Learning Outcomes
By the end of this section, you should be able to:
- 15.4.1 Describe the pathophysiology of nicotine use disorder.
- 15.4.2 Identify clinical manifestations of nicotine use disorder.
- 15.4.3 Identify the etiology and diagnostic studies related to nicotine use disorder.
- 15.4.4 Identify the characteristics of drugs used to treat nicotine use disorder.
- 15.4.5 Explain the indications, actions, adverse reactions, and interactions of drugs used to treat nicotine use disorder.
- 15.4.6 Describe the nursing implications of drugs used to treat nicotine use disorder.
- 15.4.7 Explain the client education related to drugs used to treat nicotine use disorder.
Nicotine Use
Nicotine is derived from the tobacco plant and has been in use for thousands of years. It is a highly addictive substance that facilitates great harm in clients who have nicotine use disorder (NUD). It is estimated that in the United States, more than 480,000 deaths are attributable to tobacco products, making it the number-one cause of preventable death in the country. While tobacco use has declined over the past several decades, it is estimated that 50.6 million people in the United States currently use tobacco products (Cornelius et al., 2020). Tobacco products come in a variety of forms, including cigarettes, cigars, chewing tobacco, and vaping devices. Nicotine itself is not necessarily that toxic in doses used in clients with NUDs, but it is often the other components found in tobacco products (e.g., formaldehyde, lead, arsenic, benzene, carbon monoxide) that the client is exposed to that lead to a variety of chronic health conditions such as cancer, respiratory disease, and cardiovascular disease.
Nicotine works as an agonist at the nicotinic acetylcholine receptor. At high doses, nicotine can stimulate dopamine release in the reward center of the brain, leading to many of the craving symptoms clients experience when attempting to treat NUD. Nicotine also can increase alertness and provide a feeling of pleasure and relaxation. Additionally, nicotine is an appetite suppressant, leading to some weight loss. Nicotine at extremely high doses (e.g., a child ingests unsecured vaping solution or swallows chewing tobacco) can cause significantly more toxic effects, including risks for dysrhythmia, seizures, and respiratory failure, and should be treated as a medical emergency. A relatively recent development in the consumption of nicotine is the development of vaping devices that can provide nicotine without the need to inhale hot gases as one would with a traditional cigarette. Some clients may harbor the idea that vaping devices do not contain nicotine or are safer than other sources of nicotine, but the health care provider should educate clients that these devices can be just as addictive as smoking. Vaping devices provide an additional challenge as this market is not as tightly regulated as other forms of tobacco, so there are no child-resistant safety features required on these products. Poor regulation also means that vaping solutions have been found to contain contaminants such as heavy metals, which may cause their own health risks. Vaping device malfunction has also led to device explosion, causing trauma to the hands and face.
Nicotine Withdrawal
After chronic use of tobacco-containing products, the body will develop a degree of tolerance and physical dependence. Discontinuation results in nicotine withdrawal that makes treatment of a NUD extremely difficult with exceedingly high relapse rates. Reactions that occur during nicotine withdrawal include anxiety, difficulty concentrating, irritable mood, and severe cravings for nicotine. The onset of nicotine withdrawal depends on how much nicotine is built up in the client’s body. It usually begins within 24 hours after discontinuation of nicotine-containing products and can last from days to weeks, making relapse rates quite high without the assistance of behavioral and pharmacologic intervention. Like opioid withdrawal, nicotine withdrawal is not expected to be fatal.
Drugs Used to Treat Nicotine Use Disorders
This section covers medications used to treat nicotine use disorders. These include medications that are able to replace the nicotine that a client was previously using along with agents that help reduce the withdrawal symptoms and feelings of craving that may lead to clients relapsing and using nicotine again.
Bupropion
Bupropion is traditionally used for the treatment of anxiety and depression, but it has also been found to help aid in the treatment of NUDs. Bupropion’s mechanism of action is that it inhibits the reuptake of dopamine and norepinephrine. How bupropion works to treat NUDs is unclear currently, but it is theorized that bupropion reduces craving symptoms for nicotine by increasing dopamine activity in the reward center of the brain. Bupropion can be advantageous in those individuals with concomitant NUD and depression and/or anxiety. Since bupropion does not have any actions at the nicotinic receptor, it is safe if clients relapse and begin using nicotine-containing products while taking bupropion.
Nicotine (NicoDerm/Nicorette)
Nicotine replacement therapy (NRT) is designed to replace the nicotine products that a client is currently using with products only containing nicotine. This helps reduce withdrawal symptoms and aids in the successful transition to using no nicotine. These come in a variety of dosage forms, including gums, patches, nasal sprays, lozenges, and inhalers. The appropriate dose to start a client on is highly dependent on the amount of nicotine being used by the client prior to quitting, due to physical and psychological dependence developed at higher doses.
While clients have successfully treated NUDs with vaping devices, it is important to recommend using FDA-approved products first, as these are highly regulated products and are held to a high standard for manufacturing and packaging. This is different from unregulated nicotine-containing vaping solutions, which have no FDA oversight and have been found to contain unadvertised products such as the heavy metals chromium, nickel, and lead. It is also important for clients who relapse and start using nicotine-containing products again to discontinue their NRT. This prevents the client from being exposed to even higher doses of nicotine than they were originally using and reduces the risk for adverse effects.
Varenicline
Varenicline is a partial nicotine receptor agonist that has a greater affinity for the receptor than nicotine itself. Just as buprenorphine partially activates opioid receptors to reduce withdrawal symptoms and prevent other opioids from working as well, varenicline possesses the same actions for nicotine. Nicotine is safe to use if the client relapses and begins using nicotine-containing products again. In fact, it is recommended that varenicline be initiated 1 week prior to the chosen quit date to ease the transition into nicotine abstinence.
Table 15.6 lists common medications used to treat nicotine use disorder and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Bupropion (Zyban) |
150 mg orally twice daily. Maximum dose: 300 mg/day. |
| Nicotine (NicoDerm/Nicorette) |
Gum: 2–4 mg chewed every 1–2 hours; maximum 24 pieces/day. Transdermal: One 7–21 mg patch every 24 hours applied topically daily. |
| Varenicline (Chantix) |
Days 1–3: 0.5 mg orally once daily. Days 4–7: 0.5 mg orally twice daily. Days 8–84: 1 mg orally twice daily. |
Adverse Effects and Contraindications
Bupropion should be used cautiously in clients with a history of seizures, as this can be worsened in the presence of bupropion. Bupropion, like other antidepressant medications, can increase risk for suicidal ideation, so it is important to educate the client to monitor for depressed mood and suicidal thoughts. Bupropion can also induce manic symptoms if the client has bipolar disorder. Bupropion should be avoided if the client is taking any other drugs that increase norepinephrine actions, such as selective norepinephrine reuptake inhibitors (SNRIs) (e.g., duloxetine, venlafaxine).
Side effects of nicotine replacement products generally occur when using doses exceeding what the client was using in their previous choice of nicotine-containing product. Common adverse effects include headache, oral irritation, dyspepsia, and cough.
Common adverse effects seen with varenicline include nausea, vomiting, and abnormal dreams. Varenicline should be used cautiously in clients with a history of depression and suicidal ideation or suicide attempts, as it has been shown to increase these symptoms in some clients.
Table 15.7 is a drug prototype table for the medications used to treat nicotine use disorder featuring bupropion. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Norepinephrine/dopamine reuptake inhibitor (NDRI) Mechanism of Action Blocks the reuptake of norepinephrine and dopamine in the CNS |
Drug Dosage 150 mg orally twice daily. Maximum dose: 300 mg/day. |
| Indications Smoking cessation Therapeutic Effects Lessens cravings during nicotine cessation |
Drug Interactions Clopidogrel Carbamazepine Phenytoin Haloperidol Monoamine oxidase inhibitors Levodopa Digoxin Food Interactions Ethanol |
| Adverse Effects Anxiety Insomnia Tinnitus Tachycardia Diaphoresis Weight loss Constipation Nausea Vomiting Xerostomia (dry mouth) Agitation Tremor Blurred vision |
Contraindications Hypersensitivity Increased seizure risk CNS infection CNS tumor Head injury Anorexia or bulimia nervosa (prior or current) Caution: Cognitive impairment Hypertension Weight loss Cardiovascular disease Hepatic impairment Renal impairment |
Nursing Implications
The nurse should do the following for clients who are taking a medication for NUD:
- Monitor for all sources of nicotine exposure other than just cigarettes, such as chewing tobacco and vaping devices.
- Screen for history of seizures in clients receiving bupropion.
- Advise discontinuing NRT if the client decided to begin using nicotine-containing products again.
- Screen for use of nicotine vaping solutions when asking about nicotine use.
- Monitor for signs and symptoms of worsening depression/suicidal thoughts while clients are taking bupropion or varenicline.
- Provide positive reinforcement to clients attempting to stop their nicotine use to help encourage compliance with their NUD therapy.
- Monitor sleep patterns.
- Provide client teaching regarding the drug and when to call the health care provider. See below for additional client teaching guidelines.
Safety Alert
Nicotine Replacement Therapy
Clients should discontinue all nicotine replacement therapies if tobacco product consumption resumes. If not, excessive nicotine toxicity (e.g., tachycardia, dizziness) may occur. Nicotine-containing products should also be secured in a manner to avoid accidental pediatric exposures, as nicotine exposures in young children can cause severe toxicity, including the risk for respiratory failure and death. Avoid nicotine sprays in clients with a history of asthma, as this can lead to asthma exacerbations.
Client Teaching Guidelines
The client taking a medication to treat nicotine use disorder should:
- Alert their health care provider about any signs of allergic reactions, including throat swelling, severe itching, rash, or chest tightness.
- Notify their health care provider if palpitations, chest pain, anxiety, insomnia, and/or unintended weight loss occurs.
- Inform other health care providers that they are taking these medications, including the dose and frequency.
- Take the drug with food if it causes an upset stomach.
- Take a missed dose as soon as they remember; however, they should not take double doses.
- Avoid using nicotine-containing products while using nicotine replacement therapy.
- Apply nicotine patches to clean, dry areas of skin.
- Remove nicotine patches prior to undergoing MRI procedures and resume after the procedure is complete.
- Alert their health care provider if they feel any worsening depression or suicidal thoughts.
- Increase their fluid intake to avoid constipation.
- Have sugar-free hard candy or gum on hand to alleviate dry mouth.
- Reach out to support groups to receive additional encouragement and motivation to remain compliant with NUD therapy.
Clinical Tip
Assess for Changes in Dreaming in Clients Receiving Varenicline
Clients receiving varenicline are known to develop particularly vivid dreams, which can include nightmares. Clients should be educated about this possibility and report back about any dream changes, as this may require a change in therapy.
Unfolding Case Study
Part B
Read the following clinical scenario to answer the questions that follow. This case study is a follow-up to Case Study Part A.
Six months after the last encounter, Daniel Nguyen, a 34-year-old client, presents to the primary care provider and reports that he has been doing well after starting therapy with buprenorphine-naloxone and reports no other opioid use. He states that withdrawal symptoms are minimal and manageable. He states that he now wishes for help with his cigarette-smoking habit.
History
Opioid use disorder: being treated with buprenorphine-naloxone
Cigarette smoking: smokes one pack per day for 7 years
Major depressive disorder
Current Medications
Buprenorphine-naloxone: 16 mg/4 mg orally daily
Duloxetine: 40 mg orally daily
| Vital Signs | Physical Examination | |
|---|---|---|
| Temperature: | 98.4°F |
|
| Blood pressure: | 123/78 mm Hg | |
| Heart rate: | 74 beats/min | |
| Respiratory rate: | 16 breaths/min | |
| Oxygen saturation: | 99% on room air | |
| Height: | 5'8" | |
| Weight: | 175 lb | |
FDA Black Box Warning
Bupropion
Antidepressants, including bupropion, increase the risk of suicidal thoughts and behavior in children, adolescents, and young adults up to and including 24 years of age in short-term trials. These trials did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in subjects between the ages of 25 and 64 years; there was a reduction in risk with antidepressant use in subjects ages 65 and older.