This document discusses the treatment of substance use disorders including alcohol and opioid use disorders. It covers pharmacological treatments such as naltrexone, acamprosate, disulfiram, buprenorphine, and methadone. Naltrexone, acamprosate and disulfiram are used to treat alcohol use disorder and aim for abstinence. Buprenorphine and methadone are used for medication-assisted treatment of opioid use disorder. Non-pharmacological treatments including counseling and psychosocial support are also important parts of treatment. The document provides details on the mechanisms of action, dosing, and side effects of these medications.

1. Dr. RAGHU PRASADA M S
MBBS,MD
ASSISTANT PROFESSOR
DEPT. OF PHARMACOLOGY
SSIMS & RC.
1

2.  Taking a Drug for any reason
other than a medical one…
 To get a feeling of
euphoria (high)
2

3.  uncontrollable compulsive drug
seeking and use, even in the face of
negative health and social
consequences.”
 Results from both psychological and
physical dependence on the drug
3

4.  Treatment of withdrawal symptoms
 Aversion therapy
 To reduce craving
 To prevent relapse
 Rehabilitation & psychosocial
intervention
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5. Single agent
Acamprosate
 Naltrexone
 Disulfiram
 Aimed at complete abstinence ,
can be started at any time
including withdrawal phase,
 may be started immediately
during first consultation
 Early onset with family loading,
helps in heavy drinking and may be
choice in which acamprosate trial has
failed,
 Liver function test is mandatory
 Patient completely motivated and
with good social support, still low
acceptability

6.  SSRIs (Fluoxetine,
Sertraline, Citalopram)
 Topiramate
 Baclofen
 Effective with co morbid
depression
 Can be used as single
agent, or with co
morbidities like seizure,
bipolar disorder.
 Helpful in withdrawal
management and relapse
prevention in patients with
cirrhosis liver. Also co
morbid cannabis or solvent
or benzodiazepine uses
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7. General principles of treatment
 Careful monitoring and supportive care
 Ample fluids (p/o or IV fluids if
dehydrated)
 Correction of electrolyte imbalance
 Parenteral Thiamine(100 mg p.o or i.v or
i.m) daily
 Restrict access to addicting substances
 Involve significant others in the treatment
from the initial stages
 Liaise with specialists as appropriate
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8.  Cross tolerant medications with alcohol
 Benzodiazepines
 Diazepam and Chlordiazepoxide
Lorazepam and oxazepam - short acting
(patients with liver
problems, in elderly)
 Others (more than 150 agents,
carbamazepine; valproate, ß adrenergic
antagonists etc.,)
 Emerging: Baclofen
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9. Ethanol AcetateAcetaldehyde
•Flushing
•Headache
•Palpitations
•Dizziness
•Nausea
ADH ALDH
 .
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Disulfiram

10.  Main contraindications:
recent alcohol use, pregnancy, rubber, nickel
or cobalt allergy, cognitive impairment, drug
interactions
hepatitis, neuropathy
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Disulfiram 250 mg/d-->500 mg/d
Main side effects:

11. Acamprosate (calcium acetyl homo
taurinate)
 structure similar to GABA amino
acid.
 Restores the GABA activity.
 reduce glutamate surges that
excite NMDA- Rs.
 acts as a neuro-protectant and
protect neurons from damage
caused by alcohol withdrawal
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12. The Reward
Pathway
Ethanol
Dopamine
Beta endorphin
release potentiated
Naltrexone-
aimed at reducing the psychological need or craving for alcohol.
prefrontal cortex
nucleus accumbens
VTA
Firing
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13. ▪ Main contraindication:
opiates, pregnancy
▪ Main side effects:
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Naltrexone 12.5 mg/d-->25 mg/d-->50 mg/d

14. ▪ a 5-HT3 antagonist that exerts its antidrinking effects
through cortico-mesolimbic dopamine system
modulation.
▪ improve drinking outcomes in patients with early-onset
alcoholism.
▪ Adverse events are mild
▪ starting dosage of 4 mcg/kg twice daily should be
maintained throughout treatment.
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15. 15

16. Treatment of
 Dependence and Abuse
 Intoxication
 Withdrawal
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17. Naltrexone
 Complete abstinence approach
 long term treatment helps in
maintaining complete abstinence
 extinction of drug seeking behavior
 blocking the effects of opioid over
a significant period
 Reduced craving

18. Advantage
 No tolerance or
withdrawal
 Not a schedule drug
 No abuse potential
Disadvantage
 Abstinence for 5-7
days
 Retention and
compliance issues
 Sensitivity to over
dosages
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19. Methadone
Buprenorphine
LAAM( levo Alfa acetyl methadone)

20. Advantages
 Best available
evidence
 Lower costs
 Good Retention and
abstinence rates
Disadvantages
 Mortality following
overdose
 Scheduled drug
 Supervised clinic
 Daily dosing
 Abuse and dependence
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21.  semi-synthetic opium alkaloid derivative of
thebaine.
 long acting, highly lipophilic opiate
 Mixed agonist antagonist
 Side effects – as in methadone
elevated liver enzymes
 Toxicity – Less risk, none reported
but if occurs, difficult to reverse and needs higher
doses of naloxone
.
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22. THANKYOU
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