On this podcast episode, I cover commonly used medications for opioid use disorder. Buprenorphine, methadone, and naltrexone are all potential options in OUD. I’ll discuss the pharmacology of each medication and the most common practice pearls that will show up in practice and on your board exams.
Naltrexone is often a first-line medication for AUD. It works as an opioid receptor antagonist, reducing the rewarding effects of alcohol and decreasing cravings. Patients frequently report that alcohol becomes less pleasurable while taking the medication. Oral naltrexone is typically dosed at 50 mg daily, while a long-acting injectable formulation is also available. Avoid use in patients taking opioids and use caution in significant liver dysfunction.
Acamprosate helps maintain abstinence by modulating glutamate and GABA neurotransmission. Chronic alcohol use disrupts the balance between excitatory and inhibitory pathways in the brain, and acamprosate helps restore equilibrium. It is primarily eliminated renally, making it a useful option in patients with liver disease. The most common adverse effect is diarrhea.
Disulfiram works through a completely different mechanism. It inhibits aldehyde dehydrogenase, causing acetaldehyde accumulation when alcohol is consumed. This can lead to flushing, nausea, vomiting, headache, and hypotension. Because of this aversive reaction, patient motivation and adherence are critical for success.
In this episode, we explore monoamine oxidase inhibitors (MAOIs), one of the oldest yet most effective classes of antidepressants. We discuss how MAOIs such as phenelzine, tranylcypromine, isocarboxazid, and selegiline work by increasing serotonin, norepinephrine, and dopamine levels in the brain. The episode reviews their unique role in treatment-resistant and atypical depression, key adverse effects, important dietary considerations involving tyramine-containing foods, and potentially serious drug interactions. We also highlight practical clinical pearls to help pharmacists and healthcare professionals safely and effectively use these powerful but often underutilized medications.
In this episode, we explore four unique antidepressants that do not fit neatly into the traditional SSRI or SNRI categories: trazodone, nefazodone, vilazodone, and vortioxetine. Trazodone and nefazodone are classified as serotonin antagonist and reuptake inhibitors (SARIs), working primarily through blockade of 5-HT2 receptors while also inhibiting serotonin reuptake. Trazodone’s strong antihistamine and alpha-1 blocking properties make it highly sedating and commonly used off-label for insomnia, whereas nefazodone causes less sedation but is rarely prescribed today because of its association with severe and potentially fatal liver toxicity. Both agents are notable for producing less sexual dysfunction than many traditional SSRIs.
We also discuss two newer multimodal antidepressants: vilazodone (Viibryd) and vortioxetine (Trintellix). Vilazodone combines serotonin reuptake inhibition with partial agonism at the 5-HT1A receptor, a mechanism often compared to combining an SSRI with buspirone. Vortioxetine has an even more complex pharmacology, acting as a serotonin reuptake inhibitor while modulating multiple serotonin receptor subtypes through agonist, partial agonist, and antagonist actions. This multimodal activity may contribute to benefits in cognitive symptoms associated with major depressive disorder. Throughout the episode, we compare receptor pharmacology, clinical applications, adverse effect profiles, and the unique characteristics that distinguish these medications from more commonly prescribed antidepressants.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) are a class of antidepressants that increase serotonin and norepinephrine levels in the brain. Common agents include venlafaxine (Effexor XR), desvenlafaxine (Pristiq), duloxetine (Cymbalta), levomilnacipran (Fetzima), and milnacipran (Savella). In addition to treating depression and anxiety disorders, several SNRIs have important pain indications, making them especially useful in patients with neuropathy, fibromyalgia, or chronic musculoskeletal pain. Common adverse effects include nausea, sweating, insomnia, sexual dysfunction, and elevated blood pressure. Clinicians should also remember the significant discontinuation risk associated with shorter half-life agents like venlafaxine and desvenlafaxine.
Mirtazapine is a unique antidepressant often chosen when depression occurs alongside insomnia or poor appetite. Its antihistamine activity makes it sedating, particularly at lower doses, and it commonly increases appetite and weight. Unlike many SSRIs, mirtazapine has a lower risk of sexual dysfunction and gastrointestinal side effects because it blocks 5-HT2 and 5-HT3 receptors. It is frequently dosed at bedtime and can be especially useful in older adults or medically ill patients who need both mood improvement and help with sleep or weight gain.
Bupropion is an activating antidepressant that works by increasing norepinephrine and dopamine activity rather than serotonin. It is often preferred in patients with fatigue, low motivation, hypersomnia, or concerns about sexual dysfunction and weight gain. Bupropion is also approved for smoking cessation. Common adverse effects include insomnia, anxiety, dry mouth, and headache. A major clinical pearl is its dose-related seizure risk, making it contraindicated in patients with seizure disorders or eating disorders such as anorexia nervosa or bulimia.
Welcome to today’s episode on the tricyclic antidepressants, commonly known as TCAs — one of the foundational medication classes in psychopharmacology. Although newer antidepressants like SSRIs often dominate modern prescribing, TCAs remain highly relevant in clinical practice because of their effectiveness in treatment-resistant depression, chronic pain syndromes, migraine prevention, insomnia, and certain anxiety disorders. In this episode, we’ll break down the pharmacology behind these medications, discuss how tertiary amines differ from secondary amines, review major adverse effects and drug interactions, and highlight the key clinical pearls that healthcare professionals and students need to know. Whether you’re a medical, pharmacy, nursing, or PA student preparing for exams, or a practicing clinician looking for a practical refresher, this episode will give you a solid framework for understanding this classic but still clinically important medication class.
SSRI adverse effects are critical to know. In part 2 of this 2-part series on SSRIs, we cover the most important adverse effects to know, in addition to putting a nice bow on the most important clinical practice pearls on each SSRI. Enjoy the show!
In this episode, we break down the pharmacology of selective serotonin reuptake inhibitors (SSRIs) with a focus on the high-yield clinical pearls pharmacists, medical students, and healthcare professionals need to know. We compare the major SSRIs—including fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and fluvoxamine—based on adverse effects, drug interactions, pharmacokinetics, and board exam relevance. Topics include serotonin syndrome, discontinuation syndrome, CYP450 interactions, QT prolongation, sexual dysfunction, weight changes, and SSRI selection in special populations such as older adults and pregnancy. Whether you are preparing for exams, clinical rotations, or looking to sharpen your psychopharmacology knowledge, this episode provides practical and memorable insights into one of the most commonly prescribed medication classes. This is Part 1 of 2.
Alprazolam is a short-acting benzodiazepine that enhances the inhibitory effects of gamma-aminobutyric acid (GABA) at the GABA-A receptor. Clinically, this results in anxiolytic, sedative, muscle-relaxant, and anticonvulsant effects.
After oral administration, alprazolam is rapidly absorbed, with onset of action typically within 30–60 minutes. It undergoes extensive hepatic metabolism primarily via CYP3A4 to inactive metabolites, and has an elimination half-life of approximately 11 hours, which may be prolonged in elderly patients or those with hepatic impairment.
Common adverse effects include sedation, dizziness, impaired coordination, and cognitive slowing. More serious risks include respiratory depression, especially when combined with opioids, alcohol, or other CNS depressants.
Clinically, alprazolam should be used at the lowest effective dose for the shortest possible duration. Abrupt discontinuation should be avoided; gradual tapering is essential to reduce withdrawal risk. It is a controlled substance that carries the risk of addiction and dependence.
