Stepping Up Your NRT Game: Nicotine Replacement Basics for the Emergency Physician
PAIN AND ADDICTION COMMITTEE
Jessica Moore, MD FAAEM FASAM
T
obacco use is the leading cause of preventable death in the United States, with over 480,000 deaths attributed to tobacco use per year.1 When we consider the innumerable negative health consequences of tobacco use—including anything from pulmonary disease to premature coronary artery disease to cancer risk—treatment for tobacco use disorder (TUD) may be the single most beneficial long-term intervention we can offer our ED patients who use cigarettes or other tobacco products.2 What treatment options do we have, and how do we counsel patients more effectively on smoking cessation? Fortunately, we have several safe and effective medications for TUD including nicotine replacement, varenicline, and bupropion. Below are some quick tips focused on nicotine replacement therapy (NRT). Default to combination NRT. All forms of NRT are associated
with increased treatment success in studies.3 Furthermore, combination pharmacotherapy has shown superiority in TUD treatment, as compared to monotherapy (i.e., a single form of NRT, bupropion, or varenicline alone).4-10 In general, when starting NRT, recommend treatment with both a long-acting and short-acting formulation: y Long-acting NRT: The nicotine patch is considered long-acting NRT. NRT patches are available in doses of 7mg, 14mg, and 21mg. The recommended starting dose is 7 to 14mg for someone who smokes 10 or fewer cigarettes per day; 14 to 21mg for 10 to 20 cigarettes per day; and at least 21mg for roughly one pack of cigarettes or more daily. Cigarettes come in packs of 20—think roughly 1mg per cigarette for a starting patch dose. NRT patches are available over the counter. If a patient continues to experience withdrawal symptoms or cravings with their starting patch dose, escalate to a higher dose. If 21mg is insufficient for symptom control, an additional patch can be utilized. Even high doses of NRT are generally well-tolerated. y Short-acting NRT: Short acting NRT comes in multiple formulations including a gum, lozenge, inhaler, and nasal spray. Gum and lozenges are available over the counter and come in 2mg and 4mg dosages. The NRT inhaler and nasal spray require a prescription. Counsel patients on how to use NRT effectively. NRT
gum and lozenges are often used improperly, leading to suboptimal nicotine absorption, and therefore suboptimal effect. Rather than continuously chewing NRT gum, patients should be instructed to utilize the “chew and park” method: chew the gum briefly, then place it between the cheek and gingiva so that nicotine can be absorbed transbucally. Additionally, it is important to counsel patients on the onset of action of NRT. Gum and lozenges will not take effect as quickly as cigarettes.
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COMMON SENSE NOVEMBER/DECEMBER 2024
When we consider the innumerable negative health consequences of tobacco use…treatment for tobacco use disorder may be the single most beneficial long-term intervention we can offer our ED patients.” While nicotine delivery is on the order of seconds with cigarette smoking, there is a significant delay with buccal absorption and time to effect for gum or lozenges.11 Patients may not appreciate the efficacy of NRT if they are not aware of these differences. You may hear something like, “I started chewing the nicotine gum when I had a craving, but I still ended up needing a cigarette.” If patients do not appreciate the efficacy of NRT, they may stop using it altogether. How do we optimize NRT effect? Consider one or both of the following: y Instruct patients to use short acting NRT 20 minutes before they anticipate a nicotine craving. For example, if a patient says, “I always have a cigarette on my lunch break,” instruct them to chew a piece of gum 20 minutes before lunch each day. y Liberally use short acting NRT throughout the day, to help keep overall nicotine cravings and withdrawal at bay. Anticipate side effects of NRT. Anticipating the common
side effects of NRT can allow patients to mitigate them, increasing the likelihood of treatment continuation. The most commonly reported side effects of the NRT patch include local skin reactions as well as sleep disturbances. Rotating the patch site can reduce skin irritation, as can a topical steroid. Patches can be left on at night; however, if the patient experiences significant insomnia, nightmares, or vivid dreams related to the patch, it can be taken off 30 minutes prior to bed to reduce these symptoms. NRT gum can cause GI upset, which can be reduced by utilizing the “chew and park” method.11 Reframe treatment goals. Complete smoking cessation does
not need to be the immediate emphasis of treatment. We know that the negative effects of cigarette use are cumulative: the greater the overall quantitative cigarette use (“pack-years”), the worse the patient health outcomes. While evidence for smoking reduction is still limited, from a harm >>