‘Safety First: Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness’ recommends that patients at risk of suicide, including all patients with a recent history of self-harm, who are treated with psychotropic drugs should receive modern, less toxic drugs and/or supplies lasting no more than 2 weeks.

NICE guidance: Methadone and buprenorphine for the management of opioid dependence (January 2007)

Oral methadone and buprenorphine are recommended for maintenance therapy in the management of opioid dependence. Patients should be committed to a supportive care programme including a flexible dosing regimen administered under supervision for at least 3 months, until compliance is assured. Selection of methadone or buprenorphine should be made on a case-by-case basis, but methadone should be prescribed if both drugs are equally suitable.

NICE guidance: Naltrexone for the management of opioid dependence (January 2007)

Naltrexone is recommended for the prevention of relapse in detoxified formerly opioid-dependent patients who are motivated to remain in a supportive care abstinence programme. Naltrexone should be administered under supervision and its effectiveness in preventing opioid misuse reviewed regularly.

NICE Guidance on smoking cessation (issued February 2008) has the following advice on pharmacological therapy:

Offer NRT, varenicline or bupropion, as appropriate, to people who are planning to stop smoking.

 Offer advice, encouragement and support, including referral to the NHS Smoking Service, to help people in their attempt to quit.

 NRT, varenicline or bupropion should normally be prescribed as part of an abstinent-contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date). The prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date. Normally, this will be after 2 weeks of NRT therapy, and 3 - 4 weeks for varenicline or bupropion, to allow for the different methods of administration and mode of action. Subsequent prescriptions should be given only to people who have demonstrated, on re-assessment, that their quit attempt is continuing.

 Explain the risks and benefits of using NRT to young people aged from 12 to 17, pregnant or breastfeeding women, and people who have unstable cardiovascular disorders. To maximise the benefits of NRT, people in these groups should also be strongly encouraged to use behavioural support in their quit attempt.

 Neither varenicline or bupropion should be offered to young people under 18 nor to pregnant or breastfeeding women.

 Varenicline or bupropion may be offered to people with unstable cardiovascular disorders, subject to clinical judgement.

 If a smoker’s attempt to quit is unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within 6 months unless special circumstances have hampered the person’s initial attempt to stop smoking, when it may be reasonable to try again sooner.

 Do not offer NRT, varenicline or bupropion in any combination.

 Consider offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.

 Do not favour one medication over another. The clinician and patient should choose the one that seems most likely to succeed.

1. See Appendix 2 for advice on NRT products.

2. Suicidal thoughts and behaviour have been reported in users of varenicline who have no known pre-existing psychiatric conditions, and while they continue to smoke. Anyone taking varenicline who develops depression or suicidal thoughts should stop taking their treatment and contact their doctor immediately.

1. See Appendix 2 for advice on NRT products.

2. Suicidal thoughts and behaviour have been reported in users of varenicline who have no known pre-existing psychiatric conditions, and while they continue to smoke. Anyone taking varenicline who develops depression or suicidal thoughts should stop taking their treatment and contact their doctor immediately.