Tobacco - Block 3 Flashcards
What are the causes for tobacco dependence?
- Tolerance
- Withdrawal sx
- Cravings
- Self regulation
What is the DSM 5 criteria for TUD?
Considered an addiction if 2 or more apply:
1. Withdrawl sx
2. Tolerance
3. Desire or efforts to cut down/control use
4. Great time spent in obtaining/using
5. Reduced occupational, recreational activities
6. Use despite problems
7. Larger amounts consumed than intended
8. Cravings
What are the role of a pharmacist on tobacco use?
Ask about tobacco use and secondhand exposure
Advise to quit
Assess readiness to quit
Assist in quit attempt (counseling, referral)
Arrange for patient to quit
DDI for smokin
- Induces P450
- Affects how the body metabolizes meds
- Interacts with antipsychotics, antidepressants
Tx goals for chronic relapse?
Treat for as long as it takes and eliminating withdrawal sx
What is the 2 part problem with tobacco dependence?
What is the neurotransmitter activity of nicotine?
Dopamine: pleasure, appetitie suppression
NE: arousal, appetite suppression
Ach: arousal, cognitive enhancement
Glutamate: learning, memory enhancement
Seratonin: mood modulation, appetite suppression
Endophins” reduction of anxiety, tension, pain
GABA (decrease): reduction in ax, tension, enhance reinforcing effects of nicotine
What are the sx of nicotine withdrawal?
- Irritability
- Ax
- Difficulty concentrationg
- Restlessness
- Depression
- Insomnia
- Impaired performance
- Increased appetite
- Craving
What are the approved cessation products?
- Bupropion
- Varenicline
- Nicotine patch
- Nicotine gum
- Nicotine lozenges
- Nicotine inhaler
- Nicotine nasal spray
What is 2nd line cessation med?
Off label: Nortriptyline, clonidine
Nicotine vaccine (under development)
Benefits of using NRT?
- Improves chances of quitting
- Makes indiivduals more comfortable while quitting
- Allows consumers to focus changig behaviors
- No harmful toxins
What are OTC nicotine TX?
Pathc: 7mg, 14mg, 21 mg
Gum: 2mg, 4mg
Lozenge: 2mg, 4mg
Prescription nicotine tx?
Inhaler and nasal spray
What are the ADRs of nicotine?
- HA/N/DZ
- Vivid dreams
- Insomnia
- Application site rx
- Oral sores and ulcers
- nasal tract inrritation
- Diarrhea
- Dyspepsia
CI of nicotine cessation?
- Arrhythmia
- Unstable angina
- Pregnancy (safe)
- Uncontrolled HTN
- COPD (inhaler)
DDI of nicotine tx?
- Buproprion SR (unlikely)
- Caffeine increases metabolism
- Insulin
- Antipsychotics
Counseling for nicotine patch?
- Absorbed in skin
- Can take up to 6H to reach peak
- Wear above waist, non hairy
- DOn’t cut
- Wear and reapply Q24H
- ADR: JA, N, DZ, skin irritation at site
- Don’t apply heat
- Remove if undergoing radiological procedures
- Apply upon waking
- Move patch each day to reduce ADR
- Can remove at night if bothersome
Advantages of using pathces?
- OTC
- Best adherence
- Less control over situational craving
Dosing recommendations for patches
Clients who smoke 1PPD: Step 1 (21mg)
Clients who smoke ½ PPD: Step 2 (14 mg
Clients who smoke < ½ PPD: Step 3 (7mg)
Patient remains on each step for 6 weeks before stepping down
General rec: 1mg NRT per cig smoked
* For heavy smokers: 20-39 cpd: 21-42mg
How long does patch tx last?
Minimum 10-12 weeks, consider longer
Considerations f using nicotine gum?
- Many flavors
- Not a good choice for people with jaw problems, braces, retainers, dentures, and dental work
- Irritate mouth and throat -> dryness
Counseling of nicotine gum?
- Chew few times and park
- Good for irregular smokers
- Chewing too much or too fast increases S/E’s
- No eating/drinking 15 min before or during use
Dosing of gum?
- 1 piece x 1-2 hr
- Can use 24 pieces/day
- 12 weeks recommneded, can go longer or reduce over few weeks
Counseling for lozenge?
- Moisten then “park” between cheek and gum line
- Sugar free
- May irritate mouth and throat -> dryness
- No eating / drinking 15 min before or during use
- Good for ‘irregular’ smokers Yields higher nicotine delivery relative to gum
Dosing of lozenge
1 lozenge x at least 8-10/day
Up to 20 per day
Standard course = 12 weeks
When do you use 2mg over 4mg?
2mg: Iff you smoke more than 30 min after waking
4mg: if smoke within 30 min of waking
What do combo NRT regimens look like?
Considerations for nicotine inhalers?
- Absorbed through lining of mouth
- Mimics hand-to-mouth action of smoking (script only)
- May irritate the mouth and throat and cause dryness if not used properly
Dosing of nicotine inhalers?
- 6-16 cartridges/day
- 20 min of continuous use
- Viable for 24H once opened
- Treat 12 weeks can taper over 6-12 additional weeks
- Stop use if not abstinent in 4 weeks (monotherapy)
Counseling points for inhaler?
- Inhale into mouth (not lungs), hold, exhale
- Not inhaler, so use as puffer
Considerations of nasal spray?
Nicotrol NS
1. Quick absobtion in lining of nose
2. Largest spike of nicotine
3. Sneezing, sore throat, runny nose and eyes
4. High liability for abuse
5. Good option for highly addicted users
6. Don’t inhale while spraying
Dosing of nasal sray?
- Dosage Maximum 40 per day (1 spray in each nostril)
- Average use = 1dose/hr
- 100 doses per bottle
- Standard course is 12 weeks
- Stop if abstinent in 4 weeks
Uses of bupropion SR for cessation?
- Can be used alone or in combination with NRTs
- Effective among pts with depressive disorders
- Non-sedating, activating antidepressant
- Best suppression on weight gain
ADR: HA, insomnia, agitation, dry mouth, shakiness
Dosing for Wellbutrin
150mg SR QD x 3 days; 150mg SR BID x 11 weeks
ALt: 150mg SR QD x 7 days to reduce ‘overstimulation’ S/E’s
1. Quit date at least 14 days
2. Separate dose by 8H
3. Take last dose late afternoon if evidence of sleep disturbnces
4. DC if no progress within 7 weeks
Uses of VArenicline for cessation?
- Reduces the amount of physical and mental pleasure received from tobacco by antagonizing nicotine -> redce crazings and withdrawal
- Use with NRTs not recommended
- Dosed in graduating strengths (0.5mg -> 1mg)
- N andvivid dreams
- 12 week course, but can be extended
Dosing of Varenicline
How do you manage insomnia ADR?
BUP: separate doses by 8+ hours; last dose no later than 4pm; reduce dose
NRT: remove patch 1 hour prior to bedtime and replace immediately upon awakening; reduce dose
VAR: may diminish with time; reduce dose
How do manage dry mouth ADR?
BUP: usually diminishes with time; reduce dose
How do you manage unusual/vivid dream ADR?
NRT: often diminishes with time; remove patch 1 hour prior to bedtime
VAR: may diminish with time; reduce dose
How do you manage N ADR?
VAR: may diminish over time; reduce dose; treat medicinally
How do you manage Jaw Muscle Ache, Hiccups, Nausea?
GUM: correct ‘chewing’ technique, alternate form of NRT
How do you manage mouth ulcers ADR?
NRT: popsicles; steroid injections; *magic mouthwash (MOM/Maalox + liquid benadryl + 2% viscous lidocaine, 1:1:1; shake, swish, spit)
How do you manage skin burning and itching ADR?
TNP: re-locate switch to alternate NRT
How do you manage vmiting ADR?
VAR: eat 1st; lower dos
Ways we can encourage patients to pursue smoking cessation?
Motivational interviewingq
What are the principles for motivational interviewing?
- Roll with resistance
- Express empathy
- Avoid argumentation
- Develop discrepancy
- Support self efficacy
