Medications


Hi, I’m Jessie, Clinical
Pharmacy Specialist at the St. Cloud VA
Health Care System Welcome to Class 2,
“Medications Can Help,” and thanks for taking the time
to consider this topic. There are many different
types of medications that can be helpful in the effort to quit
tobacco. In this class we will cover: Types of tobacco
cessation medications Nicotine
Replacement Medications Bupropion • Varenicline Medications affected by smoking and E-Cigarettes As was mentioned, there are
a variety of medications that can assist with
quitting tobacco use. Nicotine is typically
eliminated from the body within two weeks
of stopping use. We use medications to
make it easier for you to deal with the
behavioral change and not have to worry about
the physical addiction. This is why you will see
that therapy is recommended for a few months rather
than only two weeks. Some of these medications
used in tobacco cessation provide small doses of
nicotine to help you reduce the nicotine
level in your body. These types of
medications are called nicotine replacement medications. They reduce your cravings
for nicotine and help reduce the
withdrawal symptoms that accompany the
process of quitting. Nicotine replacement
medications include the nicotine patch,
lozenge, and gum. We will discuss how these
work later in class. In addition, there
are two medications that do not contain nicotine,
Bupropion and Varenicline. These can help you have
fewer cravings for nicotine. Some of these medications
can be used together to help you stop tobacco use. Studies show that these
combinations are effective and can work better than
one medication alone. The combinations include
the nicotine patch in combination with either
the nicotine gum or lozenge and bupropion in
combination with the nicotine patch,
nicotine gum or lozenge. Varenicline is not used
in combination with any other medications
for quitting tobacco. So you may be wondering,
“What works best?” when it comes to
quitting tobacco. At this time, it appears that
combination therapy works best. This involves using one or
more of the medications, along with behavioral
strategies, for the highest success rates. You will be learning numerous
behavioral strategies throughout these classes and you can
add those strategies to medications to increase
your quitting success. The medications chosen will
be based on your discussion with your medical
provider and determined by your medical history
and preference. All the medications we
will discuss can help to increase your chances
of quitting for good and are available
through the VA. You can contact your
tobacco cessation team, primary care provider, or
mental health provider if you are interested
in using medications to help you quit
tobacco. Let’s talk some
more about nicotine replacement medications. First, let’s review the patch. The patch provides steady
nicotine to your body but not at a level
to cause addiction. It’s job is to make you
feel more comfortable during the process of quitting,
so you can focus on changing habits and behaviors. It works as a step down process
to slowly reduce your body’s need for nicotine as you
develop those new behaviors. The patch delivers nicotine
into the body through the skin. It is typically applied to
the skin on the upper arm, upper chest, or upper back. The patch is placed down firmly so that it will stick
to your skin. It’s best not to use
lotion on your skin before using the patch. If your skin tends to be oily,
you may want to first use rubbing alcohol
to clean the area. Then when the skin is dry
you can apply the patch. You may be wondering how much
of this medication to use. If you smoke 10
cigarettes or more a day, you would begin with a 21 mg patch daily for
4-6 weeks; then you would step down to a 14 mg patch
for about 2 weeks and finally a 7 mg patch
for 2 weeks. If you smoke less than
10 cigarettes a day, you would begin with a 14 mg patch daily for
6-8 weeks and then step down to a 7 mg patch daily for
2 weeks. People often ask if
they can still smoke when using the nicotine patch. You should try to stop smoking
when wearing the patch. If you slip and smoke
a few cigarettes, continue to use the
nicotine patch. It helps to use the nicotine
gum or lozenge for cravings rather than smoking. Other strategies may help
you with cravings such as chewing gum, eating carrot
sticks, deep breathing, going for a walk,
or drinking water. But we’ll focus more on these
types of behavioral strategies in our upcoming classes. If you do have a relapse
and you are back to your original
smoking habit, it is typically best to stop
using the nicotine patch and contact the person
who prescribed the patch. They can discuss the best steps
for setting another quit day and restarting the patch when you
are ready to quit completely. As you think about this option, it’s important to review
the possible side effects. The patch can cause itching
or rash in the area where it is applied. If that occurs you could put
the patch on a different area of skin each day. Some people experience
nausea or dizziness if the dose is too high and
this should be discussed with your tobacco
cessation team. Another possible side effect
is difficulties with sleep or nightmares. If this happens it may help
to remove the patch before you go to sleep and place
a new patch upon waking. The patch is a
good option to use when you need a gradual decrease in nicotine
levels in your body, however it is not good
during situations where you utilize behavioral
strategies already and you still have
cravings and urges. This is where the nicotine
lozenges or gum comes in and helps with those
additional behavioral triggers as well as nicotine withdrawal
symptoms you may experience. If you choose to use
nicotine gum or lozenge, nicotine is delivered
to the body through the lining
of your mouth, similar to the area where
chewing tobacco is placed. So the question is
how much do we use? When using these
products by themselves the recommendations
are as follows: If you smoke your first
cigarette with 30 minutes of waking, use the 4 mg
strength of the gum or lozenge. It is recommended to use these
medications every 1-2 hours and at least 10 times a day
when first initiating. From there it would
be recommended to try and decrease
the number of times you are using the gum
or lozenge each week. For example use 10 pieces
of gum or lozenges daily for the first week, use it 9
time daily the second week, 8 times daily the third week
and so on. The goal would be to taper
off within 3-4 months of use. If you are smoking less than one
pack a day you would start with the 2 mg gum or lozenge and
follow the same schedule we just reviewed, however using the 2
mg dose instead of the 4mg dose. As noted above, a combination
of two medications may be more effective than
one medication alone. If you are using the nicotine
gum or lozenge in combination with nicotine patches
or Bupropion, you should follow the
following guidelines. • Use the 2 mg gum or lozenge
when you have a craving for tobacco or at a time you know
you will have a strong craving. Often these types of cravings
occur in the morning so you should use the gum or
lozenge right when you wake. • Try to use no more than
6-10 pieces a day when you are using the
nicotine gum or lozenge in combination with
the nicotine patch. The longer you’ve been
off tobacco, the less you need the breakthrough gum or
lozenge. You can also begin using
substitutes like sugar-free gum, mints, or candy between doses
of nicotine gum or lozenge. • It is important to note that
when your nicotine patch is titrated down to the next dose,
it is possible that your use of the nicotine gum or lozenge
may increase as the background nicotine dose from your
patch is decreased. If this occurs, slowly taper
down on the gum or lozenge thereafter as you are able. Using the gum or
lozenge involves some specific strategies
to remember. The first thing to remember is
that you don’t chew nicotine gum like you would regular gum. Instead you use the
“bite and park” method. This means you place a piece of
gum in your mouth and bite it two or three times until
you get a peppery taste or feel a tingling sensation. Then you park the gum in the
inside of your cheek and leave it there until
you no longer have that peppery taste or tingling. Then repeat the bite-and-park
method several times until there is no longer any
peppery taste to the gum. At this time you would
throw the gum out. Remember I said you should
avoid using nicotine gum like you would use chewing gum. The reason for this is that if
you use it like chewing gum, it will not allow the
nicotine to be absorbed through the lining
of your mouth. You will swallow the nicotine,
which may cause you to feel sick to your stomach
and have heartburn. In addition, your nicotine
craving will not go away since the nicotine will not be
absorbed from your stomach. It’s also important to not
combine chewing gum with nicotine gum since this
will reduce the absorption of the nicotine. Similarly, when using the
lozenge you simply place it in your mouth and put it in
the inside of your cheek and leave it there. You may rotate the place in your
cheek where you put the lozenge in order to reduce
irritation in your mouth. It’s important to not
chew or bite the lozenge. It must dissolve completely to release the entire dose
of the nicotine. With both the nicotine gum and
the nicotine lozenge, it is important that you do not eat or drink for
15 minutes before, while using and for 15 minutes after
using the products. It’s important to avoid
acidic beverages like coffee, juices, soda, and alcohol during these times since this will reduce
the absorption of the nicotine from the
gum or the lozenge. There are a couple of
possible side effects from the nicotine gum. These include irritation
of the mouth and nausea and heartburn if the
gum is chewed quickly or the lozenge is chewed
or swallowed We’ve just reviewed the nicotine
replacement medications, now I’d like to review
some other medications that can aide in tobacco cessation. Bupropion is a medication that
reduces nicotine cravings by increasing the
dopamine in the brain. Dopamine is involved in
the addiction to nicotine. Remember, Bupropion does not
include nicotine so you may still have some nicotine
withdrawal symptoms. Bupropion is also an
antidepressant, which can be beneficial for
some people who use tobacco and have a history of depression. Your medical provider will
specify the correct dosage but here are some
things to consider. First, Bupropion is a tablet
that is swallowed whole. So do not crush or
break the tablet unless instructed to do
so by your provider. This medication is started about
7-14 days before your quit date so it’s important to set
your quit date about a week or so after you start
taking Bupropion. This medication is typically
taken for 8-12 weeks but can be used longer
if needed. I’d like to wrap up this
section by talking about who should not use Bupropion
and possible side effects. Let’s start with who
should not use Bupropion. Bupropion can increase your
risk of seizures so individuals should avoid this medication if
they have a history of seizures, a current eating disorder,
or if they are drinking more than two servings
of alcohol a day. In addition, if you are taking
medications for depression, bipolar disorder or other
mental health disorder, you should discuss this
with your medical provider whether Bupropion will work
with your current medications. Possible side effects of
Bupropion include difficulty sleeping, nervousness, and dry
mouth, and less commonly rash
and swelling. Some people can experience
mood changes, depression, or suicidal or
homicidal thoughts. If you experience any of
these types of mood changes or thoughts contact your
doctor immediately. If you are in crisis, call 1-800-273-TALK or
(1-800-273-8255) and press 1 to talk with
someone immediately. You may also seek
help online at www.veteranscrisisline .net One additional medication
we’ll cover today is Varenicline or Chantix®. Varenicline works by blocking
the receptor in the brain where nicotine binds. This blocks the effect of
nicotine when you smoke or chew tobacco. This medication also acts
like a weak form of nicotine, which can help reduce nicotine
withdrawal symptoms. Varenicline is not used
in combination with nicotine replacement
medications because it blocks the
nicotine receptors, making the nicotine replacement medication
less effective. Varenicline is a tablet which
can be split if necessary and your medical provider will
specify the correct dosage. It is important to always
take Varenicline with a full glass of
water and with food to decrease the risk of an
upset stomach and vomiting. This medication is started 7-14
days before your quit date so it’s important to
set your quit date about a week or so after
you start taking it. This medication is typically
taken for 12 weeks but can be used for an additional 12 weeks
if you have successfully quit tobacco and feel you need
longer use of the medication. Your provider will assist you
with this as you move forward. With this medication we also
need to review who should not take it and what the possible
side effects may be. Please consult with your doctor
about taking Varenicline if you have a history of depression,
bipolar disorder, PTSD or other mental health disorder since
it may not be safe for you. If you have had a history of
suicidal or homicidal thoughts or acts in the past 12 months, Varenicline would not be appropriate for you. Common side effects of
Varenicline include upset stomach, nausea,
vomiting, headache, difficulty sleeping and
dream disturbances. Some individuals experience
depression, anger, irritability, suicidal thoughts or
homicidal thoughts. If any of these side effects
happen after starting Varenicline, stop taking it and
contact your medical provider or go to the ER. Again, remember if you
are in a crisis, call 1-800-273-TALK or
1-800-273-8255 and press 1 to talk speak with someone immediately. You may also seek
assistance online at www.veteranscrisisline.net We have discussed a number
of options for medications that can assist you in your
efforts to quit tobacco. As you consider your options
with tobacco cessation medications, it is also
important to know that your current tobacco habit can
affect some of the medications you may be taking for
other health conditions. Tobacco smoke affects how
some medications are used and removed from your body. This means there may be lower
amounts of medicine in your body when you are smoking so
they might not work as well. As a result, your doctor
may need to increase the dosage of certain medications. However, just the opposite
could be the case as well when you
stop using tobacco. This may also result in
a need for an adjustment in your dosage. The best plan is to talk
with your medical provider about any side effects
you may experience from your medications
after you quit smoking. Some types of medications that
can be affected by smoking include antidepressants, anti-anxiety medications, antipsychotic medications, blood thinners such as Warfarin, high blood pressure medications, and medications for heart
rhythm problems. Caffeine is also removed
from your body faster when you smoke so you might
need less caffeinated coffee or other beverages
after you quit. Typically it is good to
reduce your caffeine intake by half when you quit tobacco. There is one more topic that
is important to discuss when planning to quit tobacco. Some people look at using
e-cigarettes as an option and think this may be a good way to
get rid of their smoking habit. E-cigarettes have
health risks as well and I’d like to review
a few of them. An e-cigarette or electronic
cigarette uses a metal tube with an atomizer and a
cartridge of liquid nicotine. When the user inhales,
the atomizer converts liquid nicotine into a
vapor that is inhaled. There are concerns about
this delivery system. Nicotine concentration can vary
by brand and the e-cigarettes are not regulated E-cigarettes
expose users to harmful chemicals other than nicotine
including many of the same toxic carcinogenic compounds
found in regular cigarettes. The nicotine goes right
into the lungs through an inhaler that is absorbed in the
oral membrane. One question stands out, “Do electronic cigarettes help people quit
smoking?” Research studies have
not shown an improvement in cessation rates. Other studies show that there
is a potential for increase in nicotine addiction and
cigarette use in adolescents. There is a lack of safety
information available to know the long term risks
with E-cigarette use. The best advice is
to quit for good. We have covered a lot of
information in this class and I’m sure you have a great
deal to think about. At the VA, we are
committed to your success in your efforts to quit
using tobacco. Your facility has clinicians on
your tobacco cessation team that can help you with your
individual medication needs. Please feel free to contact a
member of your health care team via Secure Messaging or
telephone to ask your questions and find the support you need.

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