Tackle smoking cessation by offering your patients evidence-based treatment options. We discuss pharmacotherapy, mindfulness, and practical tips on how to manage short-acting nicotine replacement therapy to help your patient stop smoking. We are joined by Dr. Panagis Galiatsatos from Hopkins (@Panagis21).
By listening to this episode and completing CME, this can be used to count towards the new DEA 8-hr requirement on substance use disorders education.
First, set the stage and ensure the patient is comfortable. Create a non-judgemental environment when discussing tobacco use with your patients. Dr. Galiatsatos likes to reframe the smoking cessation journey as learning how to become a non-smoker. Dr. Galiatsatos recommends AVOIDING telling a patient to “Quit smoking;” instead, help set them up to manage their tobacco use through motivational interviewing and mindfulness. Dr. Galiatsatos reframes the goal to his patients – “It’s not about quitting, it’s about becoming a non-smoker.”
In Dr. Galiatsatos’ expert opinion, he does not view the smoking pack year history as helpful as compared to asking the following questions to get a better sense of an individual’s nicotine dependence.
To start developing a treatment plan, ask what the patient wants out of a medication for smoking cessation. Ask what they have tried in the past, and what impact that strategy had. Check whether there are interactions with any of the patient’s medications, or medical comorbidities (such as hemodialysis, or history of seizures) that could limit the pharmacotherapy options for that individual. Dr. Galiatsatos recommends using a combination of pharmacotherapy and mindfulness to help a patient stop or cut back on cigarettes.
Three long-acting “controller” medications are approved for smoking cessation: Varenicline, Bupropion, and nicotine replacement therapy (NRT) patches. A variety of short-acting NRT agents are also available including gum, lozenges, inhalers, and nasal spray.
Treat most patients with a long-acting controller medication and short-acting NRT (Barua, 2018). Combining two long-acting agents can be appropriate (e.g. varenicline + NRT patch) (Galiatsatos, 2022). Instruct patients to utilize short-acting NRT when they experience intense cravings.
It is critical to counsel a patient on the side effects of these medications, as well as the expected time to effect. Dr. Galiatsatos tells his patients, “You will likely continue to have cravings for 2 weeks before you notice anything different.” Prepare patients for side effects such as vivid dreams and nausea. The medications can be dose adjusted as needed.
NRT patches are intended to curb cravings, but they are poorly constructed to act like a cigarette as they do not reach peak nicotine levels in the same way a cigarette does (McNeil, 2010, figure 4). The NRT products will not kick in as quickly, or feel the same as a cigarette does. Make sure patients know that they need to give these products time to work, and encourage them to try the medications for at least 2 weeks. Counsel patients that nothing will fully replicate smoking, but that NRT can be used to help decrease the intensity of cravings.
Quit Dates and Medication Monitoring
In Dr. Galiatsato’s expert opinion, he does not recommend setting a quit date when starting the medication. This allows the patient to adjust to the medication, and then check in with them within a few weeks.
In his expert opinion, he often starts NRT patches at 21mg patch for everyone and assumes that every patient has a high amount of nicotine dependence. The goal is for the patient to have a 50% reduction in their smoking use, and once that occurs Dr. Galiatsatos will decrease the patient’s NRT dose from 21mg to 14mg. Then finally, decrease to 7mg when they stopped smoking and continue for 4-8 weeks after their last cigarette.
Dr. Galiatsatos recommends continuing varenicline and patches for weeks after the use of the last cigarette. Then continue to use short-acting NRT to curb any cravings.
Patches: Use surgical tape and wrap it around the patch for patients who report that the patch falls off. Some patients like that this method hides the patch. Patients can also place the patch under a bra or shirt.
Gum/Lozenges: Remember, gum and lozenges both must be parked in the cheek to allow nicotine to get absorbed into the venous system. If an individual just sucks/chews gum like candy, the patient is more likely to get nauseated. If the patient has dentures, tell them to break the lozenge into pieces, then park it on their gum, like chewing tobacco.
Nasal Spray: Nasal spray is often expensive, and will burn the first few times that a patient uses it. This sensation often improves with repetition. Once individuals are used to it, it can be effective and convenient.
Encourage your patient to use quitlines that can help them access free pharmacotherapy. Bupropion and varenicline can be helpful, and if prescribed, try to use the generic formulation to help keep costs low. Be familiar with local pharmacies that will carry the generic version of these medications.
Listeners will be able to treat patients with tobacco use disorder using evidence-based medications and counseling strategies.
After listening to this episode listeners will…
Dr. Panagis Galiatsatos reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Stahl, N, Galiatsatos P, Mullins K, Morford K, Chan, CA. “#11 Smoking Cessation: It’s Not a Drag with Dr. Panagis Galiatsatos”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/addiction September 15th, 2022.
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