NRT
Advantages
Disadvantages
Side Effects
Precautions
Nicotine Nasal Spray
Can be used regularly; delivers nicotine most rapidly of all NRTs.
More addictive than other forms of NRT; some do not prefer nasal spray; requires prescription.
Nasal irritation; tearing; runny nose, sneezing or cough headache.
MI within 2 weeks of starting; sinus issues; asthma; arrhythmia, angina; pregnant or breastfeeding; age < 18 years; TMJ disease. History of seizures; do not taking bulimia/anorexia; taking MAO inhibitor; liver disease, pregnant or breastfeeding; < age 18 years.
Bupropion SR
Simple to use; may help with depression; combined with patches.
More possible side effects than other medicines; cannot be used if history of bulimia/anorexia; or recently took monoamine oxidase (MAO) inhibitor; requires a prescription.
Nausea, dizziness; insomnia; constipation, dry mouth, rash, seizures, changes in mood or behavior; anxiety.
E-cigarettes/vaping Vaping was introduced to the U.S. market in 2007, containing both nicotine and tetrahydrocannabinol (TCH), which are poorly regulated (Werner et al, 2020). Unfortunately, there is not enough data to determine short-term or long-term effects or the type of components to blame (Broderick, 2023). Vaping is a delivery sys- tem similar to a nebulizer; however, the vaping system coats the lungs in harmful chemicals masked in a variety of flavorings and aromatic additives. Vitamin E is often used as part of the delivery system and thickening agent in the e-liquid, which is thought to be an irritant to the lungs. Other common substances found in the e-liquid include (1) diacetyl, which is a food additive (buttery taste in microwave popcorn) known to damage small passages in the lungs; (2) formaldehyde, which contributes to lung and heart disease; and (3) acrolein, which is used as a weed killer and can also damage lungs (Broderick, 2023). Several lung diseases are associated with vaping. Bronchiolitis obliterans (popcorn lung) is a rare condition result- ing from damage of the small airways from diacetyl. Inhaling this additive causes coughing, wheezing, chest pain, and shortness of breath. Symptomatic treatment is available; however, there is no lasting treatment (Broderick, 2023). Vaping-related lipoid pneumonia develops when fatty acids en- ter the lungs from the oily substances found in the e- liquid. This
induces inflammatory responses in the lungs, demonstrated by chronic cough, shortness of breath, and blood- tinged mucus. The most important treatment is eliminating vaping while the lungs heal themselves (Broderick, 2003). Primary spontaneous pneumothorax . Those who develop a col- lapsed lung due to vaping often develop air blisters on the top of the lungs that rupture and create tiny tears (Broderick, 2003). Rap- id growth found in adolescence are prone to blisters that create a weak point. The blisters do not produce symptoms but smoking and vaping increase the risk for pneumothorax (Broderick, 2003). Signs of a pneumothorax include sharp chest or shoulder pain and dyspnea. Immediate treatment includes oxygen and chest ra- diograph (CXR) confirmation with supportive treatment. E-cigarette/vaping-associated lung injury (EVALI) is strongly as- sociated with vitamin E, which is found in lung fluid of individuals with EVALI but not in those without EVALI (CDC, 2021). EVALI is a diagnosis of exclusion, but rapid recognition is critical to reducing severe outcomes. During a comprehensive review of systems, the clinician should ask about the recent use of e-cigarettes or vap- ing. If confirmed, ask about the type of substance (THC, nicotine) utilized. Laboratory tests should be guided by clinical findings as well as practice guidelines. Community-acquired pneumonia and influenza are evaluated since EVALI is difficult to differentiate from these diagnoses (CDC, 2020).
OPIOID USE DISORDERS
Opioid use disorder (OUD) has reached epidemic proportions with substantial negative impacts on society. OUD is a chronic, re- lapsing disease influenced by genetics, stress response, and prior experimentation or exposure (Brown & Capili, 2020). Mu opioid receptors (MORs) modulate nociception, stress, temperature, respiration, endocrine activity, memory, mood, and motivation (Herman et al., 2022). MORs bind opioids, delta opioids, kappa opioids, and nociception receptors to increase drug tolerance. Physical dependence can develop between 2 and 10 days of con- tinuous use, with withdrawal symptoms occurring when stopped abruptly (Herman et al., 2022). Nurse practitioners (NPs) care for patients with many ailments in many healthcare settings. Patients might seek care for an acute illness or the worsening of a chronic condition. Often, pain is the leading reason for seeking medical care. Appropriate prescrib- ing practices are critical for all medications, but drugs considered controlled substances require additional attention. The Drug Enforcement Agency (DEA), the Food and Drug Administration (FDA), and the U.S. Department of Health and Human Services (HHS) all have a role in determining the scheduling of prescription medications. As prescribers, NPs must understand federal and state requirements for prescribing all controlled substances. In ad- dition, inappropriate prescribing practices resulting in misuse/or abuse of opioids have led to many changes, including new safety and quality recommendations. Prescribing any medication must be performed with care while considering possible patient-specif- ic risks. Prescribing controlled substances requires a heightened awareness for both patient and provider. Federal and state laws
and regulations must be followed when prescribing controlled substances. Additionally, other issues, including the more widespread avail- ability of medical marijuana and the opioid epidemic, have in- creased the complexity of the controlled substance prescribing process. All prescribers must be aware of federal and state laws regulating controlled substances. Prescribing opioid analgesics for acute and chronic pain has come under intense scrutiny as the opioid epidemic has worsened. In 2020, the U.S. Department of Health and Human Services estimated that 10.1 million people misused prescription opioids. Opioid overdoses, prescription and illicit, accounted for 42,000 deaths; 40% involved a prescrip- tion opioid (HHS, 2021). Appropriately prescribing first-time opi - oid analgesics for acute pain is critical in preventing future opi- oid abuse (Goldstick et al., 2021). Individualized tapering plans minimize symptoms of opioid withdrawal while maximizing pain treatment with nonpharmacologic therapies and nonopioid medi- cations (CDC, 2022a). Understanding patient-specific risk factors and prescribing strategies for chronic pain management is also critical in preventing misuse and abuse of opioid analgesics. OUD can occur at any age but is usually first identified in the late teens or early 20s (American Psychological Association [APA], 2013). It is considered a problematic pattern of opioid use lead- ing to clinically significant impairment or distress, with at least two of the following in a 12-month period.
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Book Code: RPUS3024
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