Tobacco cessation agent of choice in patients with psych history

[spacecowgirl]

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In a stablized patient who desires to quit smoking, what cessation aid do you choose? I'm skittish about varenicline and avoid that in patients with a h/o psychiatric disorders beyond MDD or dysthymia. For bupropion, my concern is drug interactions with a lot of the concomitant medications psych patients are often taking and in people with uncontrolled anxiety.

What are your thoughts on using bupropion or varenicline and are there populations you would never use them in, use with caution, etc. There's always nicotine replacement of course...

Thanks!

 

[nitemagi]

How about a patch + prn lozenges?

And with what condition? I'd say it depends. WBT can have various interactions, but I'd be more worried about it destabalizing someone psychiatrically when its not warranted than the med interactions.

I would never use varenicline. Just too many sketchy reports. WBT I'd avoid in most people with a psychotic disorder (DA reuptake).

Stick with the classics - nicotine replacement, behavioral modification, hypnosis...

 

[OldPsychDoc]

Actually, I think a closely monitored trial of varencline can be worthwhile--I've had few "sketchy" incidents with stable patients, and if it gets them off the coffin nails, then WIN.

Just anecdotally, I've heard more dysphoria and neuropsych complaints in the non-psychiatric population. I almost tend to think that "our" patients are used to a little dysphoria, so the nicotine antagonism of the varencline is less upsetting to them. Just my half-penny's worth...

 

[Majesty]

A visit from Nancy Reagan with an egg and frying pan.

 

[spacecowgirl]

Thanks for the input. I usually go with NRT combo therapy in pts with a psych diagnosis but the cessation data is better for varenicline. It's not that different for NRT vs bupropion, however, the titration of NRT can be complicated for some folks. Granted, I'd rather they chew nicotine gum than smoke, but if they have h/o stroke, MI and DVT, I wouldn't want them to chew nicotine gum for the rest of their lives either.

I did find a Cochrane review yesterday (from 2010) about bupropion in schizophrenics that found it did reduce smoking without causing changes in their mental state.

 

[whopper]

There is no best therapy when it comes to an individual patient. Our studies only tell us what is better for most people along very specific definitions.

Chantix has been found to be more effective than other medical treatments. Bupropion and nicotine other than smoking also have their place and in many people may be a better treatment choice depending on the circumstances. All medical treatments have their side effects. While Chantix could exacerbate existing mental illness, I have not yet seen it happen in any of my patients, though I've had a few mention their dreams become more intense.

In general, while I want all my patients to stop smoking, I generally recommend them to not stop here and now unless they feel they are at a stable place in their life or they are very motivated to do it. I think most people would agree that someone with severe stressors and not yet stable in their mental illness, if their physical health is fine, should not be stopping smoking at that moment, all things being equal. (Yes of course there are exceptions such as being in a hospital where by law you cannot smoke).

In inpatient, I don't recommend the use of nicotine gum. Patients often start sticking the gum in various places. In long-term facilities, especially with forensic units, gum has been found to be used for various criminal purposes. Some of the patients figured out that after they chew it, they let it harden, and when the patients are being escorted off the unit for meals, they can quickly and surreptitiously jam it in a door, preventing the locking mechanism from catching. Now the door, that normally automatically self locks, will no longer do so.

 

[masterofmonkeys]

A visit from Nancy Reagan with an egg and frying pan.

after all these years, still the best anti-drug campaign ever run.

 

[OldPsychDoc]

after all these years, still the best anti-drug campaign ever run.

The Original

The Far More Powerful Sequel😱

 

[BobA]

As an aside, when they compared chantix and zyban head to head it looked like chantix was superior. HOWEVER, zyban is supposed to be used in combo with the patch unlike chantix. When you compare the overall effect size of Zyban+patch vs. chantix they are about equal.

 

[whopper]

I've seen studies showing Chantix was superior, but there are sometimes circumstances where one would rather give other treatments. E.g. if the person also had ADHD, was overweight, and depressed, Bupropion could handle all of it. If the person doesn't have insurance, they're going to have a hell of a time paying for Chantix.

 

[kugel]

There is no best therapy when it comes to an individual patient.

That is a tremendously important statement.
The vast majority of Evidence-based Medicine relies on using large studies of stable patients in young-to-middle adulthood without comorbid conditions. It can be very difficult to apply to that one person in front of you with a unique medical history and unique history of treatment for the disorder.

I'm not suggesting that EBM is bad or wrong. It is the best possible starting point. But then most of the practice of medicine happens after that.

Most of my patients (who are non-psychotic enough to discuss smoking cessation) can understand the pros/cons of these treatments and make reasonable choices. So why would I be choosing for them?

When patients (no matter how psychotic) ask, "Is there any way I can get a cigarette in here?" I tell them, "I have no way to get you cigarettes, but I can get you a patch to take the edge off your cravings. And I can get it to you in a matter of minutes. That's something I definitely can do for you. Can I do that for you? I'll get right on that. If you don't have the patch in 15 minutes, please come ask for it."