EXAM 3 Nicotine Use Disorder Dr. Dahl Flashcards
What is the most effective approach for smoking cessation? Pharmacotherapy or behavioral intervention?
Both are, based on guidelines
Health Impacts - smoking
-Physiologic: proinflammatory, impaired immune function, vasoconstriction, increased BP and cardiac output, more oxygen demand
-CV disease: stroke, cardiac death, ACS (acute coronary syndrome), peripheral vascular disease
Health Impacts on lungs - smoking
-emphysema
-asthma
-chronic bronchitis
-chronic obstructive pulmonary disease (COPD)
-Lung cancer
others: T2DM, cataracts (eye), erectile dysfunction, rheumatoid arthritis, decreased wound healing
Issues associated with Smokeless Tobacco
-periodontal
->Gingival recession
->Bone attachment loss
->Dental caries
-oral leukoplakia
-cancer: oral, pharyngeal, esophageal, pancreatic
Which receptors are affected by Nicotine?
-Dopamine
-Serotonin
-Norepinephrine
-Acetylcholine
-Glutamate
-GABA (reduction of anxiety and tension)
When after cessation do symptoms start?
starts within 24h -> peak 24-72h
may persist for days, weeks, or longer
-anxious
-cravings
-frustration
-irritability
-impatience
-hostility
-Insomnia
-Restlessness
-difficulty concentrating
Which test is used to assess readiness for smoking cessation?
-Fagerstorm test
low dependence (1-2)
low-moderate (3-4)
moderate (5-7)
high dependence (8+)
-Why I Smoke, Likert scale
18 questions -> helpful to find behavioral interventions
Stages of Quitting
Stage 1: not ready within the next month
Stage 2: ready within the next month
Stage 3: recent quit with last 6 months
Stage 4: former tobacco user who quit more than 6 months ago
What DDIs are associated with smoking?
-many DDIs are caused by tobacco not nicotine
-CYP 1A2 induction
How to dose adjust when CYP1A2 substrates are used?
Not a prodrug: Clozapine, Caffeine
CYP1A2 induction -> lower concentration
->while smoking: may need a higher dose
->when quitting: lower doses
Prodrug: Clopidogrel
CYP1A2 induction -> higher concentration
while smoking: lower dose
while quitting: may need a higher dose
How does nicotine affect caffeine effects when quit smoking?
CYP1A2 induction goes down -> less caffeine metabolism -> higher concentration
-> increased caffeine effects: agitation, alert, HR goes up -> this may worsen withdrawal
->cut caffeine consumption
Which drugs increase the risk for CV events even more with heavy smoking?
estrogen-containing contraceptives
-> Increase in thrombin activity, clotting factor production
-highest risk in heavy smoking (>15 cigarettes per day) and age >35
->endothelial dysfunction, changes in coagulation -> CV risk
-both increase the risk for clotting by themself, now combined even higher risk
What other DDI are expected
-Some benzodiazepines
-some antidepressants
-some antipsychotics
-beta-blockers
-inhaled insulin
-warfarin
What would a Quit Plan look like?
-QUIT DATE – should be set -> Within 2 days to 2 weeks
-Top reasons for quitting
-Smoke-free-vision
-Top triggers à Top coping strategies
-Support system
Triggers Coping strategies
-Stimulation: walk or jog to boost energy
-Handling: pencil, paper clip, stress ball
-Pleasure: alternative activities or “rewards”
-Relaxation: stress relief
-Cravings: mindfulness and medications
-Habit: Avoid situations, inform others of change
Motivational Interviewing
READS
Rolling with resistance
Express empathy
Avoid arguing
Develop discrepancy
Support Self-efficacy
Best way to treat
Medications + Counseling = MORE effective
Who might not be eligible for medical treatment in smoking cessation?
-Pregnant smokers (nictione is harmful for the baby)
-Smokeless tobacco users
-Smoking less than 10 cigarettes per day
-Adolescents < 18 years old
What are the 1st line options for medical smoking cessation?
-NRT
Non-NRT
-Bupropion
-Varenicline (more effective for monotherapy)
-> Combination therapy with short-acting and long-acting (patch) NRT is more effective than monotherapy!
-> when they use a patch also offer a gum or lozenge (short-acting)
Which approach to take in treatment-resistant patients?
may increase the dose of the 1st line drug or change to varenicline
-combinations: short-acting + long-acting (if not tried already)
OR
NRT + non-NRT medication (bupropion or chantix)
3rd line options
will not be the right answer on the exam
-Nortriptyline
-Clonidine: patients with agitation as a withdrawal symptom (may try clonidine if their BP is okay)
Which medical drug should be avoided in patients with a history of seizures?
Bupropion
it lowers the seizure threshold
Must patients stop smoking before they start nicotine products?
the package says to start after quitting
-clinically it might be fine to smoke a bit while on the patch, gum or lozenges
-> with nasal spray they might wait until they quit
What is on the label of OTC NRT products?
relative contraindication if they had a recent MI or arrhythmia
nicotine causes vasoconstriction, increases BP
->clinically they may use NRT even after MI
