COLLECTIVE PRESCRIPTION Start According to a protocol: Yes No Effective date: October 15, 2009 Next review date: October 15, 2012 Professionals who can dispense the prescription Community pharmacists working in the region of Montréal (region 06) in collaboration with professionals from quit-smoking centres in the territory or from the j'arrête help line. Target population Any person living in Montréal who wishes to quit smoking with the help of nicotine replacement therapy. The person must be a Canadian resident and have a valid health insurance card or be covered by the Interim Federal Health Program. Signing physician Prescriptions given to patients must be issued in the name of Dr. Richard Lessard, Director of Public Health, Agence de la santé et des services sociaux de Montréal. THERAPEUTIC INTENT Smoking cessation Gradual reduction in tobacco use before quitting CONDITIONS The pharmacist assesses the person's smoking status and selects nicotine replacement therapy based on the smoker's needs, as per the collective prescription. ACTIONS A pharmacist who personalizes the collective prescription must choose the nicotine replacement medication and dosage based on the smoker's preference, as per the collective prescription; give the smoker appropriate information about the medication selected; refer the smoker to a quit-smoking centre and/or to the j'arrête help line for psycho-behavioural follow-up; supervise medication therapy; fax a report to the professional at the quit-smoking centre indicating the treatment chosen, if the person agrees. If there is a problem or for additional information, contact the physician on-call at the Direction de santé publique, 514-528-2400, ext. 3523. Page 1 of 6
I. CONTRAINDICATIONS Allergy to adhesive tape (for patches) Diffuse skin disease (for patches) Severe oral and dental disease (for nicotine gum) Hypersensitivity to menthol (for inhaler) Under 18 years of age Myocardial infarction or stroke in the previous two weeks Severe or unstable angina Serious arrhythmia Pregnant or breastfeeding Warning concerning the inhaler: Possibility of bronchospasm if individual has asthma or COPD II. PHARMACOTHERAPY Nicotine gum and patches are covered concomitantly by Québec's Public Prescription Drug Insurance Plan if both treatments begin on the same date. Nicoderm and Habitrol patches covered by Public Prescription Plan Nicorette and Thrive gum covered by Public Prescription Plan Nicorette and Thrive lozenges not covered by Public Prescription Plan Nicotine cartridges not covered by Public Prescription Plan A. Individuals smoking 10 cigarettes or more a day Options: 1. Simultaneous use of two medications 2. Use of a single medication 3. Consecutive use of two medications OPTION 1: Simultaneous use of two medications 21 mg 1 patch/24 hours 1 4 to 6 Nicotine patch 14 mg 1 patch/24 hours 1 4 7 mg 1 patch/24 hours 1 2 to 4 and gum or lozenge or nicotine cartridge and 1 of the following choices One 2 mg gum Gum as needed 24 12 One 1 mg Thrive lozenge Lozenge as needed 20 12 One 2 mg Nicorette lozenge Lozenge as needed 20 12 One cartridge Cartridge as needed 16 12 Page 2 of 6
Option 2: A. Individuals smoking 10 cigarettes or more a day Use of a single medication Nicotine patches 21 mg 1 patch/24 hours 1 4 to 6 14 mg 1 patch/24 hours 1 4 7 mg 1 patch/24 hours 1 2 to 4 Nicotine gum 25 cig./day or 1 st cig. 4 mg 1 gum q 1-2 hr or as needed 24 12 smoked within 30 min. of waking up < 25 cig./day or 1 st cig. 2 mg 1 gum q 1-2 hr or as needed 24 12 smoked more than 30 min. after waking up Nicotine lozenges 20 cig./day or 1 st cig. 2 mg Thrive 1 lozenge q 1-2 hr or as needed 20 12 smoked within 30 min. of waking up 4 mg Nicorette 1 lozenge q 1-2 hr or as needed 20 12 < 20 cig./day or 1 st cig. 1 mg Thrive 1 lozenge q 1-2 hr or as needed 20 12 smoked more than 30 min. after waking up 2 mg Nicorette 1 lozenge q 1-2 hr or as needed 20 12 Nicotine inhaler 10 mg 1 cartridge as needed 16 Up to 6 months Option 3: Consecutive use of two medications 21 mg 1 patch/24 hours 1 4 Nicotine patch 14 mg 1 patch/24 hours 1 3 7 mg 1 patch/24 hours 1 2 followed by gum or lozenge or nicotine cartridge 1 of the following choices 2 mg gum 1 gum as needed 24 3 1 mg Thrive lozenge 1 lozenge as needed 20 3 2 mg Nicorette lozenge 1 lozenge as needed 20 3 Cartridge 1 cartridge as needed 16 3 Page 3 of 6
B. Individuals smoking less than 10 cigarettes a day (1) Individuals smoking 5 to 9 cigarettes/day Options: Option 1: Nicotine patch 1. Use of a single medication 2. Simultaneous use of two medications Use of a single medication 14 mg 1 patch/24 hours 1 8 7 mg 1 patch/24 hours 1 4 2 mg nicotine gum 1 gum q 1-2 hr or as needed 18 12 Nicotine lozenge 1 mg Thrive 1 lozenge q 1-2 hr or as needed 18 12 2 mg Nicorette 1 lozenge q 1-2 hr or as needed 9 12 Nicotine inhaler 1 cartridge 1 cartridge as needed 9 12 Option 2: Simultaneous use of two medications Nicotine patch 14 mg 1 patch/24 hours 1 8 7 mg 1 patch/24 hours 1 4 and and 1 of the following choices gum or lozenge or nicotine cartridge 2 mg gum 1 gum as needed 4 12 1 mg Thrive lozenge 1 losenge as needed 4 12 2 mg Nicorette lozenge 1 losenge as needed 2 12 Cartridge 1 cartridge as needed 2 12 (1) There is no proof that nicotine replacement therapy is effective for individuals smoking fewer than 10 cigarettes a day. Therefore, it is recommended to adjust the prescription based on the number of cigarettes smoked. Page 4 of 6
B. Individuals smoking less than 10 cigarettes a day (1) Individuals smoking 1 to 4 cigarettes/day Use of a single medication 2 mg nicotine gum 1 gum 1 gum as needed 8 12 Nicotine lozenge 1 mg Thrive 1 lozenge 1 lozenge as needed 8 12 2 mg Nicorette 1 lozenge 1 lozenge as needed 4 12 Nicotine inhaler 1 cartridge 1 cartridge as needed 4 12 Nicotine gum C. Reduction in the amount smoked Smokers wishing to reduce gradually in preparation for total cessation Treatment Schedule 2 mg nicotine gum (if < 25 cigarettes a day or first cigarette smoked more than 30 minutes after waking up) or 4 mg nicotine gum (if 25 cigarettes a day or first cigarette smoked within 30 minutes of waking up) 1 gum as needed, depending on the number of cigarettes a day the smoker wants to eliminate and based on the quit date that he or she has set. (maximum: 20 ) 50% reduction in daily cigarette consumption and gradual reduction until the smoker feels ready to quit completely. (maximum: 20 ) Complete cessation 1 gum q 1-2 hours or as needed x 3 months (maximum: 20 ) First 6 weeks Sixth week to the end of the fourth month Fourth to sixth month Page 5 of 6
III. INSTRUCTIONS FOR USE NICOTINE PATCH The patch should be applied first thing in the morning, on a hairless part of the body between the neck and the waist. Patients who have difficulty sleeping can remove the patch 2 hours before going to bed and put on a new one when they wake up. In case of skin rash at application site, the patient should apply the patch at a different site every day. If the rash persists more than 48 hours, see a doctor. If engaging in vigorous physical activity, remove the patch 15 minutes beforehand and apply a new one afterwards. NICOTINE GUM Nicotine gum must be chewed twice or three times and then placed between the cheek and the gums for one minute to allow absorption of the nicotine through the mucous membrane of the mouth. This step must be repeated for 30 minutes. Avoid drinking or eating for 15 minutes before and while using the gum to prevent interfering with nicotine absorption. NICOTINE LOZENGE Place the lozenge in the mouth and suck on it slowly until a taste is noticed; keep it between the cheek and the gums until the taste has disappeared. This step must be repeated for about 30 minutes. Avoid drinking or eating for 15 minutes before and while using the lozenge to prevent interfering with nicotine absorption. NICOTINE INHALER Inhale for 20 minutes. Avoid drinking or eating for 15 minutes before and while using the inhaler to prevent interfering with nicotine absorption. The individual should be told that the mouth and throat could feel irritated, or that he or she might develop a cough or rhinitis. Richard Lessard, M.D. Director of Public Health Permit no.: 1-72268-5 Date : October 7, 2009 This collective prescription is available on the Web site of the Direction de santé publique de l Agence de la santé et des services sociaux de Montréal at www.santepub-mtl.qc.ca. Page 6 of 6
Referral and follow-up form for the region of Montréal Collective prescription for nicotine replacement therapies (NRT) Quit-Smoking Centres CSSS de l Ouest-de-l Île Tel.: 514 626-2572, ext. 4463 Fax: 514 626-8813 CSSS de Dorval-Lachine-LaSalle Tel.: 514 364-2572, ext. 2240 Fax: 514 364-2336 CSSS du Sud-Ouest Verdun Tel.: 514 766-0546, ext. 4891 Fax: 514 766-7443 CSSS Cavendish Tel: 514 484-7878, ext. 3068 Fax: 514 485-6406 CSSS de la Montagne Tel.: 514 273-3800, ext. 6494 Fax: 514 380-8147 CSSS de Bordeaux-Cartierville Saint-Laurent Tel.: 514 331-2572, ext. 4455 Fax: 514 334-9451 CSSS d Ahuntsic et Montréal-Nord Tel.: 514 384-2000, ext. 7324 Fax: 514 955-2600 CSSS du Coeur-de-l Île Tel.: 514 376-4141, ext. 494 Fax: 514 722-7106 CSSS Jeanne-Mance Tel.: 514 521-1320, ext. 6557 Fax: 514 521-1886 CSSS de Saint-Léonard et Saint-Michel Tel.: 514 328-3460, ext. 1260 Fax: 514 328-1310 CSSS Lucille-Teasdale Tel.: 514 524-3544, ext. 6102 Fax: 514 253-5340 CSSS de la Pointe-de-l Île Tel.: 514 642-4050, ext. 399 Fax: 514 356-0637 Centre hospitalier de l Université de Montréal (CHUM) Tel.: 514 890-8000, ext. 15983 Fax: 514 412-7573 Signing physician: Dr. Richard Lessard, permit no. 1-72268-5 Director of Public Health Information about the patient Last and first names: Date of birth: / / Health Ins. No.: dd mm yy Address: Main tel. no.: Other tel. no.: Best time to call: morning midday evening Name of attending physician: Person s smoking profile Has been smoking for: years No. cig. a day: 1st cig. < 30 min. after waking up: Expected quit date: yes no Prior use of NRT Type: Dosage: : Type: Dosage: : Section to be completed by the pharmacist I have initiated the following nicotine replacement therapy: Type: Dosage: : Type: Dosage: : The patient accepts that the pharmacist forwards his or her contact information for follow-up: M.D. Quit-Smoking Centre j Arrête help line Pharmacist s signature Pharmacy name Name (block letters) Telephone Section to be completed by the Quit-Smoking Centre or j Arrête help line I have conducted a smoking cessation intervention with this patient, and he or she wishes to get nicotine replacement therapy. Please refer to the collective prescription for NRT. Permit Fax Date Telephone support j Arrête help line 1 866 527-7383 Fax: 514 255-9856 Signature of professional Name (block letters) Name of Quit-Smoking Centre: Telephone Direction de santé publique 514 528-2400 Date Fax october 2009