New Guidelines For Substance Use Disorders

The ground shifts for nicotine in new guidelines

STUDY: Sinclair JMA et al, Journal of Psychopharmacology 2026

STUDY TYPE: Expert consensus guideline

FUNDING: Independent

Background

The British Association for Psychopharmacology last updated their guidance on substance use disorder in 2012. Since then, DSM-5 and ICD-11 have diverged on how they define dependence, fentanyl has reshaped the opioid crisis, and tools like long-acting injectable buprenorphine and e-cigarettes have entered routine practice.

The Panel

• Addiction specialists from the UK, US, Italy, India, and Australia met twice in February 2025 to review the evidence.

Recommendations

Alcohol. For alcohol withdrawal, benzodiazepines plus thiamine are first-line. For relapse prevention, acamprosate suits patients who want to stay abstinent, and naltrexone suits those still drinking heavily who want to cut back, each with a number needed to treat of roughly 9 to 18.

Opioids. For opioid dependence, methadone, buprenorphine, and long-acting injectable buprenorphine are all effective, and take-home naloxone belongs with every patient and their family to treat overdose. If patients come off an opioid-substitution med like buprenorphine, naltrexone may help prevent relapse.

Nicotine. E-cigarettes, combination nicotine replacement therapies (eg, gum and patch), varenicline, and cytisine are top. All of those beat beat single-form nicotine replacement therapies or bupropion. Varenicline’s old neuropsychiatric warnings don’t hold up.

Stimulant and cannabis dependence remain the weak spots. No medication is approved for either, though naltrexone plus bupropion showed promise for methamphetamine. Here are some meds for cannabis cessation that passed in small controlled trials.

Laboratory Measures

Here are some areas where they recommend laboratory tests.

Alcohol withdrawal

Check electrolytes—sodium, potassium, phosphate, magnesium, calcium—in people going through alcohol withdrawal, especially older or malnourished patients or those with other medical problems. Treat any imbalances that turn up.

Check magnesium specifically in patients with abnormal heart rhythms or a history of withdrawal seizures. Dr. Aiken’s note: magnesium may be low intracellularly even when normal in the serum, and magnesium supplementation reduces liver damage from alcohol.

Consider blood alcohol level. If withdrawal symptoms appear while the level is still positive, that’s a marker of more severe, complicated withdrawal.

Alcohol Use Disorder: Liver and kidney function

Check kidney function before starting acamprosate. Severe impairment rules it out; mild-to-moderate impairment calls for a lower dose.

Check liver function and cirrhosis stage (Child-Pugh score) before and during naltrexone treatment. Naltrexone is fine in alcohol-related liver disease generally, but its active metabolites can build up in Child-Pugh B and C cirrhosis or active alcoholic hepatitis, so use caution there.

Check liver function when choosing a benzodiazepine for alcohol withdrawal. Patients with impaired livers do better on lorazepam or oxazepam, which the body processes more simply than diazepam or chlordiazepoxide.

Opioid Use Disorder: Cardiac

Check an ECG and watch the QT interval in patients on methadone, particularly at higher doses. Methadone carries a higher QT-prolongation risk than buprenorphine.

Buprenorphine after fentanyl

For buprenorphine, aim for a plasma level above 2 ng/mL—typically doses of 24 to 32 mg/day—when treating dependence on high-potency synthetic opioids like fentanyl. That threshold protects against fentanyl-induced respiratory depression.

Opioid Use Disorder: Tracking treatment progress

Use urine tests to track non-prescribed opioid use in patients on methadone or buprenorphine maintenance. Positive results are not a reason to stop medication for opioid use disorder, but may lead us to reconsider the plan and add more supportive therapies.

Smoking Cessation: Medications levels change

Consider a blood level of clozapine, olanzapine, haloperidol, fluvoxamine, and duloxetine when a patient quits smoking or stops temporarily. Tobacco smoke ramps up the liver enzyme CYP1A2, so levels of these drugs can climb once someone stops.

Diagnosis

The paper opens with a nice comparison of DSM and ICD criteria for substance use disorders:

—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report

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