NRT Guide for the Medical Provider

NRT Guide for the Medical Provider INSPIRE Tobacco Prevention Initiative Made possible with funding from the Centers for Disease Control and Preventi...
Author: Everett Jordan
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NRT Guide for the Medical Provider INSPIRE Tobacco Prevention Initiative

Made possible with funding from the Centers for Disease Control and Prevention

NRT Provider Tools and Objectives • ¡NSP!RE Tobacco Prevention Overview • Promoting Tobacco Cessation Strategies • Nicotine Replacement Therapies (NRTs) Overview • Medicare Billing for Tobacco Cessation Services • “Golden” Standard of NRT Treatment

¡NSP!RE Tobacco Prevention Goals • Prevent youth and young adults from initiating tobacco use • Expand smoke free environments and reduce exposure to secondhand smoke • Promote tobacco cessation • Reduce health disparities in Santa Clara County

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Promote Tobacco Cessation • Free Nicotine Replacement Therapies (NRTs) available through CPPW grant • Cessation Network available to support and work through issues with implementing a cessation program • Cessation Therapy Services are reimbursable through Medicare and Medical

Nicotine Replacement Therapies

Nicotine Replacement Therapy (NRT) • • • • •

FDA Approved Medication to help stop smoking Over the counter safe Gum, Lozenge, and Patch products Variable strengths and dosages Most successful attempts are combined with cessation therapy

Nicorette Gum • • • • • • •

Over the counter medication Best prescribed for light or occasional smokers Scalable prescription methods Eases oral cravings Have more control on dosing 2 mg or 4mg Flavors: Original, fresh mint, fruit chill, and cinnamon

Nicorette Gum – Cons & Side Effects • May not be socially acceptable • Difficult for dentures • Must be chewed correctly to avoid side effects or being overdosed • Mouth/jaw soreness • Hiccups, Dyspepsia, Hypersalivation

Nicorette Gum - Dosing ≥ 20 cig/day and/or 1st cig ≤ 30 min after waking up, start with 4 mg

4 mg Gum/Lozenge

Step Down

Step Down Dose 4 mg Gum/Lozenge 2 mg Gum/Lozenge

• 1 piece/2‐4 hrs Wk 7‐8

• 1 piece/2‐4 hrs Wk 9‐10 

• 1 piece/4‐8 hrs Wk 10‐12 

Nicorette Gum – Contraindications • • • • • • • • •

Pregnancy Recent MI ≤ 2 weeks Serious underlying arrhythmias Serious or worsening angina pectoris Temporomandibular joint disorder (TMJ) Difficult for dentures Recent surgery Asthma Depression Medications

Nicorette Gum – How to Use • Chew one piece slowly until you feel tingling • Pin the piece between cheek and gum until the tingling fades • Chew again • Repeat on and off for 30 minutes

Lozenge • • • • • • • •

Over the counter medication Best prescribed for light or occasional smokers Scalable prescription methods Eases oral cravings Have more control on dosing Easy to use 2 mg or 4 mg Flavors: mint and cherry

Lozenge – Cons & Side Effects • Must be allowed to melt to avoid side effects or being overdosed • May upset stomach • Nausea, Cough, Heartburn, Headache, Flatulence, Insomnia, Hiccups, Dyspepsia, Hypersalivation

Lozenge – Dosing ≥ 20 cig/day and/or 1st cig ≤ 30 min after waking up, start with 4 mg

4 mg Gum/Lozenge

Step Down

Step Down Dose 4 mg Gum/Lozenge 2 mg Gum/Lozenge

• 1 piece/2‐4 hrs Wk 7‐8

• 1 piece/2‐4 hrs Wk 9‐10 

• 1 piece/4‐8 hrs Wk 10‐12 

Lozenge – Contraindications • Pregnancy • Recent MI (≤ 2 weeks) • Serious underlying arrhythmias • Serious or worsening angina pectoris • Recent surgery • Asthma • Depression Medications

Lozenge – How to Use • Suck on 1 lozenge slowly • Switch lozenge from place to place in the mouth until gone

Quit while you work…

Nicoderm CQ Patch • Over the counter medication • Scalable prescription methods • Easy to use and conceal • Provides consistent nicotine level over 24 hours • 7 mg, 14 mg, or 21 mg

Nicoderm CQ Patch – Cons & Side Effects • Fixed Dose • Allergic Reactions to adhesive may occur • Increased heart rate o

If on blood pressure medications and taking patch and Wellbutrin together – check blood pressure on weekly basis

• Nausea, vomiting • Headache, insomnia, unusual vivid dreaming

Nicoderm CQ Patch – Dosing Step Down Dose

• 1 – 21mg patch daily Wk 1‐6

• 1 – 14mg patch daily Wk 7‐10 

• 1 – 7mg patch daily Wk 10‐12 

Nicoderm CQ Patch – Contraindications • • • • • • • •

Pregnancy Not for patient with dermatitis Recent MI ≤ 2 weeks Serious underlying arrhythmias Serious or worsening angina pectoris Recent surgery Asthma Depression Medications

Nicoderm CQ Patch – How to Use • Affix patch to clean, dry, hairless portion of skin • Place patch in a different place each day • Use medical tape to reattach if patch falls off o

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Clean skin with alcohol & dry well to help adhere Do not add lotion in area where putting patch to help adhere

Case Studies When to Prescribe the Gum, Lozenge, or Patch

Case Study 50 year old male who smokes one pack per day demonstrates a commitment to quit smoking. He does not have history of abnormal arrhythmia or angina. Which NRT method is indicated? Recommend 21 mg Patch: Start at one patch a day for 4-6 weeks OR 2 mg Gum or Lozenge: Start at 1 piece per hour for 4-6 weeks

Case Study 50 year old female smokes two or more packs per day. She does not have history of abnormal arrhythmia or angina. Which NRT method is indicated? Recommend 21 mg Patch: Start at one patch a day for 4-6 weeks AND 2 mg Gum or Lozenge: Start at 1 piece per hour for 2-3 weeks

Case Study 28 year old female smokes occasionally in social settings. She estimates less than one pack a week. She does not have a history of abnormal arrhythmia or angina. Which NRT method is indicated? Recommend to quit without NRT. If necessary, start with 2 mg Gum or Lozenge as needed (typically at the time he/she usually has a cigarette).

Case Study 35 year old male chews 3 cans of chewing tobacco a week. He does not have a history of abnormal arrhythmia or angina. Which NRT method is indicated? Recommend 21 mg Patch: Start at one patch a day for 4-6 weeks AND 2 mg Gum or Lozenge: Start at 1 piece per hour for 4-6 weeks

Case Study 55 year old male smokes 2 packs of cigarettes per day. He has used the gum and lozenge before but has relapsed. Last week, he suffered his first acute MI. Which NRT method is indicated? None. Contraindicated due to recent MI.

Case Study 28 year old female smokes as soon as she wakes. If she does not have a cigarette after meals, she becomes irritable. Patient estimates at least a pack a day. She has attempted the patch on her own without success. She does not have a history of abnormal arrhythmia or angina. Which NRT method is indicated? Recommend Group Cessation therapy in conjunction with 21mg patch and some of 2 mg gum/lozenge to control the morning craving/ strong urges or between the patch change.

Cessation Therapy Services • Contact Breathe California at 408.998.5865 • Currently, over 40 staff from many organizations are certified as cessation counselors to provide group counseling classes to help people stop smoking (call for specific locations and dates) • 5 A’s of Intervention and the 5 R’s of Motivation o

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Ask, Advise, Assess, Assist, and Arrange for follow-up Relevance, Risks, Rewards, Roadblocks, and Repetition

Medicare Billing for Cessation Services • Medicare Part B coverage includes 2 attempts each year • Each attempt may include a maximum of 4 intermediate or intensive sessions • A total of 8 sessions are covered in a 12-month period • The qualified practitioner and the patient have flexibility to choose between intermediate or intensive cessation strategies for each session

Medicare Billing Codes The following two new Health Common Procedure Coding System (HCPCS) codes have been created for billing for the two new levels of smoking and tobacco-use cessation counseling Medicare now covers: • G0375 - Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes. Short Descriptor: Smoke/Tobacco counseling 3-10 • G0376 - Smoking and tobacco-use cessation visit; intensive, greater than 10 minutes. Short Descriptor: Smoke/Tobacco counseling greater than 10

“Golden” Standard of NRT Treatment • Kaiser Permanente physicians often prescribe 2 forms of NRT to provide extra support: the patch to maintain nicotine levels and oral NRT for intense breakthrough cravings • Combining the use of the nicotine patch with another form of NRT may increase a patient’s chances of success • All forms of NRT products appear to be about equally effective when used properly

Provider Online Resources Breathe California: www.lungsrus.org

INSPIRE Tobacco Prevention Website: http://www.sccgov.org/sites/sccphd/en-us/Partners/TobaccoPrevention/Pages/default.aspx

California Smoker’s Helpline: http://www.californiasmokershelpline.org/

Medicare Smoking Cessation: http://www.medicare.gov/navigation/manage-your-health/preventiveservices/smoking-cessation.aspx?AspxAutoDetectCookieSupport=1

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Thank You INSPIRE Tobacco Prevention Initiative For more information on NRTs, visit www.sccphd.org/tobacco-prevention

Made possible with funding from the Centers for Disease Control and Prevention