Session #5 Medication

Outline Session #5 Welcome and introductions Group expectations and behaviour Medications Non-prescription Prescription Review (if time) PACT - MHG

Group Guidelines Review… Review flipchart or insert slide from week 1 for review Ask for a volunteer to read out loud PACT - MHG

Medications Help you to Choice depends on Manage cravings and withdrawal symptoms Choice depends on addiction level (Modified Fagerstrom) personal situation and preference prior quit experience For patients ready to quit – and usually if > 10 cigarettes per day   - many medications used to treat mental illness are removed from the body faster in smokers - smokers often end up on higher medication doses because of this interaction - might be possible for individuals to have some medication dose reduced if they quit smoking successfully… NOTE – not intended to go into any specifics – better to discuss one-on-one with those who actually decide to reduce or quit…mention only in general terms due to variability in individual circumstances PACT - MHG

Discussion How soon after you wake up do you need to have a cigarette? Do you get up through the night to have a cigarette? PACT - MHG

Discussion Have you tried to quit before? How long did you stay quit? Did you use a medication? PACT - MHG

Medications Medication PLUS supportive counselling greatly increases chance for a long-term quit Do not MAKE you quit You must WANT to quit! PACT - MHG

Types of medication Nicotine Replacement Therapy (NRT) Patches (long acting) Gum (short acting) Lozenge (short acting) Inhaler (short acting) Oral spray (short acting) Bupropion (Zyban) Varenicline (Champix) PACT - MHG

Nicotine Patch > 20 cigarettes a day < 20 cigarettes a day start with 21mg once/day for 3-4 weeks < 20 cigarettes a day start with 14mg once/day for 3-4 weeks Tapering: reduce patch strength every 3-4 weeks (e.g. from 21mg → 14mg → 7mg) ~ 8-12 weeks in total (can reduce more slowly if necessary) PACT - MHG

Nicotine Patch To ensure patch stays in place for 24h site s/b clean, non-hairy, completely dry apply and press from centre to outside edge apply pressure to patch for ~10 seconds Can remove overnight if interferes with sleep apply new patch in morning chew NRT gum for initial morning craving PACT - MHG

Nicotine Patch Side effects: Skin reaction – up to 50% local skin reactions Important to rotate site Hydrocortisone cream if needed Headache, dizziness, blurred vision, nausea, vivid dreams PACT - MHG

Nicotine Gum > 20 cigarettes a day < 20 cigarettes a day Thrive 2 mg, Nicorette 4 mg < 20 cigarettes a day Thrive 1 mg, Nicorette 2 mg ~ 10-12 pieces per day (max 20/day) Tapering: reduce by 1-4 pieces per day each week ~ 12 weeks in total (can reduce more slowly if necessary) PACT - MHG

Nicotine Gum Bite, Bite – until mild tingling Park between gum and cheek ~ 1 minute Repeat bite-bite-park until tingling stops (~ 30 minutes) then discard Avoid food/drink for 15 minutes before/after/during chewing (30 minutes for acidic drinks) Acidic beverages (coffee/tea/soda/juice) ↓ absorption, ↓ effectiveness PACT - MHG

Nicotine Gum Side effects burning in throat, hiccups, gas sore jaw Reduce by proper technique sore jaw PACT - MHG

Nicotine Lozenge If smoke within 30 minutes of waking Start with 4 mg If smoke in > 30 minutes of waking Start with 2 mg ~ 8-12 lozenges per day (max 15) Taper: after first six weeks, reduce #/day and strength based on withdrawal symptoms PACT - MHG

Nicotine Lozenge Suck slowly until taste is strong, rest in cheek until taste fades, repeat Lasts ~ 30 minutes Avoid food/drink for 15 minutes before/after/during (30 minutes for acidic drinks) Acidic beverages (coffee/tea/soda/juice) ↓ absorption, ↓ effectiveness PACT - MHG

Nicotine Lozenge Side effects Nausea, heartburn, hiccup Reduce by proper technique Mouth-throat irritation Headache PACT - MHG

Nicotine Inhaler PACT - MHG

Nicotine Inhaler One cylinder = ~ 20 minutes puffing 5-20minutes at a time, as would a cigarette Avoid food/drink for 15 minutes before/after/during (30 minutes for acidic drinks) Delivers ~ 4mg nicotine per cartridge Nicotine released as a vapour with each puff PACT - MHG

Nicotine Inhaler Use only at room temperature Clean mouthpiece regularly with soap/water PACT - MHG

Nicotine Inhaler Side effects Throat irritation, cough, bad taste in mouth/throat, runny nose PACT - MHG

Nicotine QuickMist Fine mist oral spray, mint taste Controls cravings in ~ 60 seconds 1-2 sprays every 30-60 minutes Maximum: 2 sprays per dose 4 sprays per hour 64 sprays per day Tapering: as cravings reduce PACT - MHG

Nicotine QuickMist Prime the dispenser before first use May need to repeat if not used for 2 days or more Hold spray nozzle close to open mouth Press nozzle once to release spray Avoid spray on lips Don’t inhale when spraying (keeps spray in mouth, not throat) Don’t swallow for a few seconds after PACT - MHG

Nicotine QuickMist Side effects: Tingling/burning lips Hiccups Annoying but not harmful Spray only in mouth, avoid spray on lips Hiccups Strong taste in mouth PACT - MHG

Nicotine Overdose Cold sweat Nausea Salivation Vomiting Abdominal pain Diarrhea Flushing Headache Dizziness Weakness Mental confusion Tremour Disturbed hearing/vision Overdose can occur easily if correct technique not used – and/or – if continuing to smoke while using NRT PACT - MHG

Reasons NOT to use NRT Unstable heart condition Pregnancy and breastfeeding Under 18 years of age UNLESS Under doctor supervision PACT - MHG

Wiggle Break!! PACT - MHG

Bupropion (Zyban) 150mg tablet daily x 3 days, then increase to twice daily ~ 12 week duration Start one week before quit date Anti-depressant drug – helps control cravings Originally on market as an anti-depressant PACT - MHG

Bupropion (Zyban) Side Effects: Do NOT use: Insomnia, dry mouth, nausea, constipation, disturbed concentration Do NOT use: Pregnancy, breast feeding Seizure disorder More that 4 servings alcohol/day PACT - MHG

Varenicline (Champix) Binds to nicotine receptors in brain Blocks nicotine from binding to receptor Acts like nicotine – small release of dopamine Feel unwell if continue to smoke PACT - MHG

Varenicline (Champix) 0.5mg tablet once daily x 3 days the twice daily x 4 days 1.0 mg tablet twice daily Minimum 12 weeks Some may benefit from 24 weeks Start 7-10 days before quit date PACT - MHG

Varenicline (Champix) Side effects Nausea, vomiting Headache, insomnia, abnormal dreams Food, water, 2nd tablet ~3-4pm DO NOT use: Pregnancy, breastfeeding Unstable mental illness CAUTON – depression, thoughts of suicide (rare) PACT - MHG

Combination therapy NRTs can be combined NRT and Zyban – possible example: daytime patch, morning gum NRT and Zyban – possible Do NOT combine NRTs and Champix Combination therapy ONLY with advice from pharmacist or doctor PACT - MHG

Discussion Are you thinking of reducing or quitting? PACT - MHG

Why reduce or quit? Quick improvements in health sleep & breathe easier sense of taste and smell improve reduce blood pressure Long term health improvements Heart, lungs, cancer, diabetes Longer life – improved quality More money! More confidence – better life balance PACT - MHG

Try using the 4 Ds Drink plenty of water Delay for 5-7 minutes Do something else Deep breathing PACT - MHG

Remember - Motivation is internal No one else can do it for you PACT - MHG

Challenge for the week: Reduce tobacco use Choose two ways you can handle withdrawal symptoms Walk for 30 minutes every day PACT - MHG