Treating Tobacco Use and Dependence at OHSU

1
Treating Tobacco Useand Dependence at OHSU
2
Program Modules (click on topic for more detail)

• The Tobacco Problem
• Summary information on nicotine dependence and
  nicotine (tobacco) withdrawal.
• Medications and behavioral support used to treat
  nicotine dependence.
• Dosing issues and special considerations for
  cessation medications.
• Patient care at OHSU hospitals and clinics

3
The Tobacco Problem
Next
Main Menu
4
The Tobacco Problem

• Tobacco dependence is a chronic disease.
• 21.5 of Oregon men and 18.4 of Oregon women
  smoke.
• Smoking related diseases claim over 7,000 Oregon
  lives annually.
• Smoking costs Oregon over 2 billion each year in
  health-care costs and lost productivity.
• Smoking is directly responsible for 87 of lung
  cancer cases and causes most cases of emphysema
  and chronic bronchitis.

Next
Main Menu
5
What Can Be Done?

• One out of two smokers will die prematurely from
  a smoking-related disease.
• Every year nearly 45 of smokers try to quit and
  only about 10 succeed.
• Most smokers try to quit smoking by just stopping
  cold turkey.
• Effective cessation medications behavioral
  treatment (e.g. coaching, counseling, quit lines)
  can double or triple success rates vs cold
  turkey.
• You save lives when you provide cessation
  treatment.

Next
Main Menu
6
Why now?

• OHSU is completely tobacco free as of September
  17, 2007.
• Patients coming to OHSU will not be able to
  smoke. This provides an important opportunity to
  talk to patients about quitting and help provide
  assistance to stop.
• Evidence-based treatment protocols are widely
  available and, with your help, are being
  implemented in OHSU hospitals and clinics.

Main Menu
7
Nicotine Dependence And Nicotine (Tobacco)
Withdrawal
Next
Main Menu
8
Nicotine Withdrawal Symptoms

• Physical symptoms (can be mistaken for adverse
  drug experiences.)
• Acute physical symptoms resolve significantly in
  3-6 weeks.
• Some cravings persist for months, but become less
  frequent.
• Medications are generally recommended for up to
  12 weeks.
• Emotional symptoms (can be mistaken for adverse
  drug experiences).
• Some emotional lability is common e.g. depressed
  affect and anxiety. (Some risk of Major
  Depressive Episode in those with recent history
  of Mood Disorder - refer for follow-up.)
• Emotional stress due to life circumstances are
  risks for later relapse (e.g. death of loved
  one).

Next
Main Menu
9
Some Withdrawal Symptoms Following AbruptSmoking
Cessation Or Reduction

• Depressed mood
• Sleep disturbance
• Irritability, frustration or anger
• Difficulty concentrating
• Cravings

• Anxiety
• Restlessness
• Increased appetite or weight gain
• Decreased heart rate

SEVERITY OF WITHDRAWAL SYMPTOMS IS A PRIMARY
CAUSE OF EARLY RELAPSE.
American Psychiatric Association (1994).
Diagnostic and statistical manual of mental
disorders (4th ed.) Washington, DC.
Next
Main Menu
10
Weight Gain And Smoking CessationResults Of A
10 Year Study

• Weight gain is a significant barrier.
• Weight gain or fear of weight gain after quitting
  can keep smokers from even trying to make a quit
  attempt, especially women.
• Most smokers quitters gained weight over 10
  years.
• Women smokers gained 3.7 lbs. (average).
• Women quitters gained 12.1 lbs. (average)
• Women quitters gained more than men quitters.
• 13.4 of women quitters gained 29 lbs. vs. 9.8
  for men quitters
• Most weight gain occurred in the 1st year.
• Some will decide to relapse to try to lose weight.

Women and smoking a report of the Surgeon
General 2001
Next
Main Menu
11
Role Of AcetylcholineNicotinic Receptors

• Acetylcholine nicotinic sub receptors are normal
  structures in the brain and elsewhere of smokers
  and never smokers (16 nicotinic subtypes
  identified).
• Nicotinic receptors modulate neurotransmitters
  (e.g. dopamine (a4ß2), norepinephrine, serotonin,
  opioid peptides, etc. in all people.
• Nicotine binding excites receptors and disrupts
  normal activity.

Next
Main Menu
12
Role Of AcetylcholineNicotinic Receptors

• Chronic nicotine exposure results in permanent
  receptor up-regulation and nicotine normal
  receptor functioning in the brain.
• Reduced nicotine binding at receptor sites due to
  reduced tobacco intake or cessation disrupts
  nicotine normal receptor activity and results
  in nicotine withdrawal symptoms.
• Receptor activity normalizes without nicotine in
  3-6 months, but up-regulated receptors remain
  indefinitely.

Next
Main Menu
13
Click here for a comprehensive Review of Tobacco
Dependence and Tobacco Dependence Treatment
Main Menu
14
Medications To Treat Withdrawal
Next
Main Menu
15
Medications

• Who should receive them?
• Nearly all smokers trying to quit, except those
  with medical contraindications, adolescents and
  those who smoke fewer than 10 cigarettes per day.
• Those who have recently quit (e.g. less than 6
  months) who are concerned about relapse may
  benefit from PRN use of flexible dosed nicotine
  replacement therapies (NRT) such as nicotine
  lozenges or gum.

Next
Main Menu
16
Purpose Of Cessation Medications

• Cessation medications are primarily designed to
  blunt withdrawal symptoms during the acute stages
  of withdrawal when a smoker quits.
• None of the medications cure nicotine dependence
  or make smokers quit.
• A commitment and desire to quit should be present
  prior to medications being dispensed.
• Using an FDA approved cessation medication with
  counseling doubles the quit rates over counseling
  alone.1

1. Fiore et al. USDHHS 2000.
Next
Main Menu
17
Purpose Of Cessation Medications

• While the primary purpose of cessation
  medications is to reduce withdrawal symptoms,
  some medications such as varenicline and
  bupropion also reduce smoking satisfaction should
  the patient smoke while on drug.1
• Varenicline2 and bupropion3 are approved for use
  beyond usual length of treatment for maintenance
  of abstinence up to 24 total weeks (relapse
  prevention).

1. Gonzales et al. JAMA 200620647-55. 2.
Tonstad et al. JAMA. 200629664-71. 3. Hurt et
al. Addict Behav 200227493-507
Next
Main Menu
18
Compliance With Medications

• The brain takes many weeks to adjust to low or no
  nicotine binding at nicotinic receptors.
• Failure of medications is often due to patients
  using less medication than recommended
  (underdosing) or discontinuing medication too
  early (similar to compliance issues with
  antibiotics).
• Ask about medication use encourage proper daily
  dosing/technique and following recommended length
  of time for dosing to increase likelihood of
  success in quitting and relapse prevention.

Next
Main Menu
19
FDA Approved First-LineCessation Medications

• Nicotine replacement therapies (NRT)
• Nicotine patch
• Nicotine lozenge
• Nicotine gum
• Nicotine inhaler
• Nicotine nasal spray
• Varenicline (Chantix) non-nicotinic
• Bupropion SR (Zyban, Welbutrin) non-nicotinic

Next
Main Menu
20
Recommended Medications

• Varenicline Most efficacious of meds (to date)
  no known drug-drug interactions, no
  contraindications, moderate cost, non-nicotinic.
• Nicotine patch Average efficacy, well accepted,
  easy to use, few contraindications, lower cost.
• Nicotine patch flexible dosing NRT (lozenge
  also gum or inhaler) Combining increases
  efficacy for more dependent smokers (4 mg lozenge
  is more efficacious than gum or inhaler).
• Bupropion, Average efficacy, lower cost, some
  contraindications, non-nicotinic

Next
Main Menu
21
Varenicline (Chantix )

• Rx
• Is as effective for women as for men.1
• No significant effect on weight gain. 1,2
• Nausea, usually mild to moderate, occurs in up to
  30 of patients. 1,2
• Dose may be reduced by half if nausea persists
  with less than a 10 decrease in efficacy.3

1. Gonzales et al. JAMA 200629647-55. 2.Jorenby
et al JAMA 200629656-63. 3. Chantix prescribing
instructions. Pfizer, Inc. 2006.
Next
Main Menu
22
Varenicline

• No black box in labeling. 3
• No known drug/drug interactions. 3
• Not been tested in pregnant women or children. 3
• Combination therapy has not been tested.
• Dose adjustment (reduced) is recommended for
  patients with severe renal impairment. 3

3. Chantix prescribing instructions. Pfizer, Inc.
2006.
Next
Main Menu
23
Varenicline

• Usual target quit day is 8th day of treatment.
• Start with 0.5 mg daily for 3 days.
• Increase to 0.5 mg twice daily for 4 days.
• Increase to 1.0 mg twice daily on day 8 until
  the end of treatment (no need to taper at end of
  Tx).
• Smoking while taking the medication does not
  increase health risk over smoking alone.
• Common adverse events nausea, sleep
  disturbance, abnormal dreams, flatulence.
• Average cost/day is 4.00.

Next
Main Menu
24
Nicotine Transdermal Patch

• OTC fixed dose. Actual nicotine bioavailability
  is approximately 50 of dose listed on patch.
• Less effective for women
• NicodermTM, NicotrolTM, HabitrolTM, ProstepTM,
  generics.
• Quit rates are similar for all patches.
• Time to peak nicotine levels in brain range from
  2 hrs (Nicoderm) to 8 hrs. (a consideration if
  patches are taken off at night)
• May delay post cessation weight gain.

Wetter et al. J Consul Clin Psychol 1999
Next
Main Menu
25
Nicotine Transdermal Patch

• For patients who smoke 10-20 cigarettes/day 21mg
  once daily for 6-8 wks. For those who smoke 20
  cigarettes/day consider adding lozenge, gum, or
  second patch.
• Step down to 14mg for 2 - 4 wks, then step down
  to 7 mg for 2-4 wks.
• Common adverse events are patch site skin
  irritation, vivid dreams and sleep disturbance.
• Can be combined with other NRT or bupropion.
• Average cost/day is 4.00 for 21mg, 3.40 for
  14mg or 7mg.

Next
Main Menu
26
Nicotine Lozenge (nicotine polacrilex)

• OTC - flexible dosing (2 mg 4 mg). Actual
  nicotine bioavailability is somewhat greater than
  50 of dose listed on packaging.
• 10-15 minutes to reach the brain.
• May be less effective for women but little gender
  data available.
• Reduces post cessation weight gain (4 mg)1
• Only NRT shown to be effective for re-treatment.1
• Can be combined with a patch or used for relapse
  prevention.

1Shiffman et al. Efficacy of a nicotine lozenge
for smoking cessation. Arch Intern Med
20021621267-1276
Next
Main Menu
27
Nicotine Lozenge

• Start one lozenge every 12 hours for first 6
  wks then one every 2-4 hours for 3 weeks, then
  one every 4-8 hours.
• Use 4 mg for patients who smoke their 1st
  cigarette within 30 minutes of awakening, others
  use 2 mg dose.
• Common adverse events mouth soreness and
  dyspepsia.
• Average cost/day is 8.88.

Next
Main Menu
28
Bupropion Hydrochloride SR(Zyban ,
WellbutrinSR, generic)

• Is as effective for women as for men1
  reduces/delays post cessation weight gain effect
  is greater in women.2
• Reduces post cessation negative affect. 3
• Not for those with seizure Hx, taking meds that
  lower seizure threshold, significant head trauma,
  anorexia or bulimia or who currently drink
  heavily or binge. Seizure risk is 1/1000 for SR.
• Efficacious for re-treatment. 4

1.Gonzales et al. Am J Prev Med 200222234-39.
2.Rigotti et al. SRNT 5th Annual Meeting,
Arlington, VA. 1999. 3.Shiffman et al.
Psychopharmacologia 200014833-40. 4.Gonzales et
al. Clin Parmacol Ther 200169438-44.
Next
Main Menu
29
Bupropion SR

• Start 150 mg once daily for 3 days, then twice
  daily for 7-12 weeks.
• Usual target quit day is day 8 of treatment.
• Common adverse events insomnia, sleep
  disturbance and headache.
• Not recommended for those with any Hx of abuse of
  stimulants. Can cause agitation.
• SR-average cost/day is 4.33.

Next
Main Menu
30
Other Nicotine Replacement Therapies
Next
Main Menu
31
Nicotine Gum (nicotine polacrilex)

• OTC - flexible dosing (2 mg 4 mg). Actual
  nicotine bioavailability is approximately 50 of
  dose listed on packaging.
• 10 15 minutes to reach the brain.
• Often less effective for women.
• Reduces/delays post cessation weight gain.
• Not recommended for those with significant dental
  work (very stiff and sticky on dental appliances
  and can cause damage).
• Can be used in combination with a patch and for
  relapse prevention.

Killen et al. J Consult Clin Psychol 1990
Next
Main Menu
32
Nicotine Gum

• Use 2 mg for patients who smoke less than 15
  cigarettes/day (one 2 mg piece every 1-2 hours).
• Use 4 mg for patients who smoke more than 15
  cigarettes/day (4 mg piece every 1-2 hours.
• Common adverse events jaw pain and mouth
  soreness.
• Average cost/day is 9.33 for 2 mg and 10.33 for
  4 mg dose.

Next
Main Menu
33
Nicotine Inhaler

• Rx - flexible dosing. Actual bioavailability is
  approximately 50 of dose listed on packaging.
• 10 15 minutes to reach the brain (buccal not
  lung absorption) similar to gum and lozenge.
• May reduce/delay post cessation weight gain.
• May be especially useful for those who miss
  puffing from smoking or women due to the
  similarity to smoking behavior.
• Can be used in combination with other NRT.

Next
Main Menu
34
Nicotine Inhaler

• Start with 6-16, 10 mg cartridges per day for
  three months.
• Taper over six to twelve weeks.
• Common adverse events mouth and throat
  irritation.
• Average cost/day is 9.50.

Next
Main Menu
35
Nicotine Nasal Spray

• Rx - flexible dosing. Actual bioavailability
  greater than 50 of the dose listed on packaging.
• 5-7 minutes to reach the brain. Most rapid onset
  of all NRTs.
• Women respond differently than men
• Some clinicians report it is particularly helpful
  for those with psychiatric or substance abuse
  disorders due to the quicker onset.
• May delay post cessation weight gain.
• Can be used in combination with other NRT.

Perkins et al. Exper Clin Psychopharmacology
1996
Next
Main Menu
36
Nicotine Nasal Spray

• Start with 1-2 0.5mg doses in each nostril every
  hour for 3-6 months.
• Taper over 4-6 weeks.
• Common adverse events nose and eye irritation.
• Average cost/day is 16.00.

Next
Main Menu
37
Dosing Suggestions ForNicotine Replacement (NRT)

• Cigarettes smoked per day can serve as a general
  guide to dosing NRT (but not other medications).
• 1 cigarette delivers 1.0 mg of nicotine on
  average, e.g., pack smoker 20 mg daily dose of
  nicotine.
• Goal for NRT(single or combined forms) is steady
  state replacement of at least 75 -85 of usual
  daily nicotine dose sufficient to manage
  withdrawal.
• Due to nicotine tolerance from smoking, risk of
  unintentional overdose from NRT alone or from
  using NRT while smoking is low.1

1. Benowitz et al. J Pharmacol Exp Ther 1998
287958-962.
Next
Main Menu
38
NRT Overview

• Contraindications
• Patch current Hx eczema or psoriasis allergy to
  adhesives or nicotine patches.
• All forms should not be used in patients with Hx
  of MI within prior 2 weeks.
• Common Adverse Events
• Patch sleep disturbance, site reaction
• Lozenge nausea, hiccups, heartburn due to
  swallowing nicotine.

Review prescribing instructions for complete
list of contraindications and adverse events.
Next
Main Menu
39
NRT Summary

• Flexible dosing forms allows individual
  tailoring.
• Women may respond more poorly to NRT 1,2,3.
• Women taking oral contraceptives4 and pregnant
  women5 have increased nicotine metabolism (more
  rapid clearance) and may need higher doses to
  suppress withdrawal symptoms.

1 Killen et al. J Consul Clin Psychol 1990. 2.
Wetter et al. J Consul Clin Psychol 1999. 3.
Perkins et al. Exper Clin Psychopharmacol 1996.
4. Benowitz et al. Clin Pharmacol Ther 2006. 5.
Dempsey et al. J Pharmacol Exper Ther 2002.

Next
Main Menu
40
NRT Summary

• NRT use may result in reduced or delayed post
  cessation weight gain during treatment.
• Smoking while using NRT poses no greater health
  risk than smoking alone.1
• Quit rates are generally similar for all forms of
  NRT.2
• Due to nicotine tolerance from smoking, risk of
  unintentional overdose from NRT alone or from
  using NRT while smoking is low.1

1. Benowitz. Cardiovascular Diseases
20034691-111. 2. Fiore et al. USDHHS 2000.
Next
Main Menu
41
Second-Line Medication(Not FDA Approved for
Smoking Cessation)

• Clonidine - Rx
• Primarily effective for women1
• Common adverse events dry mouth, dizziness,
  drowsiness, sedation.2
• Failure to gradually reduce dose may result in
  rapid increase in blood pressure, agitation,
  confusion, tremor.2

1.Covey et al. Br J Addiction 1991. 2. Fiore et
al. USDHHS 2000.
Next
Main Menu
42
Second-Line Medication(Not FDA Approved for
Smoking Cessation)

• Nortriptyline-Rx (inexpensive)
• Efficacious, but less so for women with history
  of depression 1
• Common side effects sedation, dry mouth, blurred
  vision.2
• Cardiovascular disease risk of changes in
  contractility and blood flow, arrhythmias. 2
• Pregnancy caution has been associated with fetal
  limb reduction abnormalities.

1. Hall et al.,1998 2. Fiore et al. USDHHS 2000.
Next
Main Menu
43
Click here for a copy of Smoking Cessation
Pharmacology at OHSU 2007
Main Menu
44
Special Considerations Long term use Pregnant
smokers Patients on psychiatric
medications Patients who need more intensive
treatment
Next
Main Menu
45
Longer-Term Use of Cessation Meds

• For smokers who have achieved abstinence, but
  have persistent withdrawal symptoms at the end of
  the usual course of treatment or to prevent
  relapse.
• Long-term use of NRT does not present a known
  health risk.
• Varenicline is approved for a 2nd 12-week course
  of treatment (up to 24 weeks total) to maintain
  abstinence (relapse prevention).
• Bupropion SR is approved for a 2nd course of
  treatment (up to 24 weeks total) to maintain
  abstinence.

Next
Main Menu
46
Treatment for Pregnant Smokers

• Due to potential unknown fetal risks counseling
  without cessation medication is the first choice
  of treatment.
• Risks of poor pregnancy outcomes due to fetal
  exposure to other chemicals in smoke nicotine
  are greater than exposure to nicotine alone from
  nicotine replacement therapies (NRT).
• NRTs are pregnancy category D, except for gum and
  lozenges, which are pregnancy category C.
• Varenicline and bupropion SR have not been tested
  in pregnant smokers and are both pregnancy
  category C.

Next
Main Menu
47
Patients On Psychiatric Medications

• Dose adjustments may be necessary following
  tobacco (nicotine) cessation.
• Blood levels of some psychiatric medications may
  increase substantially following smoking
  cessation (within 3-6 weeks) increasing risk of
  drug toxicity.
• Psychiatric medications that should be monitored
  include clozapine, fluphenazine, haloperidol,
  oxazepam, desmethyldiazepam, clomipramine,
  nortriptyline, imipramine, desipramine, doxepin,
  and propranolol.

Next
Main Menu
48
Patients Who Need MoreIntensive Treatment

• Patients more likely to need more intensive and
  specialized treatment.
• High nicotine dependence who smoke heavily,
  and/or has first cigarette within 30 minutes
  after waking in the morning.
• Severe withdrawal during previous quit attempts.
• Current or recent psychiatric history, especially
  mood disorders, schizophrenia.

Next
Main Menu
49
Patients Who Need MoreIntensive Treatment

• Current or recent (in last year) history of
  alcohol abuse or other chemical dependency.
• Current stressful life circumstances or major
  life changes (recent serious diagnosis or injury,
  divorce, job loss, marriage, new baby etc.).
• Current or recent stressful or high risk
  employment (police, firefighters, pilots,
  surgeons, surgical nurses, military personnel
  etc.).

Next
Main Menu
50
What Is Intensive Treatment?

• Tailored treatment to impact more specific needs
  of patients including
• Medications
• Adjusting cessation medication doses (usually
  higher).
• Longer duration of drug treatment.
• Combining cessation therapies.
• Adjusting non-cessation medication doses.
• Coaching/counseling
• More sessions over a longer period of time.
• Referral to more highly trained specialists.
• More frequent in-clinic or phone follow-up..
• Referrals to other services as needed (e.g.
  mental health).

Main Menu
51
Patient Care at OHSU Hospitals and Clinics
Next
Main Menu
52
Hospital Admission

• Patients are told about tobacco free policy when
  they schedule admissions and when they register.
• Patients are ASKED about tobacco use
• Tobacco use questions are on the initial nursing
  assessment.
• Tobacco use questions are on (some) unit
  admission orders.
• Tobacco use questions will be included in
  admission orders in the Epic system (Spring 2008).

Next
Main Menu
53
Nursing education and Tobacco Dependence Consult

• For patients who have used any tobacco in the
  last 12 months (JCAHO), nursing will review
  Smoking Cessation Guide for Hospital Patients
  (pdf online at www.ohsu.edu/healthsystem/nursing)
• For patients who have used tobacco in the last 90
  days, MD completes Tobacco Dependence Inpatient
  Orders (PO-7290).
• Tobacco Treatment Specialist Nurse Practitioner
  is paged to provide consult at 6-0027.

Next
Main Menu
54
Tobacco Dependence Consult

• Tobacco Treatment Specialist Nurse Practitioner
• Completes tobacco dependence assessment bedside
  counseling.
• Develops a treatment discharge plan.
• Includes an FDA approved medication (or
  combination) recommendations for
  counseling/coaching after discharge.
• Makes arrangements for follow-up after discharge
  and leaves instructions for patient.
• Completes preprinted progress note (HP 5336) and
  chart note.
• Flags discharge plan.
• Contacts medical team to update.

Next
Main Menu
55
Hospital Discharge

• Discharge MD
• Review progress note.
• Include tobacco cessation discharge plan in
  dictated discharge summary.
• Remind patient of tobacco cessation discharge
  plan.
• Write appropriate prescriptions.
• Copy of discharge summary to primary care
  provider.

Next
Main Menu
56
Flow Chart
Next
Main Menu
57
Outpatient Clinics ASK and ACT
Next
Main Menu
58
ASK

• Patients are reminded of OHSU policy when they
  schedule and check in for clinic visits.
• All patients are ASKED about tobacco use by the
  medical assistant. (Questions are included in the
  Epicare system).
• Patients who report tobacco use are asked if they
  would like help to quit.
• If NO, give Oregon Tobacco Quitline number to
  call when ready (1-800-784-8669). If YES, ACT (or
  REFER).

Next
Main Menu
59
ACT

• Provider discusses quitting with patient
  Quitting is the most important thing you can do
  for your health and assesses when patient wants
  to quit.
• If patient is not planning to quit now or IS
  planning to quit but in greater than 30 days,
  recommend that patient call the Oregon Tobacco
  Quitline when they are ready (1-800-784-8669.)
• If patient is planning to quit in next 30 days,
  develop a tobacco cessation TREATMENT PLAN.
• An evidence-based stop smoking treatment plan
  includes BOTH medications to stop smoking AND
  follow-up for behavioral support.

Next
Main Menu
60
ACT

• TREATMENT PLAN Development
• Medications
• Prescribe one or a combination of the FDA
  approved stop smoking/tobacco medications (see
  Smoking Cessation Pharmacology at OHSU 2007 at
  www.ohsu.edu/smokingcessation/patientcare.
• Behavioral Support
• Recommend that OHSU employees follow-up with OHSU
  Employee Wellness 4-9355.
• Recommend that patient call the Oregon Tobacco
  Quitline.
• The OTQL will triage patients to follow-up
  services covered by insurance. Also, all callers
  are eligible for 2 weeks of free patches
  uninsured callers are eligible for 4 weeks.

Next
Main Menu
61
ACT

• Treatment Plan (cont.)
• Behavioral Support (cont.)
• Consider encouraging patients to fill
  prescriptions at OHSU outpatient pharmacy. OHSU
  outpatient pharmacists are trained to provide
  tobacco cessation consultation for patients.
• Add Getting Ready to Quit? patient stop smoking
  guide to after visit summary (Epic smart phrase
  SMOKINGCESSATION.)

Next
Main Menu
62
REFER

• REFERRAL OPTION TO OHSU OUTPATIENT PHARMACIES
• OHSU outpatient pharmacists are trained to
  develop tobacco cessation treatment plans
  following a specific, OHSU medically supervised
  protocol.
• OHSU providers can refer their patients to any of
  the outpatient pharmacies to develop tobacco
  cessation treatment plans.
• Only refer patients who are ready to quit within
  30 days.
• To refer patients
• Write, call, or fax prescription to OHSU
  outpatient pharmacy with Tobacco Cessation per
  OHSU Protocol on prescription.
• Trained pharmacist will see patient, enter into
  Epic, and send information to referring provider.

Next
Main Menu
63
The Quitting Process
Precontemplation
Dont want to quit
Refer patients to the pharmacy program who are in
the PREPARATION or ACTION stage of quitting.
Contemplation
Want to quit sometime
Preparation
Will quit in next 30 days
Action
Will quit in the next 2 weeks
Maintenance
Termination
Relapse
Adapted from Knight, 1997
Next
Main Menu
64
Outpatient Pharmacy Program OHSU Collaborative
Drug TherapyManagement Agreement (CDTM)
Next
Main Menu
65
OHSU Collaborative Drug TherapyManagement
Agreement

• OHSU outpatient pharmacists can provide patient
  cessation services through the OHSU Collaborative
  Drug Therapy Management Agreement.
• The CDTM permits pharmacists to
• Recommend smoking cessation medications and
  behavioral follow-up and develop a treatment
  plan.
• Prescribe medications based on an OHSU approved
  treatment algorithm.
• Patients are referred to the pharmacy program who
  are ready to quit in the next 30 days
  (preparation/action stage).

Next
Main Menu
66
Getting Started

• For patients ready to quit, pharmacists will
• Develop a treatment plan.
• Treatment plan includes an FDA approved
  medication (or combination) recommendations for
  counseling/coaching.
• Write and fill prescriptions under the CDTM.
• Make arrangements for follow-up.
• Send information to referring provider.
• Enter into Epicare.

Next
Main Menu
67
OHSU Treatment Plan Development

• Treatment planning begins with an assessment
• Smoking and quitting history
• Tobacco dependence
• Motivation and readiness
• Health and medication histories
• Treatment Plan is based on assessment data
• Medications counseling/coaching recommendations
  either standard or intensive
• Prescription(s), dispensing
• Consideration of referral for additional
  non-cessation treatments
• Follow-up type (in-clinic, phone, quit line etc)
  and frequency.

Next
Main Menu
68
REMEMBER . . .

• Quitting smoking is the most important thing
• your patients can do to protect their present and
  future health.
• With your help, they can be successful.
• Your efforts will save lives!

Next
Main Menu
69
For more information Visit www.osu.edu/tobaccofre
e and click on Information for health
professionals or visit www.ohsu.edu/smokingcessat
ion/patientcare Email free_at_ohsu.edu with
questions or comments Call 503 494-FREE (3733)
Main Menu