Tobacco Recovery Wellness Initiative Nicotine Replacement Therapy Overview

Tobacco Recovery Wellness Initiative 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. § Review simple tips for maximizing the effectiveness of NRT § Review how to access NRTs o Insurance o Over the Counter o Quitline § Q&A

Overview of Nicotine Replacement Therapy Frank T. Leone, MD, MS Comprehensive Smoking Treatment Program University of Pennsylvania Philadelphia, PA 1 -888 PENN STOP

Disclosure Consultant Arrangements: None Equity Ownership: None Patent Arrangements: None Grants/Research Support: National Institutes of Health Pennsylvania Department of Health Promotion Council of PA National Cancer Institute. Phila Department of Public Health Employment: University of Pennsylvania Speakers' Bureau: None Other: None

Objectives • Review 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.

Nicotine Dependence Itself a Chronic Illness “There’s someone in my head, but it’s not me. ” - Pink

Mesolimbic Dopaminergic system Emotion Motivation Memory

Long term changes • Increased neuronal arborization • Increased density of nicotinic receptors • Increased sensitivity of receptor ion channels • Changes gene expression o Neuronal protein synthesis increases o Neurotransmitter synthesis increases

Smoking: A Disorder of Compulsion. • Not exactly ready, or willing, or able. • Hesitant • Patients want change, but don’t want change. • “I desperately want to quit smoking” • Ambivalent “Come back when you’re ready? ”

Nicotine Levels in Blood 29 17 14. 5 13 12. 5 10 9. 7 9. 2 7 3. 5 0 0 5 Cigarettes 8. 2 8 4. 5 10 20 Gum 30 Patch 60

Nicotine Replacement Therapy • Patch ØHelps to prevent cravings from occurring ØStart high (21 mg/day) and step down over 8 10 weeks. ØMost common side effect = local irritation ØOTC preparations only

Nicotine Patch “The Nicotine Patch is an efficacious smoking cessation treatment that patients should be encouraged to use. ” Strength of Evidence = A Pharmaco. Therapy Number of arms Estimated OR (95% CI) Estimated Abstinence Rate (95% CI) Placebo 80 1. 0 13. 8 32 1. 9 (1. 7, 2. 2) 23. 4 (21. 3, 25. 8) Nicotine Patch

Nicotine Replacement Therapy • Gum Ø 2 mg and 4 mg dose Øchewed and parked to allow mucosal absorption Ø 1 to 2 pieces per hour when used alone Øcan be used in conjunction with patch to treat sudden urges

Nicotine Gum “Nicotine Gum is an efficacious smoking cessation treatment that patients should be encouraged to use. ” Strength of Evidence = A Pharmaco. Therapy Placebo Nicotine Gum Number of arms Estimated OR (95% CI) Estimated Abstinence Rate (95% CI) 80 1. 0 13. 8 15 1. 5 (1. 2, 1. 7) 19. 0 (16. 5, 21. 9)

Nicotine Replacement Therapy • Inhaler ØHelps to treat sudden cravings once they occur ØSoftly puffed to allow mucosal absorption Ø 1 to 2 puffs per hour as needed Øcan be used alone or in conjunction with patch ØMay give smoker sense of “control”

Combination NRT “Combining the long-term patch (>14 weeks) with a selfadministered form of NRT is more efficacious than a single form. ” Strength of Evidence = A Pharmaco. Therapy Number of arms Estimated OR (95% CI) Estimated Abstinence Rate (95% CI) 1 NRT 32 1. 0 23. 4 3 3. 6 (2. 5, 5. 2) 36. 5 (28. 6, 45. 3) 2 NRT

Bupropion SR • Safe 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.

Bupropion SR “Bupropion SR is an efficacious smoking cessation treatment that patients should be encouraged to use. ” Strength of Evidence = A Pharmaco. Therapy Placebo Bupropion SR Number of arms Estimated OR (95% CI) Estimated Abstinence Rate (95% CI) 80 1. 0 13. 8 4 2. 1 (1. 5, 3. 0) 30. 5 (23. 2, 37. 8)

Patch + Bupropion “Combining Bupropion treatment with transdermal NRT is more efficacious than a single form. ” Strength of Evidence = A Pharmaco. Therapy Number of arms Estimated OR (95% CI) Estimated Abstinence Rate (95% CI) Patch 32 1. 0 23. 4 3 2. 5 (1. 9, 3. 4) 28. 9 (23. 5, 35. 1) Combo

1 800 QUIT NOW

Useful Web Resources • www. pennmedicine. org/pennstop • Twitter: @pennmedtobacco

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 illness § Current standards of pharmacotherapy generally more “aggressive” than in past.

Accessing NRTs Oluwatoyin Fadeyibi, Pharm. D, MPH Director of Pharmacy Initiatives Community Behavioral Health

Themes across Medicaid Plans § Quantity limits (varying degree) § Age limit to 18 and older § Nicotine Inhaler and Nasal Spray not covered by most § Most 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

Aetna Better Health https: //client. formularynavigator. com/Search. aspx? site. Code=3385538457 § All NRT is formulary Pharmacy Prior Authorization Team: 866 -638 -1232

Health Partners Plan http: //hpp. adaptiverx. com/web. Search/index? key=cnhmb. GV 4 Ln. Bs. YW 4 u. UG xhbl. Bk. Zl. R 5 c. GUt. MTk Pharmacy Hotline: 866 -841 -7659

Keystone First http: //www. keystonefirstpa. com/apps/formulary/index. aspx § Nicotine 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

United Health Care https: //chp. optumrx. com/Rx. Sol. Web/mvc/rx. External. Formulary. Search/displ ay. Search. do? type=Client. Formulary&&var=ACUPA&infoid=ACUPA&page= insert&par § Nicotine 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

Prior Authorization quick tips • Age limit of >18 y/o • Proof of Contraindication or intolerance to preferred alternatives • Justification for Smoking Cessation Products that are prescribed at quantities that exceeds the quantity limit

Coming soon… § Reference Table compiling all Medicaid plan coverage information § Resource list of pharmacies in Philadelphia with smoking cessation programs § Advocacy with PHMCOs for full coverage of tobacco cessation products

Additional Information § Variation in co-pay depending on product and plan § Out of pocket cost with some coupons: https: //www. goodrx. com/

Quitline Jarma J. Frisby, MS, CTTS-M Tobacco Treatment and Wellness Coordinator Philadelphia Department of Public Health 215 -685 -5693 Jarma. Frisby@phila. gov

Welcome to the Pennsylvania FREE Quitline 1 - 800 - QUIT-NOW (1 -800 -784 -8669) 1 -855 -DEJELO-YA (1 -855 -335 -3569)

Why use a Quitline? üCallers to a Quitline are more likely to quit and stay quit. QL counseling can more than double a smoker’s chances of quitting. üQuitline services are available 24 hours a day. üAll services are free, confidential and available in multiple languages; not connected to insurance status. üQuitline counselors provides resources about websites, apps, and texting programs that can help you quit.

PA Free Quitline Services • Support, 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

PA Free Quitline Services § 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 caller § QL can info and NRT to more than one person at the same address § Usually arrives in 7 -10 days

Additional Help ü If calling from a mobile phone with an out-of-state area code use: 1 -877 -724 -1090 ü Provider and individual web referral available for Quitline programs: Pa. quitlogix. org ü Contact PDPH for ordering rack cards, post cards and business size cards available from the CDC and PA Quitline.