STEPTRACKERPHARMACOLOGY + PSYCHIATRY | PSYCHIATRY | HIGH-YIELD REVIEW

ADHD, Addiction & Other Psychiatric Drugs

Stimulants and nonstimulants for ADHD; agonists, antagonists and aversives for substance use disorders; plus the drugs for weight, narcolepsy and dementia-related agitation.

FOCUS ON
ADHD: methylphenidate (blocks DA/NE reuptake), amphetamines (↑ release, reverse transporters); adverse — insomnia, ↓ appetite, growth slowing, tics, ↑ HR/BP, abuse. Nonstimulants: atomoxetine (NE reuptake; hepatotoxicity, suicidality), guanfacine, clonidine (α2). Narcolepsy: modafinil, stimulants, sodium oxybate, pitolisant. Alcohol use disorder: naltrexone (avoid in opioid users, liver failure), acamprosate (NMDA modulation; renal dosing — fine in liver disease), disulfiram (aldehyde dehydrogenase inhibitor → acetaldehyde reaction), topiramate, gabapentin. Opioid use disorder: methadone (full agonist), buprenorphine-naloxone, naltrexone (XR-IM); naloxone kits. Tobacco: varenicline (α4β2 nicotinic partial agonist), bupropion, nicotine replacement. Alcohol withdrawal: benzodiazepines; thiamine before glucose. Stimulant toxicity: benzodiazepines. Weight: GLP-1 agonists, phentermine-topiramate, naltrexone-bupropion, orlistat (lipase; fatty stools).
DRUG
MECHANISM
USE
ADVERSE · NOTES
Methylphenidate
Blocks DAT and NET
ADHD, narcolepsy
Insomnia, anorexia, growth slowing, tics, ↑ BP; abuse potential
Amphetamine · lisdexamfetamine
Enter terminals via transporter, release DA/NE (VMAT reversal)
ADHD, narcolepsy, binge eating (lisdexamfetamine)
Same as above; psychosis at high doses
Atomoxetine · viloxazine
Selective NE reuptake inhibitors
ADHD with tics, anxiety or abuse risk
Hepatotoxicity, suicidal thoughts, ↑ HR
Guanfacine · clonidine
α2 agonists
ADHD, tics
Sedation, hypotension, rebound HTN
Modafinil · armodafinil
Weak DAT inhibition, orexin effects
Narcolepsy, shift-work sleep disorder
Headache, SJS (rare), CYP3A4 induction (OCP failure)
Sodium oxybate · pitolisant
GHB (GABA-B) · H3 inverse agonist
Narcolepsy with cataplexy
Oxybate respiratory depression, abuse
Naltrexone
μ-opioid antagonist
Alcohol use disorder (↓ craving), opioid relapse prevention
Precipitates withdrawal in opioid users; avoid in acute hepatitis
Acamprosate
NMDA/GABA modulation
Maintain alcohol abstinence
Renally cleared — fine in cirrhosis, avoid in severe CKD
Disulfiram
Inhibits aldehyde dehydrogenase
Motivated abstinence
Flushing, vomiting, hypotension with alcohol; hepatitis
Methadone
Long-acting full μ agonist
Opioid use disorder (licensed programs)
QT, respiratory depression, interactions
Buprenorphine-naloxone
Partial μ agonist; naloxone deters injection
Opioid use disorder (office-based)
Precipitated withdrawal if started too early
Varenicline
α4β2 nicotinic partial agonist
Smoking cessation (most effective)
Nausea, vivid dreams
Nicotine replacement
Patch, gum, lozenge
Smoking cessation
Patch skin irritation, insomnia
Orlistat · phentermine-topiramate · naltrexone-bupropion
Pancreatic lipase inhibitor · sympathomimetic + topiramate · combined
Obesity
Orlistat steatorrhea, fat-soluble vitamin loss; phentermine ↑ BP

Mechanism — disulfiram reaction

Ethanol → acetaldehydeAlcohol dehydrogenase
→
Aldehyde dehydrogenase blockedDisulfiram (also metronidazole, some cephalosporins, sulfonylureas)
→
Acetaldehyde builds up
→
Flushing, nausea, headache, hypotension

Substance use disorder drugs

SUBSTANCE
MAINTENANCE
WITHDRAWAL
Alcohol
Naltrexone, acamprosate, disulfiram
Benzodiazepines
Opioids
Methadone, buprenorphine, XR-naltrexone
Buprenorphine, clonidine, lofexidine
Tobacco
Varenicline, bupropion, NRT
NRT

How it's tested

COMMON CONFUSIONAcamprosate is the alcohol drug for liver disease; naltrexone is the one to avoid there and in anyone needing opioids.
THE TRAPGiving glucose before thiamine to a malnourished alcoholic can precipitate Wernicke encephalopathy.
YOUR APPROACHSubstance → withdrawal management → long-term maintenance chosen by liver/kidney status and opioid needs.

If you see… think…

Flushing and vomiting after drinking on a prescribed pill → disulfiram reaction
Alcohol craving drug safe in cirrhosis → acamprosate
Smoking cessation partial agonist → varenicline
Child on ADHD drug falling off growth curve → stimulant
ADHD with tics or substance-abuse concern → atomoxetine or α2 agonist
Oily stools on a weight-loss drug → orlistat
Office-based opioid use disorder treatment → buprenorphine-naloxone
Narcolepsy with cataplexy → sodium oxybate
OCP failure after starting wakefulness drug → modafinil induction
Thiamine before glucose → prevent Wernicke encephalopathy