Nonnicotine Drug - PowerPoint PPT Presentation

Title: Nonnicotine Drug


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2
AGENDA

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• ?????????????????????
• guideline for treating tobacco use
• assessing nicotine dependence
• pharmacotherapies
• conclusion

3
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• arsenic , methane , ?????????

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19
????????????????????

• 1. ????????????????????????????????????????
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• 2. ????????????????????????????????????????
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• 3. ???????????????????????????????????????

20
?????????????????????

• ??????????? 5 ????
• PRECONTEMPLATION STAGE
• CONTEMPLATION STAGE
• PREPARATION STAGE
• ACTION STAGE
• MAINTENANCE STAGE

21
Guideline on the treatment of tobacco dependence

• Treating Tobacco Use and Dependence
• Background
• In the early 1990s, AHCPRnow AHRQ convened an
  expert panel to develop the Smoking Cessation
  Clinical Practice Guideline No. 18 which
  reflected the extant scientific research
  literature published from 1975 through 1994
  (approximately 3,000 articles).
• The guideline was published in 1996 and has
  become a popular document.
• Significant new research on tobacco use and its
  treatment has appeared since the publication of
  the original guideline.

22
Guideline on the treatment of tobacco dependence

• Treating Tobacco Use and Dependence
• Background (cont.)
• In 1998 the expert panel that developed the 1996
  Smoking Cessation Clinical Practice Guideline No.
  18 was reconvened in 1998 to conduct and update
  the guideline, Treating Tobacco Use and
  Development .
• The updated guideline is based on two systemic
  reviews of the available scientific literature,
  the original guideline and reviewed literatures
  from 1995 through January 1, 1999 (approximately
  3,000 articles), and then combined into a single
  database.

23
Guideline on the treatment of tobacco dependence

• Other guidelines which have been published
  including those from
• the American Psychiatric Association
• the American Medical Association
• the United Kingdom Guideline
• the Cochrane Collaboration
• MoPH of Thailand
• etc.

24
Treating Tobacco Use and Dependence

• The update guideline urges clinicians to provide
  both counseling and pharmacotherapy for every
  patient making a quit attempt.

25
COUNSELING

• PRACTICAL COUNSELING
• INTRATREATMENT SUPPORTIVE INTERVENTION
• EXTRATREATMENT SUPPORTIVE INTERVENTION

26
??????????????????????? Guideline

• 1. Brief Intervention
• 2. Intensive Intervention
• 3. System Intervention

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BRIEF INTERVENTION

• ???????????????????????????????????????? 5
  As
• ??????????????????????????????????????????????
  MOTIVATION INTERVENTION
• ?????????????????????????????????????????????
  RELAPSE PREVENTION INTERVENTION
  
  

28
?????????????????????5 As

• ASK ???
  ????????????????
• ADVISE ????? ????????????????
• ASSESS ???????
  ???????????????????????????
• ASSIST ????
  ????????????????????
• ARRANGE ?????? ????????

29
ASK

• ???????????????????????????????????????????????
• Vital signs
• ??? / ??????
• ??????????????????????????
• ???????? / ???????????????? / ?????????
• ??????????????????????????????????????????????

30
ADVISE

• ????? / ???????????????????????????????????
• ????????? / ??????????????????
• ??????????????????????????????????
• ??????????????????????
• ??????????????????????

31
ASSESS

• ????????????????????????????????????????
• ??????????? ???????????????
• Intensive Treatment Intensive Intervention
• ??????????????? ?????????????????
• ????????????????? ??????????????????? ? ??

32
ASSIST

• ?????????? (Help patient with quit plan)
• ??????????????????????? 2 ??????? ???????
  ??????????
• ???????? ?????? ????????????? ??????
  ???????? ???????
• ??????????????????????????????? ??????
  ???????????????
• ??????????? ?????????????? ????????

33
ASSIST

• Provide Practical Counseling
• ????? ??????? ???????????????????????????????? /
  ?????????????
• ?????????? trigger ?????????
• Alcohol
• ????????????????????????????

34
ASSIST

• Provide Intratreatment Social Support
• ?????????????????
• ?????????????????? ???????
• ????????????????????????????

35
ASSIST

• Help Patient Obtain Extratreatment Social Support
• ?????
• Smoke Free Home
• Hotline / Helpline

36
ASSIST

• Pharmacotherapy
• ???????????????????????????
• ??????????????????????

37
ASSIST

• Provide Supplementary Materials
• ??????????????????????????????????????????????????
  ????????????? ??????????????????????????????

38
ARRANGE

• ???????? / ?????????????
• ??????????
• ????????
• ????????????????????????
• First Follow Up
• ????? 1 ??????????

39
ARRANGE

• Second Follow Up
• ????? 1 ????????
• ??????????????????????????
• ???????????
• ???????????
• ????????????????????
• ????????????????? / ????????????????????????????
  ?????

40
Motivational interventions

• The 5Rs
• Relevance Encourage the patient to indicate why
  quitting is personally relevant,being as
  specific as possible.
• Risks The clinician should ask the patient to
  identify potential negative consequences of
  tobacco use. Smoking
  low-tar/low-nicotine cigarettes or use of other
  forms of tobacco will not eliminate these
  risks.
• Acute risks / Long-term risks /
• Environmental risks

41
Motivational interventions

• Rewards The clinician should ask the patient to
  identify potential benefits of stopping tobacco
  use.
• Roadblocks The clinician should ask the patient
  to identify barriers or impediments to quitting
  and note elements of treatment that could
  address barriers.
• Repetition The motivational intervention should
  be repeated every time an unmotivated patient
  visits the clinic setting.

42
Preventing Relapse to Tobacco Use

• Minimal practice relapse prevention
• These interventions should be part of every
  encounter with a
• patient who has quit recently
• Every ex-tobacco user undergoing relapse
  prevention should receive congratulations on any
  success and strong encouragement to remain
  abstinent.
• When encountering a recent quitter , use
  open-ended questions designed to initiate patient
  problem solving.
• The benefits / Any success / The problem
  encountered or anticipated threats to maintaining
  abstinence.

43
Preventing Relapse to Tobacco Use

• Prescriptive relapse prevention

44
Y
N
Y
N
Y
N
45
Assessing nicotine dependence

• CAGE Questionnaire
• Results of the CAGE questionnaire for smoking,
  modified from the test for alcoholism,are
  considered positive if two of the four questions
  are answered affirmatively.
• Cut down
• Annoyed
• Guilty
• Eye-opener

46
Assessing nicotine dependence

• The Four Cs test
• Physicians who feel comfortable discussing
  psychological issues with their patients may
  prefer this approach.
• Compulsion
• Control
• Cutting down (and withdrawal symptoms)
• Consequences

47
Assessing nicotine dependence

• The Fagerstrom Test for nicotine dependence is a
  standard instrument for assessing the intensity
  of physical addiction to nicotine.
• The higher the Fagerstrom score,the more intense
  is the patients physical dependence on nicotine.
  
• Higher score indicated that treatment of
  withdrawal symptoms will be an important factor
  in the patients plan of care.

48
First-line pharmacotherapies

• Nicotine replacement therapyNRT
• 1.Nicotine transdermal patch
• ?????
• ??????? ???????????????
• ?????????????????????????????????
• ????????????????
• ???????????????????????????????
• ?????????? ?????????????????????????????????????
  ????????????????????????? ???????????????

49

• 2. Nicotine chewing gum
• ?? buffer ?????? Sod. Bicarbonate ??? Sod.
  Carbonate ?????????????????????????
  ?????????????????????????????????
• ??????? ?????????? ?????????????????????????????
  ?????? ???????????????????????????????????????????
  ????????????????????????????????????
  ??????????????????????? 30 ????
• ????????
• ????????????????????????????
• ?????????????????????????????????????? (????
  ????,????????)
• 3.Nicotine nasal spray
• 4.Nicotine inhaler

50
First-line pharmacotherapies

• Nonnicotine drug
• Bupropion hydrochloride
• ????????????????????? bupropion ???? bupropion
  ??????? nicotine patch ??????????????????????? 1
  ??????????????????? nicotine patch ???? placebo
  (??????????? 1 ?.?. 2542)
• ????????????????????????????????
  ??????????????????????? adrenergic ???
  dopaminergic mechanism

51

• Bupropion hydrochloridecont.
• ??????????????
• ???????????? ??????? ??? ??????????
• ??????????
• ???????? 150 ??. ?????????????????? 3 ???
  ??????????????? 150 ??.????? 2 ???????????????????
  ?? 8 ??.???????? 7-9 ???????
• ???????????????????????????????????? 1-2 ???????

52

• Bupropion hydrochloridecont.
• ???????????
• ?????????????????????????????? , ????? Bulimia
  ???? anorexia nervosa
• ????????????????????????????????????????????
  ???????????????????????????????
  ??????????????????????????????????
• Drug interactions
• ???????? metabolite ??????? CYP 2B6 ????????????
  bupropion
• bupropion ????????? activity ??? CYP 2D6
  ?????????????????????????????????????? CYP2D6
  isoenzyme

53
Second-line pharmacotherapies

• More limited role than first-line medications
  because
• (1) The FDA has not approved them for a tobacco
  dependence treatment indication.
• (2) there are more concerns about potential side
  effects than exist with first-line medications.
• 1.Clonidine
• 2. Nortriptyline

54
Conclusion

• The optimal cessation outcomes may required the
  combined use of both counseling and
  pharmacotherapy.
• Tobacco dependence is a chronic condition that
  often requires repeated intervention. Clinicians
  should remain cognizant that relapse is likely,
  and it reflects the chronic nature of
  dependence,not clinicians failure nor a failure
  of their patients.
• Brief tobacco dependence treatment is effective
  , and every patient who uses tobacco should be
  offered at least brief treatment.

55
Conclusion (cont.)

• Tobacco dependence treatments are both
  clinically effective and cost-effective and they
  should be provided to every patients.
• Non-nicotine dependence patients do not mean that
  they should not provided any treatments.
• Pharmacist should provide at least brief
  treatment, prescribing instructions for specific
  medications and guide appropriate
  pharmacotherapies for the patients.

56
THE END
57

• Some clinical guidelines for prescribing
  pharmacotherapy
• (based on Treating Tobacco Use and Dependence)
• Who should receive pharmacotherapy for smoking
  cessation?
• What factors should a clinician consider when
  choosing among the five first-line
  pharmacotherapies?
• Which pharmacotherapies should be considered with
  patients particularly concerned about weight
  gain?
• When should second-line agents be used for
  treating tobacco dependence?

58

• Some clinical guidelines for prescribing
  pharmacotherapy
• (based on Treating Tobacco Use and Dependence)
• Are there pharmacotherapies that should be
  especially consider in patients with a history of
  depression?
• Are pharmacotherapeutic treatments appropriate
  for lighter smokers?
• Should nicotine replacement therapies be avoid in
  patients with a history of cardiovascular
  disease?
• May tobacco dependence pharmacotherapies be used
  long-term?
• May pharmacotherapies ever be combined?

59
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60
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