Nicotine-related disorders Answers obtained from DSM-IV-TR and the AJP Supplement of August, 2006, on substance abuse As of 1Sep08.

Percentage of population Q. Percentage of population that smokes?

Percentage of population Ans. DSM-IV has 30%. Right answer is probably closer to 21% today. The slow decrease per year has ceased and the percentage has become constant in the past few years.

Survey instrument Q. What is the name of the survey instrument used to measure level of smoking addiction

Survey instrument Ans. Fagerstrom Tolerance Questionnaire.

Other mental illness Q. Of individual with a mental illness, what percentage smoke?

Other mental illness Ans. 55 to 90%, with the 90% pertaining to people with schizophrenia.

Withdrawal Q. List the 8 DSM signs of nicotine withdrawal.

Withdrawal Ans. 1] sad 2] insomnia 3] irritable 4] anxious 5] can’t concentrate 6] restless 7] decrease pulse 8] increased appetite

Lab findings Q. What are the sleep and chemical lab findings during withdrawal?

Lab findings Ans. During withdrawal: EEG slowing Decrease catecholamine level Decrease cortisol level REM changes Neuropsychological testing impairments Decreased metabolic rate

First line medications Q. Besides nicotine replacement meds, what other meds are regarded as a first line option?

First line medications Ans. Bupropion. Varenicline

Bupropion dosing Q. What is the typical bupropion dosing schedule?

Bupropion dosing Ans. Begin with 150 mg SR 7 days before quit date, then 150 mg bid SR 2 days before stop date.

Varenicline dosing Q. What is typical varenicline dosing?

Varenicline Ans. Varies somewhat, of course, but the following is typical: 0.5 mg/d x 3 days 0.5 mg/d x 4 days Dc smoking on 7 th day 1 mg/d x 12 weeks Can go to 2 mg/d

Combination Q. Can you prescribe varenicline and bupropion in the same pt?

Combination Ans. Can use both.

Nicotine replacements Q. Nicotine replacements come in what forms?

Nicotine replacements Ans. -- patch -- gum -- lozenge -- nasal spray -- inhaler

Combinations Q. Any advantage to combining meds?

Combinations Ans. Yes, may improve results, including two nicotine replacement meds, in addition to prescribing both nicotine replacement and bupropion and varenicline.

Best results Q. Very generally, best results are achieved with?

Best results Ans. Combine meds with psychosocial approach.

Second-line agents Q. Besides nicotine replacement, varenicline, and bupropion, what other two meds are used?

Second-line meds Ans. Nortriptyline Clonidine

Nortriptyline dosing Q. Typical dosing schedule for nortriptyline?

Nortriptyline dosing Ans. Start at 25 mg/d 10 – 14 days before quit day, and increase to 75 mg/d by the quit day.

Clonidine dosing Q. What is typical clonidine dosing?

Clonidine dosing Ans. 0.1 to 0.4 mg/d on quit day for 2 to 6 weeks.

FDA Q. Has the FDA approved any meds?

FDA Ans. Nicotine replacement meds Bupropion Varenicline

Acupuncture Q. Status of acupuncture?

Acupuncture Ans. Not been proven to be effective.

Psychosocial formats Q. Four general psychosocial approaches are?

Psychosocial formats Ans. -- individual -- group -- telephone -- self-help

Psychosocial approaches Q. Regardless of format, what four psychosocial approaches have value?

Psychosocial approaches Ans. -- motivational enhancement therapy -- behavior therapies -- CBT -- social supports

Behavior therapy Q. What does behavior therapy consists of?

Behavior therapy Ans. -- contingency management -- cue exposure -- “rapid smoking” aversion

12-step-oriented groups Q. Has 12-step-oriented groups been effective?

12-step-oriented groups Ans. Have not been shown to be effective.

Hypnosis Q. Hypnosis effectiveness in this disorder?

Hypnosis Ans. Has not been shown to be effective.

Stop date Q. As part of the psychosocial approach, is abrupt cessation or gradual cessation preferred?

Stop use Ans. Once date is set to cease, better that cessation be abrupt.

Caffeine use Q. Advice as to caffeine use after stop date begins.

Caffeine use Ans. Best to avoid.

Alcohol use Q. After stop date has begun, advice as to alcohol use?

Alcohol use Ans. Best to avoid.