CENTRE FOR ADDICTION AND MENTAL HEALTH -MEDICAL DIRECTIVE ADMINISTRATION OF NICOTINE REPLACEMENT MEDICATIONS BY REGISTERED NURSES

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1 CENTRE FOR ADDICTION AND MENTAL HEALTH -MEDICAL DIRECTIVE TITLE: ADMINISTRATION OF NICOTINE REPLACEMENT MEDICATIONS BY REGISTERED NURSES POLICY #: D24 ORIGINATOR: Nicotine Dependence Clinic APPROVAL DATE: May 3, 2005 DATE OF NEXT REVIEW: Every 2 years DESCRIPTION OF PROCEDURE: Under the Regulated Health Professions Act: Controlled Act: #8: Prescribing, dispensing, selling or compounding a drug as defined in clause 113 (1) (d) of the Drug and Pharmacies Regulation Act, or supervising the part where such drugs are kept, requires a medical directive when such acts are delegated to nursing. Therefore: 1. Registered Nurses (RN) employed by CAMH, on the authority of this medical directive, may implement orders to administer the nicotine patch, gum and/or inhaler directly to in patient clients of CAMH, without prior consultation with a physician, under defined circumstances. Specified dosage ranges and for specific time periods i.e., within 72 hours are as indicated below. The RN must believe that she/he has the knowledge, skill and judgment to implement this medical directive, and must have completed the educational requirements as outlined below. 2. This medical directive also allows the RN working in the Nicotine dependence clinic (NDC) to implement orders to administer the nicotine patch, gum and or inhaler directly to in and/or out patient clients of CAMH. In addition, the RN working in the NDC may continue a clients NRT orders if previously implemented by a physician in the NDC. 3. RN s implementing this medical directive will be required to document it on the Regular/PRN/Stat Medication Order Form. Items to be documented include: date, time, drug, dosage, and signature of Nurse. Medical Directive should also be indicated on the medication sheets. 4. In addition to the information in #2 above, the RN implementing this medical directive must also document in the Progress Notes and IPCC. The RN must document what assessment he/she completed in determining the need to implement the directive, discussion with client as well as an evaluation of the client s response to the implemented treatment. 5. Any medication within this medical directive, which has been administered by a RN to a client up to the maximum dose in 72 hours, should be brought to the attention of the client s treating physician by the RN. If the treating physician prefers that the specified medication continue to be given to the client, then the physician must co-sign the medical directive on the MAR.

2 6. If a RN requires clarification of this medical directive, he/she should consult the authorizing physician within their program, as noted on p. 3 of this directive. 7. RPN s are able to continue and monitor a client on NRT but are not authorized to initiate an order for NRT. 8. The following is a list of medications covered by this Medical Directive, please refer to Appendix A for decision tree to determine which NRT to use.

3 Medication/Dosage Nicotine Replacement Therapy: Indications Contraindications/Cautions Max Dose/24h Can be given alone or in combination with nicotine gum and inhaler Nicotine Patch (21mg)/24h Smoking >15 cigarettes per day (CPD) Contact hypersensitivity the patch. Signs and symptoms of these may include erythema, pruritis, edema, hives or generalized rash or uriticaria. 21mg Nicotine Patch (14mg)/24h Nicotine Patch (7mg)/24h Nicotine Gum Recent CVA, immediately post MI, angina, life threatening arrhythmias Smoking 7-14 CPD As above 14mg Less then 7 CPD or unable to tolerate higher doses of NRT As above 7mg Can be used alone or in combination with nicotine patch and inhaler Nicotine Gum 4mg q 1h prn Willing to learn the proper technique since the nicotine has to be absorbed across the buccal mucosa. Unable to chew gum Wears dentures immediately post MI, arrhythmias, angina, active TMJ dysfunction 6 pieces of nicorette gum Nicotine Gum 2mg q 1h prn As above, use 4mg first, switch to 2mg if ct unable to tolerate 4mg gumtoo strong, S/S of nicotine toxicity with 4mg gum (nausea, diaphoresis, irritated throat, etc) As above 6 pieces of nicorette gum

4 Medication/Dosage Nicotine Replacement Therapy: Nicotine Inhaler 10mg cartridge Q1h prn (delivers 4mg nicotine per cartridge) Indications Unable to tolerate or use nicorette gum Contraindications/Cautions Max Dose/24h Recent CVA, immediately post MI, angina, life threatening arrhythmias. 6 cartridges Can be used alone or in combination with nicotine gum or patch N.B. Recent studies have shown that using NRT is safer then smoking. If you have a client with a history of heart attack or disease, consult with a physician before initiating NRT. N.B. If client experiences nausea or vomiting, diaphoresis, tremors, confusion or weakness after using NRT, this could mean they are receiving too high a dose, discontinue its use, do not let client smoke, monitor client and notify a doctor. Once client s condition stabilizes, the doctor can try a lower dose and continue to monitor client closely for the above signs. 9. This medical directive can only be implement for registered clients of CAMH, whether inpatients or outpatients, in accordance with CAMH formulary and program guidelines. AUTHORIZED TO: RN s who are employed by the Centre for Addiction and Mental Health and who have completed the educational requirements outlined below EDUCATIONAL REQUIREMENTS: The RN must have completed the self-learning module (available on T drive). This training will include indications for use of NRT, contraindications, signs and symptoms of nicotine withdrawal and overdose and actions to be taken if the client presents with the above. PREXISTING CRITERIA: Prior to dispensing any nicotine replacement within this medical directive, RN s must assess client status including: Allergies Smoking status number of cigarettes per day Length of use (cigarettes) Readiness to change Goals (reduction, abstinence) Prior experience with any NRT, any side effects, reactions, etc

5 QUALITY CONTROL/MONITORING PROCESS Educational requirements: a current or updated list of those certified to implement this medical directive must be maintained by each nursing unit The RN is also expected to maintain competency by regular use of the medical directive once a month or more. The RN is also expected to complete the educational requirements on an annual basis or more frequently as needed. Methods for monitoring this medical directive must be implemented by each unit. CONTRAINDICATIONS TO IMPLEMENTING THIS DIRECTIVE: Known history of or newly presenting adverse side effects, drug sensitivity or allergy Recent MI, CVA, angina or arrhythmias. This is not an absolute contraindication; recent studies have shown that using NRT is safer then smoking. If you have a client with a history of heart attack or disease, consult with a physician before initiating NRT. Section to be completed by Specific Program/Units implementing this Medical Directive Name of Program: Unit: Name of Program Physician(s) authorizing this Medical Directive: Signature of Authorizing Physician (s): Date:

6 APPENDIX A: DECISION TREE TO ADDRESS NICOTINE WITHDRAWAL Assess client s smoking status: Pattern of smoking: daily/non-daily/ex-smoker/never smoked Amount smoked: cigarettes smoked per day Withdrawal when stopping and how soon after stopping in the past Any signs of withdrawal at time of assessment Goals (reduction, cessation, withdrawal management) In-patient status: voluntary or involuntary Previous experience with NRT: cessation/reduction Med. Hx: Recent/previous MI, unstable angina, arrhythmia, TMJ dysfunction, dentures Daily Smoker No Non daily smoker, or No withdrawal No Medication Yes Presence of heart disease, recent heart attack, angina, arrhythmias No Allergic to nicotine patch? No Smokes cigarettes per day Yes Yes Withdrawal Symptoms: Cravings to smoke, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness not accounted for by any other mental health or physical condition. Hold NRT, contact doctor, client can still be started on NRT but only with doctor s order. Try alternative brand. If client has topical reaction to all brands, discontinue patch and provide nicorette gum or inhaler instead Less than or equal to 14 cigarettes per day Start with 14mg patch per day plus gum q 1hr prn for cravings OR Consider gum 2 or 4mg q1h alone Use inhaler if gum not suitable Greater than or equal to 15 cigarettes per day Start with 21mg patch/day plus 4mg gum q 1hr prn Use inhaler if gum not suitable Reassess in 3 days Have physician authorize within 3 days * Have MD increase patch strength depending on amount of gum used, cigarettes smoked or presence of withdrawal symptoms If client has dentures, TMJ dysfunction or is unable to chew nicorette gum, provide the inhaler instead of gum. Start with 4mg gum, if client can not tolerate 4mg (finds it is too strong) then reduce to 2mg gum. If you have any questions or concerns, contact the champion on your unit. Your manager will have a contact list. You can also refer to the medical directive policy # D 24 or the medical directive e-learning tutorial available on Insite. Nicotine Dependence Clinic - Contact List Nurse: Shelly Munro 6051, Pager ; Available for face to face or telephone consultations. Reception: Therapists:Melonie Ceresne ; Rosa Dragonetti ; Patrick Newland 6344; Stephanie Cohen ; Kip Southam

7 APPENDIX B List of Registered Nurses authorized to implemet the Medical Directive for Nicotine Replacement Name of Program/Unit: Name of Registered Nurse Date of initial authorization for medical directive Name of person overseeing the educational requirement