5 INSTRUCTOR GUIDELINES

Transcription

1 STAGE: Ready to Quit Ms. Warner has a history of essential hypertension. She is a 52-year-old woman who recently moved from out of state for a job promotion. She has been taking hydrochlorothiazide (a diuretic) for the past year. You review the medical record, which was transferred from her prior physician s office, and note that her blood pressure has remained elevated (137/94) for over a year. She is mildly overweight (about 10 pounds) for her height and has no other medical problems. KEY POINTS THIS PATIENT has high blood pressure that has been uncontrolled for over a year is in the preparation stage for quitting previously failed trying to quit when using the nicotine gum THE CLINICIAN informs the patient of the effects of smoking on cardiovascular disease advises the patient to quit assesses the patient s compliance with the nicotine gum regimen (used during previous quit attempt) assists the patient in selecting a course of therapy assesses psychological and other factors associated with the patient s ability to quit; assists the patient with appropriate coping mechanisms counsels the patient on appropriate use of the nicotine patch and arranges follow-up counseling Rev CASE 5 Page 1 of 13

2 Step 1: ASK s with elevated blood pressure are at risk for numerous cardiovascular problems, including myocardial infarction, heart failure, and stroke. Smoking can accelerate and worsen these conditions. s practicing in primary care clinics should routinely review their patients smoking status and provide stage-appropriate smoking cessation interventions at each opportunity. Addressing and treating tobacco dependence is an essential component in the overall prevention and treatment of cardiovascular disease. As part of the medical history taken to determine other cardiovascular risk factors, it is important for the provider to determine whether the patient smokes. Ms. Warner, I see that your blood pressure has been elevated for quite a while. Please tell me how you are taking your blood pressure medication. I take one blood pressure pill every morning, with a glass of orange juice. And do you smoke cigarettes or use any other form of tobacco? I smoke cigarettes. Step 2: ADVISE You may already know this, but smoking worsens blood pressure control and can lead to serious cardiovascular disease. I strongly encourage you to quit. Rev CASE 5 Page 2 of 13

3 Step 3: ASSESS Have you given any thought to quitting? Yes, I ve been thinking about quitting, a lot recently. I ve just started a new position, bought a new house, and my family is starting over in a different area of the country. I think I m ready to finally quit smoking. That s excellent. Would you consider quitting sometime within the next month? I haven t really decided when I ll quit. But there s no sense putting it off. I think I could be ready to quit in the next month. What s the best method? This patient is ready to quit in the next month (in the preparation stage). Step 4: ASSIST Assess tobacco use history: current use Well, there are many different methods and we can try to pick the one best suited for you. But I ll need to get some information from you first. About how much do you currently smoke per day? Right now, I smoke between one half and a full pack each day. Rev CASE 5 Page 3 of 13

4 Assess tobacco use history: past use Has the number of cigarettes that you smoke per day changed recently? I smoke less during the week at work because nobody else smokes at work. I used to smoke a pack a day, but now I m down to half a pack on work days. How long have you been smoking? About 25 years now. Have you ever tried to quit? I ve tried to quit several times. The last time was years ago when nicotine gum became available without a prescription. I kicked the habit for about a week, but I hated the taste of the gum and I didn t think it worked very well. Finally, I went back to smoking. What about the other times you tried to quit? I tried hypnotherapy with a friend about 10 years ago. It seemed to work for a couple of weeks, but I still craved cigarettes. I was hungry all the time, too. And I started snacking a lot. I worried about gaining weight, so I went back to smoking. Rev CASE 5 Page 4 of 13

5 Ms. Warner, you tried nicotine gum on your last attempt. Can you tell me how you used the gum? How many pieces did you use each day? I chewed the gum whenever my cravings were out of control. I chewed about six pieces a day. I was using the dose for light smokers. I m glad I didn t get the stronger gum. I couldn t stand the taste, and it was hard for me to keep the gum in my mouth longer than 5 10 minutes. Did you think the gum helped to alleviate your cravings for cigarettes? The gum reduced my cravings a little, but I d never use it again. I threw out half of a starter pack. Although this patient did not receive an adequate trial with nicotine gum, she should not be challenged with a more aggressive administration schedule. The recommended initial dose for this patient should have been 2 mg every 1 2 hours (12 24 pieces/day). This patient has made it clear that the gum delivery system is not a reasonable option for her. It sounds like the gum is out of the question for you. The taste of the gum was so bad you were only about to tolerate one fourth to one half of the recommended dose. That s a common complaint, although there are new flavors available. Do you think you will need some form of nicotine replacement to help you quit? I d like something to help with the cravings. Okay, there are other options besides nicotine gum. We can talk about those a little later. I have a few more questions. Rev CASE 5 Page 5 of 13

6 Discuss key issues: reasons/motivation for wanting to quit First it seems like you are motivated to quit now because you want to start over, given your recent move and job change. Are there any other reasons you want to quit smoking? I have two children, a 17-year-old daughter and a 15-year-old son. Thankfully, neither of them smokes. I hate that I m setting a bad example. Also, I watched my former mother-in-law die of lung cancer 5 years ago. She smoked two packs a day for 50 years. I don t want to go through that myself. Discuss key issues: confidence in ability to quit You ve got a lot of things going on in your life right now. A new job, new home, teenagers adjusting to new schools. Do you think this a good time to quit smoking? We ve been here 6 weeks now, and I think we re finally getting settled. I d like to quit smoking before I get too set in my ways. I ve already cut down on my use at work. I really want to quit completely. I think I can handle it. Discuss key issues: social support for quitting You said you have two children at home. Do you have any other family members or friends who can assist or support you during this time period? I m divorced and haven t met many people outside of work since we moved. Being in a new place will actually help, because my old friends and co-workers were all big smokers. My children have wanted me to quit for years. Rev CASE 5 Page 6 of 13

7 Discuss key issues: concerns about weight gain Are you concerned about gaining weight when you quit? I m already overweight. I certainly don t want to gain any more. I started smoking again the last time I tried to quit because of the weight issue. Is there anything I can take to prevent weight gain? I understand, based on your previous quit attempts, that weight gain is an issue for you. Unfortunately many people who try to diet while trying to quit smoking end up not being able to quit. They re trying to do too many things all at once, and it s hard. In general I don t recommend that my patients worry about weight gain when they re in the early stages of quitting smoking. I try to help them get through the rough parts, then work on any weight gain. Keep in mind that, on average, patients gain between 5 and 10 pounds after quitting smoking. I am not trying to minimize your concerns about weight. And, of course, it s up to you whether you want to work on both simultaneously. There are some strategies that can help you to minimize weight gain while you quit, and we can discuss those. Discuss key issues: concerns about withdrawal symptoms You ve already told me that you re concerned about withdrawal symptoms. Here s an information sheet that describes the different withdrawal symptoms that you can expect and how to alleviate them. Also, using a form of nicotine as your therapy, such as the nicotine patch, nasal spray, or inhaler, will help with cravings quite a bit. The clinician should give the patient the Withdrawal Symptoms Information Sheet. Yes, I ve read and seen TV commercials about the nicotine patch. I think the patch might help. Rev CASE 5 Page 7 of 13

8 Discuss key issues: stress-related smoking Do you find you smoke when you re stressed? No I mostly smoke because I enjoy it. Usually not because I m stressed. Discuss key issues: routines and situations associated with tobacco use Are there certain situations when you re more likely to smoke than others? For example, are there any routines that you associate with smoking? Well, I smoke in the morning with coffee, while driving, and while talking on the phone. I used to smoke in bars and restaurants with friends, but not anymore. Facilitate quitting process: discuss methods for quitting Let s review the different methods you can use to stop smoking. You ve already expressed interest in using the nicotine patch to help with your cravings for cigarettes. I think this is a good idea. There are also prescription nicotine replacement products available. These include the nasal spray and oral inhaler. If you re interested in a nonnicotine medication, there s a product called Zyban that s also quite effective. Although none of these products is a cure for smoking, they approximately double your chances of quitting. Nicotine replacement products help many of my patients deal with the symptoms of nicotine withdrawal while they implement changes in their lifestyle to become nonsmokers. We ll also need to talk about coping techniques to help you handle situations where you may be tempted to smoke. This includes anticipating situations that trigger your smoking and developing strategies to avoid these situations or substitute different behaviors for smoking. Any of the nicotine replacement products or Zyban would be reasonable for you to consider. Does any one particularly appeal to you? Rev CASE 5 Page 8 of 13

9 I guess I m leaning toward the patch. I kind of like the idea of once-a-day dosing and the fact that the patch can lessen the withdrawal symptoms. Facilitate quitting process: discuss coping strategies Let s develop some strategies to deal with situations that you associate with smoking. I m going to suggest a few alternatives to smoking for you. While talking on the phone: Speak while standing instead of sitting. Substitute gum, toothpicks, swizzle sticks, or straws for cigarettes. Doodle to keep your hands occupied. Use a timer to limit the length of your telephone calls. While driving: Remove cigarettes from your car and clean out the ashtrays. Consider having the interior detailed to remove the tobacco smell. If you feel the urge to smoke, take a deep breath instead. Do some self-massage, which has been shown in a research study to reduce cravings for nicotine. Listen to a talk radio station or a book-on-tape to keep your mind occupied. In morning, while drinking coffee: As soon as you get up each day, remind yourself that you are a nonsmoker. You can go through another day without cigarettes. Change the order of your morning routine. If you usually have your coffee before you shower, shower first. Change what you do. Listen to the radio instead of the television. Eat a smaller breakfast, or try new breakfast foods. Change where you do things. Read the paper in a different part of the house. Get dressed in a different room. Try changing your brand of coffee, or drink a different flavored coffee for a few weeks (e.g., nonfat latte or cappuccino). Try drinking tea or fruit juice instead of coffee. Instead of sitting at the table and reading the paper with your coffee, use the time to go for a short, brisk walk before you shower. This also will help you to combat weight gain, plus it s healthy, and the fresh air will help you to wake up. Rev CASE 5 Page 9 of 13

10 Facilitate quitting process: set a quit date We ll need to set a quit date sometime within the next 2 weeks. Give yourself a couple of days to prepare yourself for the big day. How about a week from today? It s my son s 16th birthday. That ll be another reason to celebrate. I just hope I won t be too cranky that day. Great idea. Make sure your family knows you re quitting smoking. You ll need their help and understanding for the next several months. Quitting smoking is a wonderful gift for your son! On the night before your quit date, throw away all cigarettes and ashtrays. You might also consider removing any high-fat, high-calorie snacks that you d be tempted to eat while you are quitting. Restock your kitchen with low-calorie foods: vegetables (e.g., carrots, celery, frozen peas), fruits (e.g., apples, oranges, strawberries), sugarless gum, and hard candies. Facilitate quitting process: recommend Tobacco Use Log Before you actually quit smoking for good, I would like you to keep a diary of your current smoking patterns using a Tobacco Use Log. This will help us to identify activities and situations that trigger your smoking. Determining your smoking habits and patterns will help us to develop strategies to maximize your chances of quitting. Let me review the Tobacco Use Log with you now. Continue your regular tobacco use for the next 6 days. Do not attempt to reduce your tobacco use during this time. The intent is to document current tobacco use habits and patterns. I normally suggest a full week of documentation (to account for fluctuations in smoking patterns as a function of the day of the week), but because you plan to quit on your son s birthday, we ll have only 6 days; this will be fine. Rev CASE 5 Page 10 of 13

11 Use a separate log sheet each day. Because you smoke cigarettes per day, you ll need only one sheet per day. Record the following information in the Tobacco Use Log each time you smoke: Cigarette number Time of day Brief description of the activity or situation just before you lit up, and the situation while using the tobacco Rating of the importance of that cigarette, at that time, using the following scale: 1 = Not very important (would not have missed it) 2 = Moderately important 3 = Very important (would have missed it a great deal) I ll call you next Wednesday afternoon that s 6 days from now to review the Tobacco Use Log. At that time we ll develop some coping strategies to help you overcome the temptation to use tobacco. After you have carefully monitored when, where, and why you have smoked for several days, you ll list the top three situations where you found you wanted to smoke. Remember, to successfully quit smoking, you must be aware of the situations where you are most likely to smoke. You must be ready to change your routines to avoid situations that may trigger your smoking. When you find yourself in one of those situations, you must be prepared to change what you do and how you think so that you do not reach for a cigarette. Anticipate trouble situations and develop avoidance or substitute plans for smoking. We can discuss this further next Wednesday after you ve determined your major triggers for smoking. Do you think this sounds like a reasonable approach? I ve never quit smoking like this before. I just did it without any planning. No wonder I failed. Facilitate quitting process: discuss withdrawal symptoms You said that in the past you had difficulty quitting because you were craving cigarettes and were hungry all the time. Although the nicotine patch should help with the cravings, you might experience these symptoms again. I d like you to call me if you experience troublesome withdrawal symptoms while on the nicotine patch. Rev CASE 5 Page 11 of 13

12 Facilitate quitting process: provide medication counseling The following information is for discussion at the follow-up session, just prior to quitting. (Note: The products indicated by an asterisk are recommended to be tapered in the following manner: 14 mg for 2 weeks, then 7 mg for 2 weeks.) Let s discuss the use of the nicotine patch. I know you ve used nicotine gum in the past, and the principles with the patch are the same. The only difference is the nicotine patch provides a steady, controlled amount of nicotine throughout the day to reduce withdrawal symptoms and cravings for cigarettes. Given that you smoke half to a full pack per day, I would start with (select one): * Nicoderm CQ Step 1 (21 mg) patch daily for 6 weeks (worn 16 or 24 hours/day) Generic nicotine patch (21 mg) patch daily for 4 weeks (worn 16 or 24 hours/day) Some information that you ll need to know about the patch: Rotate application sites (do not use same site for at least 1 week). Do not smoke while wearing the patch. If the patch falls off, put on a new one, in a different skin area. Water (showering, bathing, swimming) will not affect the patch if applied correctly. Normal side effects include mild itching, burning, or tingling in the first hour. Skin may appear red after removing the patch, but this should subside during the day. If skin becomes swollen or a rash appears, do not put on a new patch. This may be a reaction to the adhesive. It s important to follow the dosing instructions exactly, and to stay on the therapy for the entire course of treatment even when you think you may be OK without using a patch. This will increase your likelihood of quitting. Facilitate quitting process: offer to assist throughout the quit attempt Quitting smoking is a process that may take weeks or months until you feel that you have truly become a nonsmoker. Quitting smoking is every bit as important for your overall health as controlling your high blood pressure. As part of your routine care through this clinic, I m going to help you with quitting. Rev CASE 5 Page 12 of 13

13 Step 5: ARRANGE These next few weeks are going to be a challenge, but remember this is something that you can do. I d like to see you again in 2 weeks. At that time we can recheck your blood pressure and see how you are doing off cigarettes. I ll call you next Wednesday afternoon to check in with you just before your quit date. We can review your Tobacco Use Log, develop coping strategies, and review the proper use of the nicotine patch. Is that date good for you? Yes, that works for me. It s best to page me because I m not reliably in one place. Great. Do you have any other questions or concerns? No, not that I can think of right now. OK, we will talk again on Wednesday. Rev CASE 5 Page 13 of 13