Clinical Tools
CLINICAL TOOLS
Evidence-Based Tools for the Psychiatric Prescriber
Clinical reference tools for PMHNPs — titration schedules, switching protocols, and interaction checking. All content is reviewed by board-certified PMHNPs and grounded in current clinical guidelines.
🔒 Members Only. These clinical references are intended for Lumina members (licensed prescribers and PMHNP students). Join the waitlist →
⚠ Draft — Pending Clinical Review. These tools are interactive clinical decision support in active development. Verify every result against FDA labeling and current guidelines. Do not use as the sole basis for patient care decisions until final review is published.
Available Tools
💊 Drug Interaction Checker
Curated psychiatric drug-interaction matrix with severity ratings. Jump to Tool →
📊 Titration Guide
Step-by-step titration schedules for psychiatric medications — Lamotrigine, Lithium, and more. Jump to Tool →
🔄 Switching & Withdrawal Protocols
Interactive calculators: SSRI↔MAOI washout, CIWA-Ar, COWS, benzodiazepine taper, antipsychotic cross-taper. Jump to Tool →
💊 Drug Interaction Checker
What's in the curated matrix?
Serotonergic combinations & MAOI washouts; lithium with NSAIDs/ACE-I/ARB/thiazides; clozapine with fluvoxamine/ciprofloxacin/smoking cessation; lamotrigine with valproate/enzyme inducers/estrogen-containing OCPs; carbamazepine autoinduction & OCP failure; QTc-additive combinations; CYP2D6 inhibitor + tamoxifen; benzodiazepine + opioid; bupropion seizure-threshold pairings; stimulant + MAOI; buprenorphine + benzodiazepine; methadone QTc & CYP3A4. See sources at page bottom.
📊 Titration Guide
Cross-referenced against FDA prescribing information and current clinical guidelines. Jump to: Lamotrigine · Lithium · Quetiapine · Clozapine · Buprenorphine · Naltrexone · Methadone
Lamotrigine (Lamictal)
Indication referenced: Bipolar I maintenance. Not FDA-approved for acute bipolar depression monotherapy.
Standard adult (no interacting AEDs)
| Week | Dose |
|---|---|
| 1–2 | 25 mg PO daily |
| 3–4 | 50 mg PO daily |
| 5 | 100 mg PO daily |
| 6 | 200 mg PO daily (target) |
With valproate (half-dose)
| Week | Dose |
|---|---|
| 1–2 | 25 mg PO every other day |
| 3–4 | 25 mg PO daily |
| 5 | 50 mg PO daily |
| 6 | 100 mg PO daily (target) |
With enzyme inducers without VPA (CBZ, phenytoin, phenobarbital, primidone, rifampin) — double-dose
| Week | Dose |
|---|---|
| 1–2 | 50 mg PO daily |
| 3–4 | 100 mg PO daily (divided) |
| 5 | 200 mg PO daily (divided) |
| 6 | 300 mg PO daily (divided) |
| 7 | 400 mg PO daily (divided) (target) |
Missed doses / restart
If lamotrigine has been missed for more than 5 consecutive days, restart titration from Week 1 to mitigate boxed-warning rash risk. (Half-life is shorter with inducers and longer with valproate — when in doubt, restart.)
Counseling / hold criteria
- Counsel: call immediately for any rash, especially weeks 1–8.
- Hold for rash with mucosal involvement, fever, lymphadenopathy, facial swelling, eosinophilia, or systemic symptoms (possible DRESS).
- Estrogen-containing OCPs and pregnancy reduce levels ~50%; anticipate level rebound during the OCP pill-free week. Consider TDM and dose adjustment.
Sources: Lamotrigine FDA PI (current). Stahl, Prescriber's Guide 7e. Maudsley Prescribing Guidelines 14e. APA Bipolar Practice Guideline.
Lithium Carbonate
Indications referenced: Bipolar I (acute mania, maintenance). Narrow therapeutic index.
Baseline workup
- SCr/eGFR, BUN, electrolytes
- Urinalysis (baseline concentrating ability)
- TSH, free T4
- Calcium
- CBC
- Urine pregnancy test (Ebstein anomaly counseling)
- ECG if age ≥40 or cardiac history
- Weight/BMI
Starting dose
Adult: 300 mg PO BID–TID (600–900 mg/day). Elderly / impaired renal function: 150 mg BID. IR for initiation; ER (Lithobid) reduces GI upset and peak-related tremor.
Target serum levels (12-h trough)
| Indication | Target (mEq/L) |
|---|---|
| Acute mania | 1.0–1.2 (up to 1.5 if tolerated) |
| Maintenance | 0.6–1.0 |
| Elderly | 0.4–0.8 |
| Toxicity | ≥1.5 mild · ≥2.0 moderate · ≥2.5 severe (medical emergency) |
Monitoring
| Parameter | Frequency |
|---|---|
| Lithium level | 5 days after each dose change → every 3 mo while titrating → every 6–12 mo when stable |
| SCr/eGFR | q3 mo × 1 year, then q6–12 mo |
| TSH | q6 mo |
| Calcium | Annually |
| Weight, BMI | Every visit |
Level timing
Levels must be a 12-hour trough. Off-trough levels are not interpretable.
Key drug interactions
- NSAIDs (except aspirin, sulindac): raise levels.
- Thiazides: reduce clearance, raise levels.
- ACE-I / ARBs: raise levels.
- Dehydration / low-Na diet: raises levels.
- Caffeine withdrawal: caffeine increases lithium renal clearance; cessation reduces clearance and raises levels.
Sources: Lithium FDA PI. Stahl 7e. APA Bipolar Practice Guideline. Maudsley 14e. NICE CG185.
Quetiapine (Seroquel IR / XR)
Indications referenced: Schizophrenia, Bipolar I (acute mania, depression, maintenance), MDD adjunctive (XR).
Schizophrenia (IR)
Day 1: 25 mg BID. Day 2: 50 mg BID. Day 3: 100 mg BID. Day 4: 150 mg BID. Day 5+: titrate by 25–50 mg BID per response. Target 300–400 mg/day in divided doses; max 800 mg/day.
Bipolar mania (IR)
Day 1: 50 mg BID. Day 2: 100 mg BID. Day 3: 150 mg BID. Day 4: 200 mg BID. Target 400–800 mg/day by day 6.
Bipolar depression (XR)
Day 1: 50 mg QHS. Day 2: 100 mg QHS. Day 3: 200 mg QHS. Day 4 onward: 300 mg QHS (label-recommended target).
MDD adjunctive (XR)
Days 1–2: 50 mg QHS. Day 3+: 150 mg QHS. Range 150–300 mg/day.
Special populations
- Elderly: start 25–50 mg/day; titrate by 25–50 mg/day. Mortality black box in dementia-related psychosis.
- Hepatic impairment: start 25 mg/day, increase by 25–50 mg/day to effective dose.
- CYP3A4 inhibitors (ketoconazole, clarithromycin): reduce dose to 1/6 of usual. CYP3A4 inducers (carbamazepine, phenytoin, rifampin): may need 5x dose increase.
Monitoring
Baseline weight, BP, fasting glucose, lipid panel. Repeat at 12 weeks, then annually. Consider lens/cataract eval per label (q6mo). ECG if QTc risk factors.
Sources: Quetiapine FDA PI (Seroquel, Seroquel XR). Stahl 7e. Maudsley 14e. APA Schizophrenia 2020.
Clozapine (Clozaril)
Indication referenced: Treatment-resistant schizophrenia. Recurrent suicidal behavior in schizophrenia/schizoaffective. REMS required for ANC monitoring (FDA shared system effective Nov 2024).
Baseline workup
- CBC with differential (ANC must be ≥1500/µL; ≥1000/µL for benign ethnic neutropenia)
- Weight, BMI, waist circumference
- Fasting glucose, HbA1c, lipid panel
- BP/HR (sitting and standing), ECG, troponin, CRP (myocarditis baseline)
- LFTs, BUN/Cr
- Pregnancy test if applicable; smoking and caffeine status (CYP1A2)
Standard inpatient titration
| Day | Dose |
|---|---|
| 1 | 12.5 mg PO once or BID |
| 2 | 25 mg BID |
| 3–5 | Increase by 25–50 mg/day to 100 mg BID |
| 6–14 | Increase by 50–100 mg every 1–2 days to target |
| 14+ | Target 300–450 mg/day in divided doses; max 900 mg/day |
Outpatient / slow titration
Increase by 25 mg every 1–2 days. Therapeutic plasma level 350–600 ng/mL (toxicity risk >1000).
Missed doses
ANC monitoring (FDA REMS)
| ANC | Action |
|---|---|
| ≥1500 | Continue; weekly x 6 mo, then q2wk x 6 mo, then monthly |
| 1000–1499 | Continue; recheck 3x/week until ≥1500, then resume schedule |
| 500–999 | Interrupt; daily ANC; resume when ≥1000 |
| <500 | Discontinue (severe neutropenia). Heme consult. Daily ANC until ≥1000, then 3x/week until ≥1500. |
Smoking and CYP1A2
Cigarette smoke induces CYP1A2; abrupt smoking cessation can raise levels 50–70%. Reduce dose ~25% within 1 week of cessation; recheck level.
Adjuncts
Anticholinergic burden (sialorrhea: bedtime atropine drops 1% sublingual or glycopyrrolate). Constipation prophylaxis (PEG, senna) — ileus is potentially fatal.
Sources: Clozapine FDA PI. Clozapine REMS Program (2024 update). Stahl 7e. Maudsley 14e (clozapine plasma level table). APA Schizophrenia 2020.
Buprenorphine for OUD (Suboxone, Subutex, Sublocade)
Indication referenced: Opioid use disorder maintenance. X-waiver eliminated by MAT Act 2023; any DEA-registered prescriber may now prescribe.
Baseline / induction readiness
- Confirm OUD diagnosis (DSM-5)
- Patient must be in objective opioid withdrawal: COWS ≥8 (preferred ≥12) before first dose to avoid precipitated withdrawal
- Last short-acting opioid ≥12–16 h ago; long-acting ≥24–48 h; methadone ≥72 h (and at ≤30 mg)
- Pregnancy test, LFTs, HIV/HCV screen
Day 1 induction (SL film/tablet)
| Time | Dose |
|---|---|
| 0 h (after COWS confirmed) | 2–4 mg SL |
| +1–2 h | If withdrawal persists: 2–4 mg additional (total day 1: 8 mg recommended; up to 16 mg) |
Day 2–7
Increase by 2–4 mg/day to target 16 mg/day (range 8–24 mg). Most patients stable at 16–24 mg/day. FDA max 24 mg/day for buprenorphine/naloxone (Suboxone).
Home / unobserved induction
Acceptable for patients with stable housing and reliable contact. Provide written COWS instructions, dosing schedule, and same-day phone follow-up.
Microinduction (Bernese method)
For patients on full opioid agonists who cannot tolerate withdrawal:
| Day | Buprenorphine |
|---|---|
| 1 | 0.5 mg SL once |
| 2 | 0.5 mg SL BID |
| 3 | 1 mg SL BID |
| 4 | 2 mg SL BID |
| 5 | 3 mg SL BID |
| 6 | 4 mg SL BID |
| 7 | 12 mg SL once; stop full agonist |
| 8+ | 16 mg SL once daily |
Sublocade (extended-release SC monthly)
Requires ≥7 days of stable transmucosal buprenorphine first. 300 mg SC abdominal x 2 monthly doses, then 100 mg SC monthly (may continue 300 mg/month if needed). Inject by HCP only.
Pregnancy
Buprenorphine monoproduct (Subutex) historically preferred; current evidence supports buprenorphine/naloxone as well. Continue MOUD — do not taper.
Sources: Buprenorphine FDA PIs (Suboxone, Subutex, Sublocade). SAMHSA TIP 63 (2021). ASAM National Practice Guideline 2020. MAT Act 2023.
Naltrexone (ReVia, Vivitrol)
Indications referenced: Alcohol use disorder, opioid use disorder (after detox).
Baseline workup
- LFTs (AST/ALT, bilirubin); avoid if acute hepatitis or liver failure
- Urine drug screen confirming no opioid use
- Pregnancy test
- Counseling on overdose risk if relapse occurs after blockade wears off (loss of tolerance)
Oral naltrexone (AUD or OUD)
Optional naloxone challenge: 0.4–0.8 mg IM/SC; observe 30 min for withdrawal. If negative: 50 mg PO daily. Some clinicians start with 25 mg x 1–2 days to assess tolerance. Maintenance 50 mg/day; may use 100 mg MWF or 150 mg M/Th regimens for adherence. Max 150 mg/dose.
Vivitrol (extended-release IM)
380 mg IM gluteal q4 weeks. Alternate buttocks. Use the supplied 1.5-inch needle for non-obese; 2-inch needle for obese patients. Avoid SC infiltration (necrosis risk).
Surgical / acute pain planning
Stop oral naltrexone 72 h before elective surgery; Vivitrol effect persists 30 days. For breakthrough acute pain: regional anesthesia, ketamine, NSAIDs, or high-dose opioids in monitored setting.
Monitoring
LFTs at baseline, 1 month, then q3–6 months. Counsel on overdose risk after discontinuation. Document medication-assisted treatment in shared care plan.
Sources: Naltrexone FDA PI (oral and Vivitrol). SAMHSA TIP 63 (OUD), TIP 49 (AUD). ASAM 2020. APA AUD Practice Guideline 2018.
Methadone for OUD
Indication referenced: Opioid use disorder maintenance. For OUD, must be dispensed via SAMHSA-certified Opioid Treatment Program (OTP). Office-based prescribing for OUD remains restricted (2024 SAMHSA rule expansion permits OTP take-home flexibility, not office prescribing).
Baseline workup (OTP)
- Confirm OUD diagnosis (DSM-5), document ≥1 year continuous opioid dependence (federal requirement, with exceptions)
- ECG for QTc (especially if >100 mg/day anticipated, cardiac history, electrolyte abnormalities, or interacting drugs)
- Pregnancy test, HIV/HCV/HBV screen, TB screen
- Urine drug screen, breathalyzer
- Med rec for QT-prolonging drugs (ondansetron, fluoroquinolones, fluconazole, antipsychotics)
Induction (SAMHSA / federal opioid treatment standards)
| Day | Dose |
|---|---|
| 1 | 20–30 mg PO (initial); reassess at 2–4 h. May give additional 5–10 mg if persistent withdrawal. Total day 1 must not exceed 40 mg unless documented tolerance. |
| 2–4 | Hold day 1 dose; do not increase. Steady state not yet reached. |
| 5+ | Increase by 5–10 mg every 5–7 days based on withdrawal symptoms and craving |
| Maintenance | Typical effective range 60–120 mg/day; some patients require >120 mg (check QTc and trough level) |
QTc monitoring
| QTc | Action |
|---|---|
| <450 ms | Continue; recheck if dose >100 mg or new QT-prolonging drug |
| 450–500 ms | Discuss risk; reduce dose or switch to buprenorphine; remove QT-prolonging meds |
| >500 ms | Strongly consider discontinuation or alternative MOUD |
Drug interactions
CYP3A4 inducers (rifampin, phenytoin, carbamazepine, efavirenz) lower methadone levels — risk of withdrawal and relapse. CYP3A4 inhibitors raise levels — risk of overdose. Avoid combining with benzodiazepines unless clinically essential (FDA 2017 advisory; black box).
Pregnancy
Methadone (or buprenorphine) is standard of care for OUD in pregnancy. Doses often need to increase by 30–50% in 3rd trimester due to increased clearance; may need split dosing. Continue MOUD — do not taper.
Sources: Methadone FDA PI. SAMHSA Federal Opioid Treatment Standards (42 CFR Part 8). SAMHSA TIP 63 (2021). ASAM National Practice Guideline 2020. CSAT Methadone Mortality Reassessment.
🔄 Switching & Withdrawal Protocols
Interactive calculators and scoring tools. All outputs are decision support — confirm against current FDA labeling and patient-specific factors.
Antidepressant Switching Tool
Per-drug, dose-aware switching schedules. Uses FDA prescribing information, Stahl 7e, Maudsley 14e, and serotonin-syndrome washout rules. Always individualize.
FINISH discontinuation mnemonic = Flu-like, Insomnia, Nausea, Imbalance, Sensory disturbance, Hyperarousal. Highest risk with paroxetine, venlafaxine IR, fluvoxamine; very low with fluoxetine.
CIWA-Ar (Alcohol Withdrawal)
10 items. Items 1–9: 0–7. Item 10 (orientation): 0–4. Max 67.
Total: 0
COWS (Clinical Opiate Withdrawal Scale)
11 items. For buprenorphine induction, target ≥8–12 to reduce risk of precipitated withdrawal.
Total: 0
Benzodiazepine & Z-Drug Taper Calculator
Comprehensive multi-BZD taper engine. Sums diazepam-equivalents across all entries, applies an evidence-based protocol, and outputs a step-by-step schedule with both diazepam-equivalent and original-drug mg per step. Includes CIWA-B (Busto 1989) and special-population modifiers.
Patient's current BZD/Z-drug regimen
Taper protocol
Special-population modifiers
CIWA-B — Clinical Institute Withdrawal Assessment for Benzodiazepines (Busto 1989)
Score after each dose reduction. Pause taper or extend interval if total >20.
Equivalence basis: Ashton 2002 / Maudsley 14e / Bostwick 2012. Z-drugs cross-tapered to diazepam at zolpidem 10 mg ≈ diazepam 10 mg, eszopiclone 3 mg ≈ diazepam 10 mg, zaleplon 20 mg ≈ diazepam 10 mg. Anchor: diazepam 10 mg = 1 unit.
Clinical sources: Ashton CH. Benzodiazepines: How They Work and How to Withdraw (2002, Newcastle). Maudsley 14e. Bostwick JR et al. 2012 J Clin Pharm Ther. SAMHSA TIP 45. VA/DoD SUD Guideline 2021.
Antipsychotic Switching Tool
Per-drug, dose-aware cross-taper schedules with chlorpromazine and olanzapine equivalents (Leucht 2016, Gardner 2010). Adjusts pace for receptor-binding mismatch, partial agonism, anticholinergic rebound, and LAI elimination tail.
Clozapine: re-titrate from 12.5–25 mg if ≥48 h missed. LAI overlap (Risperidone Consta ≈ 3 wk; Aripiprazole Maintena ≈ 14 d; Paliperidone Sustenna — no overlap needed when initiated with loading regimen).
📚 Clinical Citation Sheet (PMHNP Reviewer Reference)
Per-rule, per-protocol, and per-titration source mapping for board-certified PMHNP review prior to lifting the Draft banner. Click each section to expand.
Drug Interaction Checker — curated rule sources
| Rule pattern | Primary source(s) |
|---|---|
| SSRI/SNRI + MAOI — serotonin syndrome contraindication | FDA PI (all SSRIs/SNRIs/MAOIs); Boyer & Shannon NEJM 2005; Sternbach 1991 |
| SSRI/SNRI + serotonergic opioid (tramadol, meperidine, tapentadol, methadone, fentanyl) | FDA Drug Safety Communication 2016; tramadol/meperidine FDA PI |
| SSRI + triptan — serotonin syndrome (low absolute risk) | FDA Alert 2006; Evans 2010 (Headache) |
| DXM + SSRI — serotonergic + CYP2D6 | FDA PI (dextromethorphan/quinidine, Nuedexta) |
| Lamotrigine + estrogen-containing OCP — ~50% level reduction | Lamotrigine FDA PI; Sabers 2003 (Neurology) |
| Enzyme-inducing AED + OCP — failure risk | ACOG Committee Opinion 540; AED FDA PIs (CBZ, PHT, OXC, topiramate >200 mg) |
| CYP2D6 inhibitor (paroxetine, fluoxetine, bupropion) + tamoxifen — reduced endoxifen | FDA Drug Safety Comm 2009; NCCN Breast Cancer Guidelines |
| Clozapine + smoking cessation — CYP1A2 induction loss | Clozapine FDA PI; Maudsley 14e |
| Warfarin + SSRI — GI bleed risk | FDA PI; Wallerstedt 2009 BMJ |
| SSRI + NSAID — GI bleed risk | de Abajo 2008; AGA Clinical Practice Update 2019 |
| BZD + alcohol or opioid — respiratory depression | FDA Black Box 2016 (BZD/opioid co-prescribing) |
| Methadone + CYP3A4 inducer — withdrawal | Methadone FDA PI; SAMHSA TIP 63 |
| Buprenorphine + BZD — respiratory depression | FDA Drug Safety Comm 2017; SAMHSA TIP 63 |
| Aripiprazole / brexpiprazole / cariprazine dose adjustment with CYP3A4 or CYP2D6 inhibitors | Respective FDA PIs |
| Lurasidone / quetiapine / paliperidone with strong CYP3A4 inhibitors | Respective FDA PIs |
| Clozapine + valproate (level changes); valproate + carbapenem (level drop); CBZ + doxycycline / warfarin | Respective FDA PIs; Maudsley 14e |
| Gabapentinoid + opioid — respiratory depression | FDA Drug Safety Comm 2019 |
| Modafinil + OCP — failure risk | Modafinil FDA PI |
| Stimulant + antihypertensive — antagonism / BP swings | Stimulant FDA PIs; AHA Statement 2008 |
| SSRI + tamsulosin — orthostasis | FDA PI; Bird 2013 |
| Atomoxetine + CYP2D6 inhibitor / MAOI | Atomoxetine FDA PI |
| Guanfacine + CYP3A4 modulators | Guanfacine ER FDA PI (Intuniv) |
Live label data is augmented at runtime by the OpenFDA /drug/label.json endpoint (boxed warnings, contraindications, drug interactions sections). RxNorm spelling autocomplete via /REST/spellingsuggestions.json.
Antidepressant Switching Tool — AD_META source mapping
| Drug class | Half-life, MAOI washout, disc-syndrome rating |
|---|---|
| SSRIs (fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine, vilazodone, vortioxetine) | Each FDA PI; Stahl 7e Ch 7; norfluoxetine 7–15 d half-life requires 5-week MAOI washout for fluoxetine |
| SNRIs (venlafaxine IR/XR, desvenlafaxine, duloxetine, levomilnacipran, milnacipran) | Each FDA PI; Stahl 7e; venlafaxine IR disc-syndrome rate documented in Fava 2006 |
| Bupropion IR/SR/XL — MAOI hypertensive crisis | Bupropion FDA PI; Stahl 7e |
| TCAs — clomipramine 21-d MAOI washout (highly serotonergic) | Clomipramine FDA PI; APA MDD Practice Guideline |
| MAOIs (phenelzine, tranylcypromine, isocarboxazid, selegiline transdermal, moclobemide) — 14-d MAO regeneration before serotonergic agent | Each FDA PI; selegiline patch tyramine-diet threshold ≥9 mg/24 h |
| Hyperbolic taper for high disc-syndrome drugs | Horowitz & Taylor 2019 Lancet Psychiatry; Maudsley Deprescribing Guidelines 2024 |
| FINISH discontinuation mnemonic | Berber 1998 (J Clin Psychiatry) |
Antipsychotic Switching Tool — AP_META source mapping
| Reference | Use in tool |
|---|---|
| Leucht et al. 2016 Schizophrenia Bulletin | Olanzapine-equivalent doses for SGAs and FGAs (10 mg olanzapine reference) |
| Gardner et al. 2010 Am J Psychiatry | Chlorpromazine equivalents (international expert consensus method) |
| FDA PIs | Starting dose, usual range, max dose for each drug; lurasidone food requirement; ziprasidone food + QTc; iloperidone slow titration; clozapine REMS |
| FDA Clozapine REMS Program (Nov 2024 update) | ANC monitoring thresholds; missed-dose re-titration |
| Aripiprazole Maintena, Risperdal Consta, Sustenna/Trinza, Sublocade FDA PIs | LAI overlap rules and elimination tail times |
| Stahl 7e and Maudsley 14e | Anticholinergic burden, sedation, QTc, prolactin, weight ratings |
| Stroup et al. 2011 Am J Psychiatry | Plateau / cross-taper outcome data |
Titration Guides — per-drug source mapping
| Guide | Sources |
|---|---|
| Lamotrigine | Lamotrigine FDA PI (rash titration schedule); Calabrese 2003; APA Bipolar 2002 + reaffirmations; Maudsley 14e |
| Lithium | Lithium FDA PI; APA Bipolar Practice Guideline; NICE CG185; Maudsley 14e (level table) |
| Quetiapine IR/XR | Seroquel and Seroquel XR FDA PIs; Stahl 7e; APA Schizophrenia 2020 |
| Clozapine | Clozapine FDA PI; Clozapine REMS 2024; Maudsley 14e (plasma levels); APA Schizophrenia 2020 |
| Buprenorphine (SL film/tab, Sublocade) | Suboxone, Subutex, Sublocade FDA PIs; SAMHSA TIP 63 (2021); ASAM National Practice Guideline 2020; MAT Act 2023 |
| Naltrexone (oral, Vivitrol) | Naltrexone FDA PIs; SAMHSA TIP 63 and TIP 49; APA AUD 2018; ASAM 2020 |
| Methadone for OUD | Methadone FDA PI; SAMHSA Federal OTP Standards 42 CFR Part 8; SAMHSA TIP 63; ASAM 2020 |
Withdrawal scales — instrument citations
| Scale | Citation |
|---|---|
| CIWA-Ar (Alcohol) | Sullivan et al. 1989 Br J Addict 84:1353 |
| COWS (Opiate) | Wesson & Ling 2003 J Psychoactive Drugs 35:253 |
| BZD taper (Ashton method) | Ashton 2002 Benzodiazepines: How They Work and How to Withdraw (Newcastle) |
Benzodiazepine & Z-Drug Taper — sources
| Component | Source |
|---|---|
| Equivalence anchor (diazepam 10 mg) | Ashton 2002 (Newcastle); Maudsley 14e |
| Per-drug equivalence (alprazolam 0.5, clonazepam 0.5, lorazepam 1, oxazepam 15, etc.) | Ashton 2002 Equivalence Table; Bostwick et al. 2012 J Clin Pharm Ther |
| Z-drug cross-tolerance (zolpidem 10 mg, eszopiclone 3 mg, zaleplon 20 mg) | Maudsley 14e; FDA PIs; Brandt & Leong 2017 |
| Ashton classic and accelerated protocols | Ashton CH. Benzodiazepines: How They Work and How to Withdraw (2002) |
| Hyperbolic taper | Horowitz & Taylor 2019 Lancet Psychiatry; Maudsley Deprescribing Guidelines 2024 |
| VA/DoD inpatient short-acting | VA/DoD Substance Use Disorder Clinical Practice Guideline 2021 |
| Special-population modifiers (elderly, hepatic, pregnancy, opioid, prior seizure) | Maudsley 14e; SAMHSA TIP 45; FDA Drug Safety Communication 2016 (BZD/opioid black box); ACOG Committee Opinion 711 |
| CIWA-B scale | Busto UE et al. 1989 J Subst Abuse Treat |
| Phenobarbital cross-taper consideration | Kawasaki et al. 2012 J Hosp Med; ASAM guidance |
Reviewer sign-off checklist
- Verify each interaction rule against current Lexicomp / Micromedex entries
- Spot-check 5 random switching scenarios against APA / NICE / Maudsley current edition
- Confirm Quetiapine / Clozapine / Buprenorphine / Naltrexone / Methadone titration matches latest FDA PI
- Confirm REMS, OTP, and 42 CFR Part 8 statements current as of review date
- Document reviewer name, NPI, license number, review date, and version SHA in internal log before lifting Draft banner
Decision-support classification. This page is decision support for licensed prescribers, not a CDS-certified system, not a substitute for Lexicomp / Micromedex / UpToDate, and not a CDSS subject to FDA Section 520(o)(1)(E) device classification (per 21st Century Cures Act exemption: provides recommendations to HCPs, allows independent review of basis, does not analyze image/signal/pattern data). PMHNP reviewer sign-off required before removing the Draft banner.
Join The FREE Challenge
Enter your details below to join the challenge.