Nicotine Replacement Therapy Overview June 20 2018 a Learning Objectives Review the biological basis of tobacco dependence Discuss the current standards of practice for using nicotine replacement therapies ID: 1009870
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1. Tobacco Recovery Wellness Initiative Nicotine Replacement Therapy Overview June 20, 2018a
2. Learning ObjectivesReview the biological basis of tobacco dependence.Discuss the current standards of practice for using nicotine replacement therapies.Review simple tips for maximizing the effectiveness of NRTReview how to access NRTs InsuranceOver the CounterQuitlineQ&A
3. Overview of Nicotine Replacement TherapyFrank T. Leone, MD, MSComprehensive Smoking Treatment ProgramUniversity of PennsylvaniaPhiladelphia, PA1-888 PENN STOP
4. DisclosureConsultant Arrangements: None Equity Ownership: NonePatent Arrangements: NoneGrants/Research Support: National Institutes of Health Pennsylvania Department of Health. Health Promotion Council of PA National Cancer Institute. Phila Department of Public HealthEmployment: University of PennsylvaniaSpeakers' Bureau: NoneOther: None
5. ObjectivesReview the biological basis of tobacco dependence.Discuss the current standards of practice for using nicotine replacement therapies.Review simple tips for maximizing the effectiveness of NRT.
6. Nicotine Dependence Itself a Chronic Illness“There’s someone in my head, but it’s not me.” - Pink Floyd 1973
7. Mesolimbic Dopaminergic system
8. Long term changesIncreased neuronal arborizationIncreased density of nicotinic receptorsIncreased sensitivity of receptor ion channelsChanges gene expressionNeuronal protein synthesis increasesNeurotransmitter synthesis increases
9. Smoking: A Disorder of Compulsion.Not exactly ready, or willing, or able.HesitantPatients want change, but don’t want change.“I desperately want to want to quit smoking”Ambivalent“Come back when you’re ready?”
10. Nicotine Levels in Blood
11. Nicotine Replacement TherapyPatchHelps to prevent cravings from occurring Start high (21mg/day) and step down over 8 - 10 weeks.Most common side effect = local irritationOTC preparations only
12. Nicotine PatchPharmaco-TherapyNumber of armsEstimated OR (95% CI)Estimated Abstinence Rate (95% CI)Placebo801.013.8Nicotine Patch321.9 (1.7, 2.2)23.4 (21.3, 25.8) “The Nicotine Patch is an efficacious smoking cessation treatment that patients should be encouraged to use.” Strength of Evidence = A
13. Nicotine Replacement TherapyGum2mg and 4 mg dosechewed and parked to allow mucosal absorption1 to 2 pieces per hour when used alonecan be used in conjunction with patch to treat sudden urges
14. Nicotine GumPharmaco-TherapyNumber of armsEstimated OR (95% CI)Estimated Abstinence Rate (95% CI)Placebo801.013.8Nicotine Gum151.5 (1.2, 1.7)19.0 (16.5, 21.9)“Nicotine Gum is an efficacious smoking cessation treatment that patients should be encouraged to use.” Strength of Evidence = A
15. Nicotine Replacement TherapyInhalerHelps to treat sudden cravings once they occur Softly puffed to allow mucosal absorption1 to 2 puffs per hour as neededcan be used alone or in conjunction with patch May give smoker sense of “control”
16. Combination NRTPharmaco-TherapyNumber of armsEstimated OR (95% CI)Estimated Abstinence Rate (95% CI)1 NRT321.023.42 NRT33.6(2.5, 5.2)36.5(28.6, 45.3)“Combining the long-term patch (>14 weeks) with a self-administered form of NRT is more efficacious than a single form.” Strength of Evidence = A
17. Bupropion SRSafe with continued smoking.Less weight gain.Start 7-10 days prior to quit date.Duration: 8-12 weeks, consider up to 6 months or longer in h/o depression.Combine with NRT for better results.
18. Bupropion SRPharmaco-TherapyNumber of armsEstimated OR (95% CI)Estimated Abstinence Rate (95% CI)Placebo801.013.8Bupropion SR42.1 (1.5, 3.0)30.5 (23.2, 37.8)“Bupropion SR is an efficacious smoking cessation treatment that patients should be encouraged to use.” Strength of Evidence = A
19. Patch + BupropionPharmaco-TherapyNumber of armsEstimated OR (95% CI)Estimated Abstinence Rate (95% CI)Patch321.023.4Combo32.5(1.9, 3.4)28.9(23.5, 35.1)“Combining Bupropion treatment with transdermal NRT is more efficacious than a single form.” Strength of Evidence = A
20. 1 800 QUIT NOW1 800 QUIT NOW1 800 QUIT NOW
21. Useful Web Resources www.pennmedicine.org/pennstopTwitter: @pennmedtobacco
22. Points to Remember Smoking is the behavioral manifestation (cardinal sign) of a disturbance in brain biology induced by exposure to nicotine.The cardinal symptom of this pathology is compulsion to smoke, manifest as reluctance.Nicotine Replacement Therapy (NRT) is safe, effective, cost-effective, and has an impact on morbidity of psychiatric illnessCurrent standards of pharmacotherapy generally more “aggressive” than in past.
23. Accessing NRTsOluwatoyin Fadeyibi, Pharm.D, MPHDirector of Pharmacy Initiatives Community Behavioral Health
24. Themes across Medicaid PlansQuantity limits (varying degree)Age limit to 18 and older Nicotine Inhaler and Nasal Spray not covered by mostMost don’t cover brand name options (except for Chantix – which is still under patent)All plans designate as preferred, generic versions of: Patch, Lozenge, Buproprion and gum
25. Aetna Better Healthhttps://client.formularynavigator.com/Search.aspx?siteCode=3385538457All NRT is formularyPharmacy Prior Authorization Team: 866-638-1232
26. Health Partners Planhttp://hpp.adaptiverx.com/webSearch/index?key=cnhmbGV4LnBsYW4uUGxhblBkZlR5cGUtMTkPharmacy Hotline: 866-841-7659
27. Keystone Firsthttp://www.keystonefirstpa.com/apps/formulary/index.aspxNicotine gum, Patch, lozenges and Bupropion are all preferred in generic formulations.Chantix – preferred Nicotine inhaler and spray are non-preferred, and need prior authorization Pharmacy Services: 1-800-588-6767
28. United Health Carehttps://chp.optumrx.com/RxSolWeb/mvc/rxExternalFormularySearch/displaySearch.do?type=ClientFormulary&&var=ACUPA&infoid=ACUPA&page=insert&parNicotine gum, Patch, lozenges and Bupropion are all preferred in generic formulations.Chantix – preferred Nicotine inhaler and spray are non-preferred, and need prior authorization UHC Contact: 1800-414-9025 TTY: 711
29. Prior Authorization quick tipsAge limit of >18y/oProof of Contraindication or intolerance to preferred alternatives Justification for Smoking Cessation Products that are prescribed at quantities that exceeds the quantity limit
30. Coming soon… Reference Table compiling all Medicaid plan coverage informationResource list of pharmacies in Philadelphia with smoking cessation programsAdvocacy with PHMCOs for full coverage of tobacco cessation products
31. Additional Information Variation in co-pay depending on product and planOut of pocket cost with some coupons: https://www.goodrx.com/
32. QuitlineJarma J. Frisby, MS,CTTS-MTobacco Treatment and Wellness CoordinatorPhiladelphia Department of Public Health215-685-5693Jarma.Frisby@phila.gov
33. Welcome to the Pennsylvania FREE Quitline 1- 800- QUIT-NOW(1-800-784-8669)1-855-DEJELO-YA (1-855-335-3569)
34. Why use a Quitline?Callers to a Quitline are more likely to quit and stay quit. QL counseling can more than double a smoker’s chances of quitting. Quitline services are available 24 hours a day.All services are free, confidential and available in multiple languages; not connected to insurance status.Quitline counselors provides resources about websites, apps, and texting programs that can help you quit.
35. PA Free Quitline ServicesSupport, advice, and counseling from experienced Quitline coaches Up to five quit coach calls (call is initiated by the coach at a time that best suits your availability) Assistance in developing a personalized quit plan Unlimited, inbound calls for additional support during times of high risk for using tobacco
36. Four weeks of free nicotine replacement therapy (patches, lozenges, gum) available after completion of first call and setting a quit date. Combination therapy available.NRT and self-help materials mailed to callerQL can info and NRT to more than one person at the same address Usually arrives in 7-10 daysPA Free Quitline Services
37. If calling from a mobile phone with an out-of-state area code use: 1-877-724-1090Provider and individual web referral available for Quitline programs: Pa.quitlogix.org Contact PDPH for ordering rack cards, post cards and business size cards available from the CDC and PA Quitline. Additional Help
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