EXAM 3 Nicotine Use Disorder Dr. Dahl

Question 1

What is the most effective approach for smoking cessation? Pharmacotherapy or behavioral intervention?

Answer 1

Both are, based on guidelines

Question 2

Health Impacts - smoking

Answer 2

-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

Question 3

Health Impacts on lungs - smoking

Answer 3

-emphysema
-asthma
-chronic bronchitis
-chronic obstructive pulmonary disease (COPD)

-Lung cancer

others: T2DM, cataracts (eye), erectile dysfunction, rheumatoid arthritis, decreased wound healing

Question 4

Issues associated with Smokeless Tobacco

Answer 4

-periodontal
->Gingival recession
->Bone attachment loss
->Dental caries
-oral leukoplakia
-cancer: oral, pharyngeal, esophageal, pancreatic

Question 5

Which receptors are affected by Nicotine?

Answer 5

-Dopamine
-Serotonin

-Norepinephrine
-Acetylcholine

-Glutamate
-GABA (reduction of anxiety and tension)

Question 6

When after cessation do symptoms start?

Answer 6

starts within 24h -> peak 24-72h
may persist for days, weeks, or longer

-anxious
-cravings
-frustration
-irritability
-impatience
-hostility
-Insomnia
-Restlessness
-difficulty concentrating

Question 7

Which test is used to assess readiness for smoking cessation?

Answer 7

-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

Question 8

Stages of Quitting

Answer 8

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

Question 9

What DDIs are associated with smoking?

Answer 9

-many DDIs are caused by tobacco not nicotine
-CYP 1A2 induction

Question 10

How to dose adjust when CYP1A2 substrates are used?

Answer 10

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

Question 11

How does nicotine affect caffeine effects when quit smoking?

Answer 11

CYP1A2 induction goes down -> less caffeine metabolism -> higher concentration

-> increased caffeine effects: agitation, alert, HR goes up -> this may worsen withdrawal

->cut caffeine consumption

Question 12

Which drugs increase the risk for CV events even more with heavy smoking?

Answer 12

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

Question 13

What other DDI are expected

Answer 13

-Some benzodiazepines
-some antidepressants
-some antipsychotics
-beta-blockers
-inhaled insulin
-warfarin

Question 14

What would a Quit Plan look like?

Answer 14

-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

Question 15

Triggers Coping strategies

Answer 15

-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

Question 16

Motivational Interviewing

Answer 16

READS

Rolling with resistance
Express empathy
Avoid arguing
Develop discrepancy
Support Self-efficacy

Question 17

Best way to treat

Answer 17

Medications + Counseling = MORE effective

Question 18

Who might not be eligible for medical treatment in smoking cessation?

Answer 18

-Pregnant smokers (nictione is harmful for the baby)
-Smokeless tobacco users
-Smoking less than 10 cigarettes per day
-Adolescents < 18 years old

Question 19

What are the 1st line options for medical smoking cessation?

Answer 19

-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)

Question 20

Which approach to take in treatment-resistant patients?

Answer 20

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)

Question 21

3rd line options
will not be the right answer on the exam

Answer 21

-Nortriptyline

-Clonidine: patients with agitation as a withdrawal symptom (may try clonidine if their BP is okay)

Question 22

Which medical drug should be avoided in patients with a history of seizures?

Answer 22

Bupropion
it lowers the seizure threshold

Question 23

Must patients stop smoking before they start nicotine products?

Answer 23

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

Question 24

What is on the label of OTC NRT products?

Answer 24

relative contraindication if they had a recent MI or arrhythmia

nicotine causes vasoconstriction, increases BP
->clinically they may use NRT even after MI

Question 25

What are the signs of nicotine toxicity?

Answer 25

-GI: N/V/D
-heart goes up
-cold sweats
-blurry vision
-dizziness, headache
-drooling

Question 26

OTC precaution

Answer 26

-heart disease: recent MI (2 weeks), uncontrolled HTN with meds, arrhythmias

-active stomach ulcer
-pregnancy
-under 18

-> may still be used under the supervision of a provider

Question 27

Nicotine Gum dosing

Answer 27

first cigarette within the first 30 min: 4 mg

after 30 min: 2 mg

-> Lozenges preferred in those who have temporomandibular joint (TMJ) disease or dental work done

ADE: jaw muscle soreness (are they chewing too much? -> they should do chew and park to prevent releasing too much nicotine by too much chewing)

Question 28

What is the max amount of Nicotine gums per day?

Answer 28

24 pieces

Question 29

Lozenge dosing

Answer 29

first cigarette within the first 30 min: 4 mg

after 30 min: 2 mg

allow to dissolve slowly over 20-30 min
rotate areas in the mouth

Question 30

Patient that smoked a lot, which product may fit

Answer 30

Gum or lzenge bc it is a oral substitute and might delay weight gain

use at least 9 pieces a day to increase efficacy in the initial week

Question 31

What should you avoid before using gum or lozenges?

Answer 31

no food or beverage 15 min before or during use

Question 32

What are the dose instructions for nasal sprays as NRT?

Answer 32

2 sprays (1 in each nostril) = 1 dose

Use 1-2 doses/h - max: 5 doses/h
8-40 doses/day - max: 40 doses/day

avoid in chronic nasal disorders (rhinitis, nasal polyps, sinusitis)

Question 33

Which dose of transdermal nicotine patches are used?

Answer 33

it comes in 7, 14, 21 mg

> 10 cigarettes per day: start at 21 mg
<10 cigarettes per day: start at 14 mg

Question 34

How to treat skin irritations with transdermal nicotine patches?

Answer 34

local skin irritations are normal (around the area of application) -> use hydrocortisone cream

if extends beyond that area or hydrocortisone cream doesn’t help -> REFER

Question 35

When should NRT patches be removed?

Answer 35

-change after 24h
-bothersome dreams
-sleep disturbances
-MRI screen -> it may cause burns bc it can contain metal

Question 36

What are the contraindications of Bupropion use?

Answer 36

-seizure disorder
-anorexia nervosia and bulimia
-MAO inhibitors

Question 37

When should Bupropion treatment be started?

Answer 37

1-2 weeks before Quit Date
-it needs time before we have enough levels in the system

treat for 7-12

Question 38

How long should you treat with Bupropion?

Answer 38

treat for 7-12 weeks

may extend to 6-12 months

Question 39

Which formulation of Bupropion is approved for smoking cessation therapy?

Answer 39

12h Sustained released (SR) formulation

if they are taking it twice a day make sure there is an 8h gap in between

Question 40

MOA Varenicicline (Chatnix)

Answer 40

blocks the nicotinic receptor (α4β2) and partially agonizes them

-Chantix will cause moderate levels of dopamine - so not the same sensation as with smoking

Question 41

When to initiate Varenicline therapy?

Answer 41

-Begin 1 week before Quitting
OR
SLOW TURKEY
-begin 8-35 days before quitting
-Start Chantix and slowly cut back smoking (50% every 4 weeks) -> abstinence at 12 weeks (may need to extend Chantix therapy afert quitting)

Question 42

What are the common side effects of Varenicline?

Answer 42

Nausea !!! -> take after eating with a full glass of water

also headache, insomnia, abnormal dreams

Question 43

When to consider alternative treatment strategies?
Not on exam

Answer 43

very heavy smokers:
-combine Bupropion + Varenicline
(CAUTION: bupropion had a BBW for depressed mood, agitation, suicidal thoughts, suicide attempts)

heavy side effects with Varenicline (nausea):
lower the dose
1mg daily or 0.5 mg BID

side effects with Bupropion (dry mouth, headaches, etc): low dose
150 mg once daily

-agitation withdrawal: add clonidine
-OFF-label use of higher dose of Varenicline and nicotine patch (42 mg, double the dose)