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Treating Tobacco Use and Dependence at OHSU

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Smoking related diseases claim over 7,000 Oregon lives annually. Smoking costs Oregon over $2 billion each year in health-care costs and lost productivity. ... – PowerPoint PPT presentation

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Title: Treating Tobacco Use and Dependence at OHSU


1
Treating Tobacco Use and Dependence at OHSU
2
Program Modules (click on topic for more detail)
  • The Tobacco Problem
  • Summary information on nicotine dependence and
    nicotine (tobacco) withdrawal.
  • Medications and behavioral support used to treat
    nicotine dependence.
  • Dosing issues and special considerations for
    cessation medications.
  • Patient care at OHSU hospitals and clinics

3
The Tobacco Problem
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4
The Tobacco Problem
  • Tobacco dependence is a chronic disease.
  • 21.5 of Oregon men and 18.4 of Oregon women
    smoke.
  • Smoking related diseases claim over 7,000 Oregon
    lives annually.
  • Smoking costs Oregon over 2 billion each year in
    health-care costs and lost productivity.
  • Smoking is directly responsible for 87 of lung
    cancer cases and causes most cases of emphysema
    and chronic bronchitis.

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5
What Can Be Done?
  • One out of two smokers will die prematurely from
    a smoking-related disease.
  • Every year nearly 45 of smokers try to quit and
    only about 10 succeed.
  • Most smokers try to quit smoking by just stopping
    cold turkey.
  • Effective cessation medications behavioral
    treatment (e.g. coaching, counseling, quit lines)
    can double or triple success rates vs cold
    turkey.
  • You save lives when you provide cessation
    treatment.

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6
Why now?
  • OHSU is completely tobacco free as of September
    17, 2007.
  • Patients coming to OHSU will not be able to
    smoke. This provides an important opportunity to
    talk to patients about quitting and help provide
    assistance to stop.
  • Evidence-based treatment protocols are widely
    available and, with your help, are being
    implemented in OHSU hospitals and clinics.

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7
Nicotine Dependence And Nicotine (Tobacco)
Withdrawal
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8
Nicotine Withdrawal Symptoms
  • Physical symptoms (can be mistaken for adverse
    drug experiences.)
  • Acute physical symptoms resolve significantly in
    3-6 weeks.
  • Some cravings persist for months, but become less
    frequent.
  • Medications are generally recommended for up to
    12 weeks.
  • Emotional symptoms (can be mistaken for adverse
    drug experiences).
  • Some emotional lability is common e.g. depressed
    affect and anxiety. (Some risk of Major
    Depressive Episode in those with recent history
    of Mood Disorder - refer for follow-up.)
  • Emotional stress due to life circumstances are
    risks for later relapse (e.g. death of loved
    one).

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9
Some Withdrawal Symptoms Following Abrupt Smoking
Cessation Or Reduction
  • Depressed mood
  • Sleep disturbance
  • Irritability, frustration or anger
  • Difficulty concentrating
  • Cravings
  • Anxiety
  • Restlessness
  • Increased appetite or weight gain
  • Decreased heart rate

SEVERITY OF WITHDRAWAL SYMPTOMS IS A PRIMARY
CAUSE OF EARLY RELAPSE.
American Psychiatric Association (1994).
Diagnostic and statistical manual of mental
disorders (4th ed.) Washington, DC.
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10
Weight Gain And Smoking Cessation Results Of A
10 Year Study
  • Weight gain is a significant barrier.
  • Weight gain or fear of weight gain after quitting
    can keep smokers from even trying to make a quit
    attempt, especially women.
  • Most smokers quitters gained weight over 10
    years.
  • Women smokers gained 3.7 lbs. (average).
  • Women quitters gained 12.1 lbs. (average)
  • Women quitters gained more than men quitters.
  • 13.4 of women quitters gained 29 lbs. vs. 9.8
    for men quitters
  • Most weight gain occurred in the 1st year.
  • Some will decide to relapse to try to lose weight.

Women and smoking a report of the Surgeon
General 2001
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11
Role Of Acetylcholine Nicotinic Receptors
  • Acetylcholine nicotinic sub receptors are normal
    structures in the brain and elsewhere of smokers
    and never smokers (16 nicotinic subtypes
    identified).
  • Nicotinic receptors modulate neurotransmitters
    (e.g. dopamine (a4ß2), norepinephrine, serotonin,
    opioid peptides, etc. in all people.
  • Nicotine binding excites receptors and disrupts
    normal activity.

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12
Role Of Acetylcholine Nicotinic Receptors
  • Chronic nicotine exposure results in permanent
    receptor up-regulation and nicotine normal
    receptor functioning in the brain.
  • Reduced nicotine binding at receptor sites due to
    reduced tobacco intake or cessation disrupts
    nicotine normal receptor activity and results
    in nicotine withdrawal symptoms.
  • Receptor activity normalizes without nicotine in
    3-6 months, but up-regulated receptors remain
    indefinitely.

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13
Click here for a comprehensive Review of Tobacco
Dependence and Tobacco Dependence Treatment
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14
Medications To Treat Withdrawal
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15
Medications
  • Who should receive them?
  • Nearly all smokers trying to quit, except those
    with medical contraindications, adolescents and
    those who smoke fewer than 10 cigarettes per day.
  • Those who have recently quit (e.g. less than 6
    months) who are concerned about relapse may
    benefit from PRN use of flexible dosed nicotine
    replacement therapies (NRT) such as nicotine
    lozenges or gum.

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16
Purpose Of Cessation Medications
  • Cessation medications are primarily designed to
    blunt withdrawal symptoms during the acute stages
    of withdrawal when a smoker quits.
  • None of the medications cure nicotine dependence
    or make smokers quit.
  • A commitment and desire to quit should be present
    prior to medications being dispensed.
  • Using an FDA approved cessation medication with
    counseling doubles the quit rates over counseling
    alone.1


1. Fiore et al. USDHHS 2000.
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17
Purpose Of Cessation Medications
  • While the primary purpose of cessation
    medications is to reduce withdrawal symptoms,
    some medications such as varenicline and
    bupropion also reduce smoking satisfaction should
    the patient smoke while on drug.1
  • Varenicline2 and bupropion3 are approved for use
    beyond usual length of treatment for maintenance
    of abstinence up to 24 total weeks (relapse
    prevention).

1. Gonzales et al. JAMA 200620647-55. 2.
Tonstad et al. JAMA. 200629664-71. 3. Hurt et
al. Addict Behav 200227493-507
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18
Compliance With Medications
  • The brain takes many weeks to adjust to low or no
    nicotine binding at nicotinic receptors.
  • Failure of medications is often due to patients
    using less medication than recommended
    (underdosing) or discontinuing medication too
    early (similar to compliance issues with
    antibiotics).
  • Ask about medication use encourage proper daily
    dosing/technique and following recommended length
    of time for dosing to increase likelihood of
    success in quitting and relapse prevention.

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19
FDA Approved First-Line Cessation Medications
  • Nicotine replacement therapies (NRT)
  • Nicotine patch
  • Nicotine lozenge
  • Nicotine gum
  • Nicotine inhaler
  • Nicotine nasal spray
  • Varenicline (Chantix) non-nicotinic
  • Bupropion SR (Zyban, Welbutrin) non-nicotinic

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20
Recommended Medications
  • Varenicline Most efficacious of meds (to date)
    no known drug-drug interactions, no
    contraindications, moderate cost, non-nicotinic.
  • Nicotine patch Average efficacy, well accepted,
    easy to use, few contraindications, lower cost.
  • Nicotine patch flexible dosing NRT (lozenge
    also gum or inhaler) Combining increases
    efficacy for more dependent smokers (4 mg lozenge
    is more efficacious than gum or inhaler).
  • Bupropion, Average efficacy, lower cost, some
    contraindications, non-nicotinic

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21
Varenicline (Chantix )
  • Rx
  • Is as effective for women as for men.1
  • No significant effect on weight gain. 1,2
  • Nausea, usually mild to moderate, occurs in up to
    30 of patients. 1,2
  • Dose may be reduced by half if nausea persists
    with less than a 10 decrease in efficacy.3

1. Gonzales et al. JAMA 200629647-55. 2.Jorenby
et al JAMA 200629656-63. 3. Chantix prescribing
instructions. Pfizer, Inc. 2006.
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22
Varenicline
  • No black box in labeling. 3
  • No known drug/drug interactions. 3
  • Not been tested in pregnant women or children. 3
  • Combination therapy has not been tested.
  • Dose adjustment (reduced) is recommended for
    patients with severe renal impairment. 3

3. Chantix prescribing instructions. Pfizer, Inc.
2006.
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23
Varenicline
  • Usual target quit day is 8th day of treatment.
  • Start with 0.5 mg daily for 3 days.
  • Increase to 0.5 mg twice daily for 4 days.
  • Increase to 1.0 mg twice daily on day 8 until
    the end of treatment (no need to taper at end of
    Tx).
  • Smoking while taking the medication does not
    increase health risk over smoking alone.
  • Common adverse events nausea, sleep
    disturbance, abnormal dreams, flatulence.
  • Average cost/day is 4.00.

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24
Nicotine Transdermal Patch
  • OTC fixed dose. Actual nicotine bioavailability
    is approximately 50 of dose listed on patch.
  • Less effective for women
  • NicodermTM, NicotrolTM, HabitrolTM, ProstepTM,
    generics.
  • Quit rates are similar for all patches.
  • Time to peak nicotine levels in brain range from
    2 hrs (Nicoderm) to 8 hrs. (a consideration if
    patches are taken off at night)
  • May delay post cessation weight gain.

Wetter et al. J Consul Clin Psychol 1999
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25
Nicotine Transdermal Patch
  • For patients who smoke 10-20 cigarettes/day 21mg
    once daily for 6-8 wks. For those who smoke 20
    cigarettes/day consider adding lozenge, gum, or
    second patch.
  • Step down to 14mg for 2 - 4 wks, then step down
    to 7 mg for 2-4 wks.
  • Common adverse events are patch site skin
    irritation, vivid dreams and sleep disturbance.
  • Can be combined with other NRT or bupropion.
  • Average cost/day is 4.00 for 21mg, 3.40 for
    14mg or 7mg.

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26
Nicotine Lozenge (nicotine polacrilex)
  • OTC - flexible dosing (2 mg 4 mg). Actual
    nicotine bioavailability is somewhat greater than
    50 of dose listed on packaging.
  • 10-15 minutes to reach the brain.
  • May be less effective for women but little gender
    data available.
  • Reduces post cessation weight gain (4 mg)1
  • Only NRT shown to be effective for re-treatment.1
  • Can be combined with a patch or used for relapse
    prevention.

1Shiffman et al. Efficacy of a nicotine lozenge
for smoking cessation. Arch Intern Med
20021621267-1276
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27
Nicotine Lozenge
  • Start one lozenge every 12 hours for first 6
    wks then one every 2-4 hours for 3 weeks, then
    one every 4-8 hours.
  • Use 4 mg for patients who smoke their 1st
    cigarette within 30 minutes of awakening, others
    use 2 mg dose.
  • Common adverse events mouth soreness and
    dyspepsia.
  • Average cost/day is 8.88.

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28
Bupropion Hydrochloride SR (Zyban ,
WellbutrinSR, generic)
  • Is as effective for women as for men1
    reduces/delays post cessation weight gain effect
    is greater in women.2
  • Reduces post cessation negative affect. 3
  • Not for those with seizure Hx, taking meds that
    lower seizure threshold, significant head trauma,
    anorexia or bulimia or who currently drink
    heavily or binge. Seizure risk is 1/1000 for SR.
  • Efficacious for re-treatment. 4

1.Gonzales et al. Am J Prev Med 200222234-39.
2.Rigotti et al. SRNT 5th Annual Meeting,
Arlington, VA. 1999. 3.Shiffman et al.
Psychopharmacologia 200014833-40. 4.Gonzales et
al. Clin Parmacol Ther 200169438-44.
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29
Bupropion SR
  • Start 150 mg once daily for 3 days, then twice
    daily for 7-12 weeks.
  • Usual target quit day is day 8 of treatment.
  • Common adverse events insomnia, sleep
    disturbance and headache.
  • Not recommended for those with any Hx of abuse of
    stimulants. Can cause agitation.
  • SR-average cost/day is 4.33.

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30
Other Nicotine Replacement Therapies
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31
Nicotine Gum (nicotine polacrilex)
  • OTC - flexible dosing (2 mg 4 mg). Actual
    nicotine bioavailability is approximately 50 of
    dose listed on packaging.
  • 10 15 minutes to reach the brain.
  • Often less effective for women.
  • Reduces/delays post cessation weight gain.
  • Not recommended for those with significant dental
    work (very stiff and sticky on dental appliances
    and can cause damage).
  • Can be used in combination with a patch and for
    relapse prevention.

Killen et al. J Consult Clin Psychol 1990
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32
Nicotine Gum
  • Use 2 mg for patients who smoke less than 15
    cigarettes/day (one 2 mg piece every 1-2 hours).
  • Use 4 mg for patients who smoke more than 15
    cigarettes/day (4 mg piece every 1-2 hours.
  • Common adverse events jaw pain and mouth
    soreness.
  • Average cost/day is 9.33 for 2 mg and 10.33 for
    4 mg dose.

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Nicotine Inhaler
  • Rx - flexible dosing. Actual bioavailability is
    approximately 50 of dose listed on packaging.
  • 10 15 minutes to reach the brain (buccal not
    lung absorption) similar to gum and lozenge.
  • May reduce/delay post cessation weight gain.
  • May be especially useful for those who miss
    puffing from smoking or women due to the
    similarity to smoking behavior.
  • Can be used in combination with other NRT.

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34
Nicotine Inhaler
  • Start with 6-16, 10 mg cartridges per day for
    three months.
  • Taper over six to twelve weeks.
  • Common adverse events mouth and throat
    irritation.
  • Average cost/day is 9.50.

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Nicotine Nasal Spray
  • Rx - flexible dosing. Actual bioavailability
    greater than 50 of the dose listed on packaging.
  • 5-7 minutes to reach the brain. Most rapid onset
    of all NRTs.
  • Women respond differently than men
  • Some clinicians report it is particularly helpful
    for those with psychiatric or substance abuse
    disorders due to the quicker onset.
  • May delay post cessation weight gain.
  • Can be used in combination with other NRT.

Perkins et al. Exper Clin Psychopharmacology
1996
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36
Nicotine Nasal Spray
  • Start with 1-2 0.5mg doses in each nostril every
    hour for 3-6 months.
  • Taper over 4-6 weeks.
  • Common adverse events nose and eye irritation.
  • Average cost/day is 16.00.

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Dosing Suggestions For Nicotine Replacement (NRT)
  • Cigarettes smoked per day can serve as a general
    guide to dosing NRT (but not other medications).
  • 1 cigarette delivers 1.0 mg of nicotine on
    average, e.g., pack smoker 20 mg daily dose of
    nicotine.
  • Goal for NRT(single or combined forms) is steady
    state replacement of at least 75 -85 of usual
    daily nicotine dose sufficient to manage
    withdrawal.
  • Due to nicotine tolerance from smoking, risk of
    unintentional overdose from NRT alone or from
    using NRT while smoking is low.1

1. Benowitz et al. J Pharmacol Exp Ther 1998
287958-962.
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NRT Overview
  • Contraindications
  • Patch current Hx eczema or psoriasis allergy to
    adhesives or nicotine patches.
  • All forms should not be used in patients with Hx
    of MI within prior 2 weeks.
  • Common Adverse Events
  • Patch sleep disturbance, site reaction
  • Lozenge nausea, hiccups, heartburn due to
    swallowing nicotine.

Review prescribing instructions for complete
list of contraindications and adverse events.
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NRT Summary
  • Flexible dosing forms allows individual
    tailoring.
  • Women may respond more poorly to NRT 1,2,3.
  • Women taking oral contraceptives4 and pregnant
    women5 have increased nicotine metabolism (more
    rapid clearance) and may need higher doses to
    suppress withdrawal symptoms.

1 Killen et al. J Consul Clin Psychol 1990. 2.
Wetter et al. J Consul Clin Psychol 1999. 3.
Perkins et al. Exper Clin Psychopharmacol 1996.
4. Benowitz et al. Clin Pharmacol Ther 2006. 5.
Dempsey et al. J Pharmacol Exper Ther 2002.

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NRT Summary
  • NRT use may result in reduced or delayed post
    cessation weight gain during treatment.
  • Smoking while using NRT poses no greater health
    risk than smoking alone.1
  • Quit rates are generally similar for all forms of
    NRT.2
  • Due to nicotine tolerance from smoking, risk of
    unintentional overdose from NRT alone or from
    using NRT while smoking is low.1

1. Benowitz. Cardiovascular Diseases
20034691-111. 2. Fiore et al. USDHHS 2000.
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41
Second-Line Medication (Not FDA Approved for
Smoking Cessation)
  • Clonidine - Rx
  • Primarily effective for women1
  • Common adverse events dry mouth, dizziness,
    drowsiness, sedation.2
  • Failure to gradually reduce dose may result in
    rapid increase in blood pressure, agitation,
    confusion, tremor.2

1.Covey et al. Br J Addiction 1991. 2. Fiore et
al. USDHHS 2000.
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Second-Line Medication (Not FDA Approved for
Smoking Cessation)
  • Nortriptyline-Rx (inexpensive)
  • Efficacious, but less so for women with history
    of depression 1
  • Common side effects sedation, dry mouth, blurred
    vision.2
  • Cardiovascular disease risk of changes in
    contractility and blood flow, arrhythmias. 2
  • Pregnancy caution has been associated with fetal
    limb reduction abnormalities.

1. Hall et al.,1998 2. Fiore et al. USDHHS 2000.
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Click here for a copy of Smoking Cessation
Pharmacology at OHSU 2007
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44
Special Considerations Long term use Pregnant
smokers Patients on psychiatric
medications Patients who need more intensive
treatment
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Longer-Term Use of Cessation Meds
  • For smokers who have achieved abstinence, but
    have persistent withdrawal symptoms at the end of
    the usual course of treatment or to prevent
    relapse.
  • Long-term use of NRT does not present a known
    health risk.
  • Varenicline is approved for a 2nd 12-week course
    of treatment (up to 24 weeks total) to maintain
    abstinence (relapse prevention).
  • Bupropion SR is approved for a 2nd course of
    treatment (up to 24 weeks total) to maintain
    abstinence.

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Treatment for Pregnant Smokers
  • Due to potential unknown fetal risks counseling
    without cessation medication is the first choice
    of treatment.
  • Risks of poor pregnancy outcomes due to fetal
    exposure to other chemicals in smoke nicotine
    are greater than exposure to nicotine alone from
    nicotine replacement therapies (NRT).
  • NRTs are pregnancy category D, except for gum and
    lozenges, which are pregnancy category C.
  • Varenicline and bupropion SR have not been tested
    in pregnant smokers and are both pregnancy
    category C.

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Patients On Psychiatric Medications
  • Dose adjustments may be necessary following
    tobacco (nicotine) cessation.
  • Blood levels of some psychiatric medications may
    increase substantially following smoking
    cessation (within 3-6 weeks) increasing risk of
    drug toxicity.
  • Psychiatric medications that should be monitored
    include clozapine, fluphenazine, haloperidol,
    oxazepam, desmethyldiazepam, clomipramine,
    nortriptyline, imipramine, desipramine, doxepin,
    and propranolol.

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Patients Who Need More Intensive Treatment
  • Patients more likely to need more intensive and
    specialized treatment.
  • High nicotine dependence who smoke heavily,
    and/or has first cigarette within 30 minutes
    after waking in the morning.
  • Severe withdrawal during previous quit attempts.
  • Current or recent psychiatric history, especially
    mood disorders, schizophrenia.

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Patients Who Need More Intensive Treatment
  • Current or recent (in last year) history of
    alcohol abuse or other chemical dependency.
  • Current stressful life circumstances or major
    life changes (recent serious diagnosis or injury,
    divorce, job loss, marriage, new baby etc.).
  • Current or recent stressful or high risk
    employment (police, firefighters, pilots,
    surgeons, surgical nurses, military personnel
    etc.).

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What Is Intensive Treatment?
  • Tailored treatment to impact more specific needs
    of patients including
  • Medications
  • Adjusting cessation medication doses (usually
    higher).
  • Longer duration of drug treatment.
  • Combining cessation therapies.
  • Adjusting non-cessation medication doses.
  • Coaching/counseling
  • More sessions over a longer period of time.
  • Referral to more highly trained specialists.
  • More frequent in-clinic or phone follow-up..
  • Referrals to other services as needed (e.g.
    mental health).

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Patient Care at OHSU Hospitals and Clinics
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Hospital Admission
  • Patients are told about tobacco free policy when
    they schedule admissions and when they register.
  • Patients are ASKED about tobacco use
  • Tobacco use questions are on the initial nursing
    assessment.
  • Tobacco use questions are on (some) unit
    admission orders.
  • Tobacco use questions will be included in
    admission orders in the Epic system (Spring 2008).

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Nursing education and Tobacco Dependence Consult
  • For patients who have used any tobacco in the
    last 12 months (JCAHO), nursing will review
    Smoking Cessation Guide for Hospital Patients
    (pdf online at www.ohsu.edu/healthsystem/nursing)
  • For patients who have used tobacco in the last 90
    days, MD completes Tobacco Dependence Inpatient
    Orders (PO-7290).
  • Tobacco Treatment Specialist Nurse Practitioner
    is paged to provide consult at 6-0027.

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Tobacco Dependence Consult
  • Tobacco Treatment Specialist Nurse Practitioner
  • Completes tobacco dependence assessment bedside
    counseling.
  • Develops a treatment discharge plan.
  • Includes an FDA approved medication (or
    combination) recommendations for
    counseling/coaching after discharge.
  • Makes arrangements for follow-up after discharge
    and leaves instructions for patient.
  • Completes preprinted progress note (HP 5336) and
    chart note.
  • Flags discharge plan.
  • Contacts medical team to update.

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Hospital Discharge
  • Discharge MD
  • Review progress note.
  • Include tobacco cessation discharge plan in
    dictated discharge summary.
  • Remind patient of tobacco cessation discharge
    plan.
  • Write appropriate prescriptions.
  • Copy of discharge summary to primary care
    provider.

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Flow Chart
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Outpatient Clinics ASK and ACT
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ASK
  • Patients are reminded of OHSU policy when they
    schedule and check in for clinic visits.
  • All patients are ASKED about tobacco use by the
    medical assistant. (Questions are included in the
    Epicare system).
  • Patients who report tobacco use are asked if they
    would like help to quit.
  • If NO, give Oregon Tobacco Quitline number to
    call when ready (1-800-784-8669). If YES, ACT (or
    REFER).

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ACT
  • Provider discusses quitting with patient
    Quitting is the most important thing you can do
    for your health and assesses when patient wants
    to quit.
  • If patient is not planning to quit now or IS
    planning to quit but in greater than 30 days,
    recommend that patient call the Oregon Tobacco
    Quitline when they are ready (1-800-784-8669.)
  • If patient is planning to quit in next 30 days,
    develop a tobacco cessation TREATMENT PLAN.
  • An evidence-based stop smoking treatment plan
    includes BOTH medications to stop smoking AND
    follow-up for behavioral support.

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ACT
  • TREATMENT PLAN Development
  • Medications
  • Prescribe one or a combination of the FDA
    approved stop smoking/tobacco medications (see
    Smoking Cessation Pharmacology at OHSU 2007 at
    www.ohsu.edu/smokingcessation/patientcare.
  • Behavioral Support
  • Recommend that OHSU employees follow-up with OHSU
    Employee Wellness 4-9355.
  • Recommend that patient call the Oregon Tobacco
    Quitline.
  • The OTQL will triage patients to follow-up
    services covered by insurance. Also, all callers
    are eligible for 2 weeks of free patches
    uninsured callers are eligible for 4 weeks.

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ACT
  • Treatment Plan (cont.)
  • Behavioral Support (cont.)
  • Consider encouraging patients to fill
    prescriptions at OHSU outpatient pharmacy. OHSU
    outpatient pharmacists are trained to provide
    tobacco cessation consultation for patients.
  • Add Getting Ready to Quit? patient stop smoking
    guide to after visit summary (Epic smart phrase
    SMOKINGCESSATION.)

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REFER
  • REFERRAL OPTION TO OHSU OUTPATIENT PHARMACIES
  • OHSU outpatient pharmacists are trained to
    develop tobacco cessation treatment plans
    following a specific, OHSU medically supervised
    protocol.
  • OHSU providers can refer their patients to any of
    the outpatient pharmacies to develop tobacco
    cessation treatment plans.
  • Only refer patients who are ready to quit within
    30 days.
  • To refer patients
  • Write, call, or fax prescription to OHSU
    outpatient pharmacy with Tobacco Cessation per
    OHSU Protocol on prescription.
  • Trained pharmacist will see patient, enter into
    Epic, and send information to referring provider.

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The Quitting Process
Precontemplation
Dont want to quit
Refer patients to the pharmacy program who are in
the PREPARATION or ACTION stage of quitting.
Contemplation
Want to quit sometime
Preparation
Will quit in next 30 days
Action
Will quit in the next 2 weeks
Maintenance
Termination
Relapse
Adapted from Knight, 1997
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Outpatient Pharmacy Program OHSU Collaborative
Drug Therapy Management Agreement (CDTM)
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OHSU Collaborative Drug Therapy Management
Agreement
  • OHSU outpatient pharmacists can provide patient
    cessation services through the OHSU Collaborative
    Drug Therapy Management Agreement.
  • The CDTM permits pharmacists to
  • Recommend smoking cessation medications and
    behavioral follow-up and develop a treatment
    plan.
  • Prescribe medications based on an OHSU approved
    treatment algorithm.
  • Patients are referred to the pharmacy program who
    are ready to quit in the next 30 days
    (preparation/action stage).

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Getting Started
  • For patients ready to quit, pharmacists will
  • Develop a treatment plan.
  • Treatment plan includes an FDA approved
    medication (or combination) recommendations for
    counseling/coaching.
  • Write and fill prescriptions under the CDTM.
  • Make arrangements for follow-up.
  • Send information to referring provider.
  • Enter into Epicare.

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OHSU Treatment Plan Development
  • Treatment planning begins with an assessment
  • Smoking and quitting history
  • Tobacco dependence
  • Motivation and readiness
  • Health and medication histories
  • Treatment Plan is based on assessment data
  • Medications counseling/coaching recommendations
    either standard or intensive
  • Prescription(s), dispensing
  • Consideration of referral for additional
    non-cessation treatments
  • Follow-up type (in-clinic, phone, quit line etc)
    and frequency.

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REMEMBER . . .
  • Quitting smoking is the most important thing
  • your patients can do to protect their present and
    future health.
  • With your help, they can be successful.
  • Your efforts will save lives!

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For more information… Visit www.osu.edu/tobaccofre
e and click on Information for health
professionals or visit www.ohsu.edu/smokingcessat
ion/patientcare Email free_at_ohsu.edu with
questions or comments Call 503 494-FREE (3733)
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