the day,
abdominal
cramps, responds to dose reduction. Self-limiting,
diarrhoea
occurs in the first 24hrs usually.
Self-limiting, simple analgesia. Stop if it does
Headache
not resolve.
Muscle pain
Wears off after 1 week
polydipsia
Consider dose reduction
Rash, pruritis
Stop*
Depression,
suicidal
Stop*
ideation
hallucinations
Stop*
thrombocytopenia
Stop*
Increase frequency of monitoring, consider
reducing the dose for twice the upper limit and
Liver damage
stopping the medicines for three times the
upper limit
Sleepiness and fatigue Usually on initiation or dose increase.
Halitosis
Usually self-limiting on initiation.
Nausea & vomiting
Advise on taking with food or reduce the dose.
Shortness of breath
Stop*
Allergic skin reactions
Antihistamines help or stop*
Decreased libido
Stop or consider dose reduction*
Increase frequency of monitoring, consider
Liver
damage reducing the dose for twice the upper limit and
(hepatitis)
stopping the medicines for three times the
upper limit
Peripheral neuropathy
Decreasing the dose can help or stop*
High or low mood or
Stop*
psychotic symptoms
Interactions
 Clinical meaningful interactions to note with other medicines are rare with these medicines,
review the SmPC should adverse effects occur.
 Caution when combining strong opioids with naltrexone or nalmefene due to the risk of
respiratory depression.

Disulfiram should not be combined with alcohol. Assessment of the risk of this should be
done with the patients before it is initiated.
References
i
NHS Electronic Drug Tariff April 2015. Available [Online] via: http://www.ppa.org.uk/edt/April_2015_v2/mindex.htm
(Accessed 8th April 2014).
ii http://www.nice.org.uk/guidance/ta325/resources/guidance-nalmefene-for-reducing-alcohol-consumption-in-peoplewith-alcohol-dependence-pdf
iii London New Drugs Group / London Medicines Evaluation Network Review. Nalmefene for alcohol dependence.
October 2013. Available [Online] via: http://www.medicinesresources.nhs.uk/upload/Nalmefene_final.pdf (Accessed
7th April 2014)