Smoking Cessation Nicotine Replacement Therapy NRT Available in gum lozenge patch and inhaler Aims to replace the nicotine obtained from cigarettes reducing withdrawal symptoms when stopping smoking Use of NRT is preferable to smoking because it does not contain non nicotine toxic substances such as carbon monoxide and tar produce dramatic surges in blood nicotine levels produce strong dependence Nicotine Replacement Therapy Odds ratio for abstinence with NRT compared to control is 1 73 patch 1 76 gum 1 66 inhaler 2 08 4mg lozenge 3 69 Odds are independent of intensity of additional support provided to smoker or setting in which NRT offered In highly dependent smokers there is significant benefit of 4mg gum over 2mg gum odds ratio 2 67 Increases quit rates 1 5 2 fold regardless of setting NRT is safe should be routinely recommended to smokers product choice depends on practical personal considerations Level of nicotine dependence and NRT dosage As a general rule smokers who are nicotine dependent will have less intense withdrawal symptoms if provided with an adequate dosage of NRT For example A trial for the nicotine lozenge used the TTFC time to first cigarette measure of dependence to allocate dosage those who smoke within 30 mins of waking 4mg lozenge those who wait longer than 30 mins 2mg lozenge Note the lozenge provides 25 more nicotine than the gum as it dissolves completely Increase in nicotine concentration ng ml 14 Smoking produces much higher nicotine levels than NRT 12 10 8 Cigarette Gum 4 mg 6 Gum 2 mg 4 Inhaler 2 0 Patch 5 10 15 20 Minutes Source Balfour DJ Fagerstr m KO Pharmacol Ther 1996 72 51 81 25 30 NRT Dosage Plasma nicotine levels significantly lower from NRT than smoking MIMS recommended dosages Gum maximum 40 per day Lozenge maximum 15 per day Patch healthy people 10 cigs day 45 kgs one patch daily 2 1mg 24 hr or 15mg 16hr cardiovascular disease 10 cigs day 45 kgs one patch daily 14mg 24hr or 10mg 16hr Inhaler Self titrate dose according to withdrawal symptoms 6 12 cartridges day Directions for use of NRT products Gum nicotine absorbed through oral mucosa chew till a peppery tingling feeling flatten gum and park between gum cheek or under tongue Lozenge nicotine absorbed through oral mucosa move round mouth from time to time and suck until dissolved takes 20 30 minutes Patch nicotine absorbed through skin place on clean nonhairy site on chest or upper arm on waking place new patch on new site each day to prevent skin reaction Inhaler nicotine absorbed through oral mucosa inhale air through cartridge for 20 minutes Bupropion Zyban First non nicotine medication shown effective for cessation Blocks neural re uptake of dopamine and or noradrenaline Start one week prior to quit day limited application for inpatients An option for patients after discharge and patients can be referred to their GP to discuss their options The only pharmacotherapy available on PBS Contraindications include patients with seizure disorder current or prior bulimia or anorexia nervosa use of a MAO inhibitor within the previous 14 days Combination therapy Highly dependent smokers may benefit from combining patch with self administered form of NRT lozenge gum inhaler More effective than single form of NRT Use combined treatments if unable to remain abstinent or if still experiencing withdrawal symptoms using single therapy Increased success depends on the use of two distinct delivery systems one passive ie patch one active or at liberty ie gum lozenge inhaler Opioids Basic Opioid Facts Description Opium derived or synthetics which relieve pain produce morphine like addiction and relieve withdrawal from opioids Medical Uses Pain relief cough suppression diarrhea Methods of Use Intravenously injected smoked snorted or orally administered Agonists Partial Agonists and Antagonists Agonist Morphine like effect e g heroin Partial Agonist Maximum effect is less than a full agonist e g buprenorphine Antagonist No effect in absence of an opiate or opiate dependence e g naloxone Opioid Agonists Natural derivatives of opium poppy Opium Morphine Codeine Synthetics Propoxyphene Darvon Darvocet Meperidine Demerol Fentanyl citrate Fentanyl Methadone Dolophine Levo alpha acetylmethadol ORLAAM Opioid Partial Agonists Buprenorphine Buprenex Suboxone Subutex Pentazocine Talwin Opioid Antagonists Naloxone Narcan Naltrexone ReVia Trexan SOURCE National Institute on Drug Abuse www nida nih gov Partial vs Full Opioid Agonist death Opiate Effect Full Agonist e g methadone Partial Agonist e g buprenorphine Antagonist e g Naloxone Dose of Opiate What Happens When You Use Opioids Acute Effects Sedation euphoria pupil constriction constipation itching and lowered pulse respiration and blood pressure Results of Chronic Use Tolerance addiction medical complications Withdrawal Symptoms Sweating gooseflesh yawning chills runny nose tearing nausea vomiting diarrhea and muscle and joint aches Possible Acute Effects of Opioid Use Surge of pleasurable sensation rush Warm flushing of skin Dry mouth Heavy feeling in extremities Drowsiness Clouding of mental function Slowing of heart rate and breathing Nausea vomiting and severe itching Heroin Withdrawal Syndrome Intensity varies with level chronicity of use Cessation of opioids causes a rebound in function altered by chronic use First signs occur shortly before next scheduled dose Duration of withdrawal is dependent upon the half life of the drug used Peak of withdrawal occurs 36 to 72 hours after last dose Acute symptoms subside over 3 to 7 days Protracted symptoms may linger for weeks or months Opioid Withdrawal Syndrome Acute Symptoms Pupillary dilation Lacrimation watery eyes Rhinorrhea runny nose Muscle spasms kicking Yawning sweating chills gooseflesh Stomach cramps diarrhea vomiting Restlessness anxiety irritability Opioid Withdrawal Syndrome Protracted Symptoms Deep muscle aches and pains Insomnia disturbed sleep Poor appetite Reduced libido impotence anorgasmia Depressed mood anhedonia Drug craving and obsession Treatment Options for Opioid Addicted Individuals Behavioral treatments educate patients about the conditioning process and teach relapse prevention strategies Medications such as methadone and buprenorphine operate on the opioid receptors to relieve craving Combining the two types of treatment enables patients to stop using opioids and return to more stable and productive lives Opioid Dependence Treatment Medically Assisted Withdrawal Relieves withdrawal