Naltrexone

- Alcohol use disorder treatment (first-line) ^a 

- Can cause weight loss

- May prevent accidental opioid overdose.

- Contraindicated in opioid use disorder / opioid agonist treatment or any use of opioids (surgery, dental pain)

- Can cause weight loss and nausea

- Liver enzyme elevation, requires monitoring ^a 

Start at 25 mg daily PO with food. Increase to 50 mg after one week. Consider off-label dosing 100–150 mg daily if helpful. ^a 

Bupropion

- ADHD treatment (off-label)

- Can cause weight loss

- Effective antidepressant

- Smoking cessation treatment.

- Seizure risk

- Mania risk in bipolar/ schizoaffective disorder

- Misuse/ insufflation/ injection risk

- Can cause weight loss

Start at 150 mg daily, XL formulation preferred. Increase to 300 mg after a few weeks. Can increase to 450 mg if tolerated (increased seizure risk).

Mirtazapine

- Insomnia treatment (off-label)

- Effective antidepressant

- Risk of weight gain or appetite increase

- Mania risk in bipolar/ schizoaffective disorder

- Risk of weight gain and sedation

Start at 15 mg QHS. Increase to 30 mg QHS after a few weeks. Max dose 45 mg QHS.

Topiramate

- Seizure prophylaxis benefit

- Alcohol use disorder treatment (off-label)a

- Risk of weight loss

- Cognitive side effect risk Teratogenic risk

- Adherence/ discontinuation risk (seizures)

- Risk of weight loss

Titrate gradually starting at 25 mg once daily. Increase total daily dose gradually (by 25–50 mg weekly) to max 300 mg/day. Doses over

-50 mg/day should be in two divided doses.

Psychostimulants (methylphenidate, amphetamine-type stimulants, modafinil)

- Concurrent ADHD treatment Risk of weight loss

- Likely more effective for cocaine than amphetamine-type drug

*Long-acting formulations are recommended

- Contraindicated in psychosis or mania, even if induced by substance useb

- Misuse – consider duration of prescription, or observed doses at pharmacy

- Cardiac arrhythmia risk

Depends on specific formulation. Start low and increase as tolerated.