1. Tobacco Recovery Wellness Initiative
Nicotine Replacement Therapy Overview
June 20, 2018 a

2. Learning Objectives Review the biological basis of tobacco dependence.
Discuss the current standards of practice for using nicotine replacement therapies.
Review simple tips for maximizing the effectiveness of NRT
Review how to access NRTs
Insurance
Over the Counter
Quitline
Q&A

3. Overview of Nicotine Replacement Therapy
Frank T. Leone, MD, MS
Comprehensive Smoking Treatment Program
University of Pennsylvania
Philadelphia, PA
1-888 PENN STOP

4. Disclosure Consultant Arrangements: None Equity Ownership: None
Patent Arrangements: None
Grants/Research Support: National Institutes of Health Pennsylvania Department of Health.
Health Promotion Council of PA
National Cancer Institute.
Phila Department of Public Health
Employment: University of Pennsylvania
Speakers' Bureau: None
Other: None

5. Objectives Review the biological basis of tobacco dependence.
Discuss the current standards of practice for using nicotine replacement therapies.
Review simple tips for maximizing the effectiveness of NRT.

6. Nicotine Dependence Itself a Chronic Illness
“There’s someone in my head, but it’s not me.” - Pink Floyd 1973

7. Mesolimbic Dopaminergic system
Emotion
Motivation
Memory

8. Long term changes Increased neuronal arborization
Increased density of nicotinic receptors
Increased sensitivity of receptor ion channels
Changes gene expression
Neuronal protein synthesis increases
Neurotransmitter synthesis increases

9. Smoking: A Disorder of Compulsion.
Not exactly ready, or willing, or able.
Hesitant
Patients want change, but don’t want change.
“I desperately want to want to quit smoking”
Ambivalent
“Come back when you’re ready?”

10. Nicotine Levels in Blood

11. Nicotine Replacement Therapy
Patch
Helps to prevent cravings from occurring
Start high (21mg/day) and step down over weeks.
Most common side effect = local irritation
OTC preparations only

12. Estimated Abstinence Rate
Nicotine Patch
“The Nicotine Patch is an efficacious smoking cessation treatment that patients should be encouraged to use.” Strength of Evidence = A
Pharmaco-
Therapy
Number of arms
Estimated OR
(95% CI)
Estimated Abstinence Rate
Placebo 80
1.0
13.8
Nicotine Patch 32
1.9
(1.7, 2.2)
23.4
(21.3, 25.8)

13. Nicotine Replacement Therapy
Gum
2mg and 4 mg dose
chewed and parked to allow mucosal absorption
1 to 2 pieces per hour when used alone
can be used in conjunction with patch to treat sudden urges

14. Estimated Abstinence Rate
Nicotine Gum
“Nicotine Gum is an efficacious smoking cessation treatment that patients should be encouraged to use.” Strength of Evidence = A
Pharmaco-
Therapy
Number of arms
Estimated OR
(95% CI)
Estimated Abstinence Rate
Placebo 80
1.0
13.8
Nicotine Gum 15
1.5
(1.2, 1.7)
19.0
(16.5, 21.9)

15. Nicotine Replacement Therapy
Inhaler
Helps to treat sudden cravings once they occur
Softly puffed to allow mucosal absorption
1 to 2 puffs per hour as needed
can be used alone or in conjunction with patch
May give smoker sense of “control”

16. Estimated Abstinence Rate
Combination NRT
“Combining the long-term patch (>14 weeks) with a self-administered form of NRT is more efficacious than a single form.” Strength of Evidence = A
Pharmaco-
Therapy
Number of arms
Estimated OR
(95% CI)
Estimated Abstinence Rate
1 NRT 32
1.0
23.4
2 NRT 3
3.6
(2.5, 5.2)
36.5
(28.6, 45.3)

17. Bupropion SR Safe with continued smoking. Less weight gain.
Start 7-10 days prior to quit date.
Duration: 8-12 weeks, consider up to 6 months or longer in h/o depression.
Combine with NRT for better results.

18. Estimated Abstinence Rate
Bupropion SR
“Bupropion SR is an efficacious smoking cessation treatment that patients should be encouraged to use.” Strength of Evidence = A
Pharmaco-
Therapy
Number of arms
Estimated OR
(95% CI)
Estimated Abstinence Rate
Placebo 80
1.0
13.8
Bupropion SR 4
2.1
(1.5, 3.0)
30.5
(23.2, 37.8)

19. Estimated Abstinence Rate
Patch + Bupropion
“Combining Bupropion treatment with transdermal NRT is more efficacious than a single form.” Strength of Evidence = A
Pharmaco-
Therapy
Number of arms
Estimated OR
(95% CI)
Estimated Abstinence Rate
Patch 32
1.0
23.4
Combo 3
2.5
(1.9, 3.4)
28.9
(23.5, 35.1)

20. 1 800 QUIT NOW
1 800 QUIT NOW
1 800 QUIT NOW

21. Useful Web Resources www.pennmedicine.org/pennstop

22. Points to Remember
Smoking is the behavioral manifestation (cardinal sign) of a disturbance in brain biology induced by exposure to nicotine.
The cardinal symptom of this pathology is compulsion to smoke, manifest as reluctance.
Nicotine Replacement Therapy (NRT) is safe, effective, cost-effective, and has an impact on morbidity of psychiatric illness
Current standards of pharmacotherapy generally more “aggressive” than in past.

23. Director of Pharmacy Initiatives Community Behavioral Health
Accessing NRTs
Oluwatoyin Fadeyibi, Pharm.D, MPH
Director of Pharmacy Initiatives
Community Behavioral Health

24. Themes across Medicaid Plans
Quantity limits (varying degree)
Age limit to 18 and older
Nicotine Inhaler and Nasal Spray not covered by most
Most don’t cover brand name options (except for Chantix – which is still under patent)
All plans designate as preferred, generic versions of: Patch, Lozenge, Buproprion and gum

25. Pharmacy Prior Authorization Team: 866-638-1232
Aetna Better Health
All NRT is formulary
Pharmacy Prior Authorization Team:

26. Health Partners Plan Pharmacy Hotline: 866-841-7659
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Pharmacy Hotline:

27. Keystone First
Nicotine gum, Patch, lozenges and Bupropion are all preferred in generic formulations.
Chantix – preferred
Nicotine inhaler and spray are non-preferred, and need prior authorization
Pharmacy Services:

28. United Health Care UHC Contact: 1800-414-9025 TTY: 711
aySearch.do?type=ClientFormulary&&var=ACUPA&infoid=ACUPA&page=i nsert&par
Nicotine gum, Patch, lozenges and Bupropion are all preferred in generic formulations.
Chantix – preferred
Nicotine inhaler and spray are non-preferred, and need prior authorization
UHC Contact: TTY: 711

29. Prior Authorization quick tips
Age limit of >18y/o
Proof of Contraindication or intolerance to preferred alternatives
Justification for Smoking Cessation Products that are prescribed at quantities that exceeds the quantity limit

30. Coming soon…
Reference Table compiling all Medicaid plan coverage information
Resource list of pharmacies in Philadelphia with smoking cessation programs
Advocacy with PHMCOs for full coverage of tobacco cessation products

31. Additional Information
Variation in co-pay depending on product and plan
Out of pocket cost with some coupons:

32. Quitline Jarma J. Frisby, MS,CTTS-M
Tobacco Treatment and Wellness Coordinator
Philadelphia Department of Public Health

33. Welcome to the Pennsylvania FREE Quitline
QUIT-NOW
( )
1-855-DEJELO-YA
( )

34. Why use a Quitline?
Callers to a Quitline are more likely to quit and stay quit. QL counseling can more than double a smoker’s chances of quitting.
Quitline services are available 24 hours a day.
All services are free, confidential and available in multiple languages; not connected to insurance status.
Quitline counselors provides resources about websites, apps, and texting programs that can help you quit.

35. PA Free Quitline Services
Support, advice, and counseling from experienced Quitline coaches
Up to five quit coach calls (call is initiated by the coach at a time that best suits your availability)
Assistance in developing a personalized quit plan
Unlimited, inbound calls for additional support during times of high risk for using tobacco

36. PA Free Quitline Services
Four weeks of free nicotine replacement therapy (patches, lozenges, gum) available after completion of first call and setting a quit date. Combination therapy available.
NRT and self-help materials mailed to caller
QL can info and NRT to more than one person at the same address
Usually arrives in 7-10 days

37. Additional Help
If calling from a mobile phone with an out-of-state area code use:
Provider and individual web referral available for Quitline programs: Pa.quitlogix.org
Contact PDPH for ordering rack cards, post cards and business size cards available from the CDC and PA Quitline.