Table 5. Nicotine Replacement Therapies
NRT
Advantages
Disadvantages
Side Effects
Precautions
Nicotine patches
Can be used with other modalities; steady dosing; OTC
Unable to change doses; may need augmented therapy
Headache; sleep disturbances; skin sensitivity Nausea; hiccups; insomnia; headache; cough
Caution with starting within 2 weeks of MI. Arrhythmia; angina; pregnant or breastfeeding; age < 18 years Caution with starting within 2 weeks of MI. Arrhythmia, angina; pregnant or breastfeeding; age < 18 years Caution with starting within 2 weeks of MI. Arrhythmia, angina; pregnant or breastfeeding; age < 18 years; TMJ disease Caution with starting within 2 weeks of MI. Asthma and chronic lung disease; arrhythmia, angina; pregnant or breastfeeding; age < 18 years; TMJ disease Caution with starting within 2 weeks of MI; sinus issues; asthma, arrhythmia, angina; pregnant or breastfeeding; age < 18 years; TMJ disease History of seizures; do not take with bulimia/anorexia; taking MAO inhibitor; liver disease, pregnant or breastfeeding; < age 18 years
Nicotine lozenges
Can be used regularly with withdrawal symptoms or urges; can control amount of nicotine delivered; may help substitute for a cigarette in the mouth; OTC withdrawal symptoms or urges; can control amount of nicotine delivered; may help substitute for a cigarette in the mouth; OTC Can be used regularly with withdrawal symptoms or urges with patches; can control amount of nicotine delivered; may help substitute for a cigarette in the mouth; OTC Can be used regularly; delivers nicotine most rapidly of all NRTs
Use it regularly; do not eat/drink for 15 minutes before using or when the mouth is full; can cause dyspepsia Use it regularly; do not eat/drink for 15 minutes before using or when in the mouth; can cause dyspepsia; may be hard to use with dentures/dental work Use it regularly; do not eat/drink for 15 minutes before using or when the mouth; More addictive than other forms of NRT; some do not prefer nasal spray; requires prescription More possible side effects than other medicines; cannot be used if history of bulimia/anorexia; or recently took MAO inhibitor; requires a prescription
Nicotine gum Can be used regularly with
Mouth/jaw soreness; stomach; hiccups; nausea/vomiting
Nicotine oral inhaler
Mouth and throat irritation; runny nose; cough, headache, hiccups
Nicotine nasal spray
Nasal irritation; tearing; runny nose, sneezing or cough headache Nausea, dizziness; insomnia; constipation, dry mouth, rash, seizures, changes in mood or behavior; anxiety
Bupropion SR Simple to use; may help with depression; combined with patches
Community-acquired pneumonia and influenza present with similar symptoms, and EVALI is difficult to differentiate from these diagnoses. 58 Rapid recognition is critical to reduce severe outcomes. During a comprehensive review of systems, the clinician should ask about recent use of e-cigarettes or vaping. If confirmed, ask about the type of substance (THC, nicotine) utilized. Treatment is supportive, and corticosteroids have shown to be effective, but further study is warranted. 146 Marijuana Marijuana refers to the dried leaves, flowers, stems, and seeds from the Cannabis sativa or Cannabis indica plant. The plant contains tetrahydrocannabinol (THC) and other similar compounds. Extracts can also be made from the cannabis plant. Cannabinoids exert various physiological effects by interacting with specific cannabinoid receptors (CB receptors) present in the brain and periphery. 59 People smoke marijuana in hand-rolled cigarettes (joints) or in pipes or water pipes (bongs). They also smoke it in blunts—emptied cigars that have been partly or completely refilled with marijuana. Marijuana is mixed in food ( edibles ), such as brownies, cookies, or candy, or brewed as a tea. A popular method of use is smoking or eating different forms of THC-rich resins or gummies.
Cannabis is known to have behavioral and physiological effects. Behavioral effects include feelings of euphoria, relaxation, altered time perception, lack of concentration, and impaired learning. Memory and mood changes such as panic and paranoid reactions have also been reported. Physiological effects include rapid changes in heart rate and diastolic blood pressure, conjunctival suffusion, dry mouth and throat, increased appetite, vasodilatation, and decreased respiratory rate. Cannabis also affects the immune and endocrine system, and its abuse is associated with lung damage and EEG alterations. 59 Medical Marijuana Legislation Medical marijuana refers to using the whole, unprocessed marijuana plant or its essential extracts to treat symptoms of illness and other conditions. The FDA has neither recognized nor approved the marijuana plant as medicine. The DEA considers marijuana a Schedule 1 controlled substance due to the lack of scientific research. However, a growing body of literature (scientific and anecdotal) has led to the increasing use of medical marijuana for various conditions, including pain, seizures, posttraumatic stress disorder (PTSD), and other disorders. The DEA considered rescheduling marijuana to Schedule II in August 2017 but decided against it. 60
The DEA has agreed to support additional research on marijuana and make the process easier for researchers. However, despite the lack of scientific confirmation, over 50% of the states and the District of Columbia have legalized marijuana, while other states maintain restricted access. In 2013, the federal government took a lenient approach to federal law enforcement regarding marijuana and provided guidance allowing states to legalize medical marijuana. However, in January 2018, this memo was rescinded, and now the status of state- level legalization of medical marijuana is uncertain. The medical marijuana debate has highlighted the issue of states rights versus the federal government. Since 2018, another 19 states have legalized recreational marijuana, and 39 states have legalized medical marijuana. More recently, in 2022, the current attorney general, Merrick Garland, has reiterated that the Department of Justice will not prioritize prosecuting marijuana use “given the nation’s ongoing opioid and methamphetamine epidemic[s].” 61 Medical marijuana is the same as or similar to the plant used for recreational purposes but is prescribed by an authorized clinician. Each state has regulations regarding qualified practitioners who can recommend medical marijuana and the recommendations for types of legal medical marijuana. In addition, states may require individuals to obtain a medical marijuana card, allowing them to purchase medical marijuana from a dispensary.
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