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Medical Directive HFHT 22-NRT only
Title:
Activation Date:
Smoking Cessation Medical Directive
May 2015
Sponsoring/Contact Person:
Number:
Review due by:
HFHT 22
May 2017
Antony Gagnon, PharmD, CDE
Pharmacy Program Manager
(905) 667-4867
[email protected]
Order and/or Delegated Procedure:
Appendix Attached:
Yes
No
Title: Appendix A and B
1. Pharmacists, Registered Nurses (RN) or Registered Practical Nurses (RPN) employed by, or working with, a
physician member of the Hamilton Family Health Team (HFHT), on the authority of this medical directive, may
implement orders to administer the nicotine patch, gum and/or inhaler directly to patients of the HFHT, without
prior consultation with a physician, under defined circumstances. Specified dosage ranges are as indicated in the
table and decision tree below. The pharmacist, RN or RPN must believe that she/he has the knowledge, skill and
judgment to implement this medical directive. RNs and RPNs must have completed the educational requirements
as outlined below.
2. In addition, the pharmacist, RN or RPN working at the HFHT may continue and/or adjust a patient’s NRT orders
if previously implemented by a physician.
3. In recognizing that pharmacists, RNs and RPNs working under this medical directive possess advanced
knowledge regarding the use of NRT, this medical directive allows the pharmacist, RN and RPN to initiate and
continue NRT above the usual recommended dosages (after discussion with the physician for patches > 35 mg/d)
or in combinations of different NRT formulations as appropriate, consistent with the current practice at nicotine
dependence clinics (e.g., CAMH).
4. The following is a list of medications covered by this Medical Directive, please refer to Appendix A for decision
tree to determine which NRT to use.
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Table 1
Medication/Dosage
Nicotine Replacement
Therapy:
Nicotine Patch
Can be given alone or in
combination with
nicotine gum, inhaler,
and lozenges
Nicotine Patch
(21mg)/24h
Nicotine Patch
(14mg)/24h
Nicotine Patch
(7mg)/24h
Indications
Contraindications/Cautions Max Dose/24h
Smoking >15
cigarettes per day
(CPD)
Contact hypersensitivity to
the patch. Signs and
symptoms of these may
include erythema, pruritus,
edema, hives or generalized
rash or urticaria.
Smoking 7-14 CPD
**35mg
*Pregnancy, recent CVA,
immediately post MI, angina,
life threatening arrhythmias
As above
**35mg
Less than 7 CPD or
unable to tolerate
higher doses of
NRT
As above
**35mg
Willing to learn the
proper technique
since the nicotine
has to be absorbed
across the buccal
mucosa.
Unable to chew gum
Wears dentures,
immediately post MI,
arrhythmias, angina, active
TMJ dysfunction
20 pieces of nicotine
gum
Nicotine Gum
Can be used alone or in
combination with
nicotine patch, inhaler,
and lozenges
Nicotine Gum 4mg q 1h
prn
Nicotine Gum 2mg q 1h
prn
As above, use 4mg As above
first, switch to 2mg
if patient unable to
tolerate 4mg gumtoo strong, S/Sx of
nicotine toxicity
with 4mg gum
(nausea,
diaphoresis,
irritated throat, etc.)
20 pieces of nicotine
gum
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Medication/Dosage
Nicotine Replacement
Therapy:
Nicotine Inhaler
Can be used alone or in
combination with
nicotine gum, patch, or
lozenges
Nicotine Inhaler 10mg
cartridge Q1h prn
(delivers 4mg nicotine
per cartridge)
Indications
Contraindications/Cautions Max Dose/24h
Unable to tolerate or * Pregnancy, recent CVA,
use nicotine gum
immediately post MI,
angina, life threatening
arrhythmias.
6 cartridges
unable to tolerate or
use nicotine gum or
inhaler
* Pregnancy, recent CVA,
immediately post MI,
angina, life threatening
arrhythmias.
15 nicotine lozenges
per day
unable to tolerate or
use nicotine gum or
inhaler
As above
15 nicotine lozenges
per day
Nicotine Lozenge
Can be used alone or in
combination with
nicotine gum, patch or
inhaler
Nicotine Lozenge 2mg Q
1-2 hrs PRN
Nicotine Lozenge 4mg Q
1-2 hrs PRN
use 4mg first,
switch to 2mg if
patient unable to
tolerate 4mg
lozenge
S/Sx of nicotine
toxicity with 4mg
lozenge (nausea,
diaphoresis, irritated
throat, etc.)
*Recent studies have shown that using NRT is safer then smoking. Any patient who is pregnant or who had a
recent CVA or MI, or any arrhythmias should be initiated on NRT only after a discussion with the physician.
The Pharmacist, RN or RPN can then continue these patients on NRT and reduce dosages accordingly. Any
increase in dosage should be discussed with the physician first.
**Patients can be titrated up to and including 35 mg patch dosage by the Pharmacist, RN or RPN. Higher
dosages should be discussed with the physician first. The pharmacist or RN can then continue patients on
dosages of 35 mg or higher as recommended by the physician, or reduce dosage accordingly, but not increase
the dosage further.
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N.B. If patient experiences nausea or vomiting, diaphoresis, tremors, confusion or weakness after using NRT,
this could mean they are receiving too high a dose, discontinue its use, do not let patient smoke, monitor
patient and notify a physician. Once patient’s condition stabilizes, the physician can try a lower dose and
continue to monitor patient closely for the above signs.
Recipient Patients:
Appendix Attached:
Yes
No
Title:
1. Patients of HFHT Family Physicians who have provided consent and who do not have contraindications as per
section below.
Authorized Implementers:
Appendix Attached:
Implementers
Yes
No
Title: Appendix C Authorized
RNs, RPNs and pharmacists who are working for the HFHT. RNs and RPNs must have completed the educational
requirements outlined below
EDUCATIONAL REQUIREMENTS:
RNs and RPNs must have completed the TEACH training 3 day training program or equivalent (to be assessed by
program manager), training on the Stop Study, and training on the CAMH/Stop Portal. This training will include
indications for use of NRT, contraindications, signs and symptoms of nicotine withdrawal and overdose and actions
to be taken if the patient presents with the above.
Indications:
Appendix Attached:
Yes
No
Title:
Prior to dispensing any nicotine replacement within this medical directive, RNs, RPNs and pharmacists must assess
patient status including:
 Allergies
 Smoking status – number of cigarettes per day
 Length of use (cigarettes)
 Readiness to change
 Goals (reduction, abstinence)
 Prior experience with any NRT, any adverse effects, reactions, etc.
Contraindications:


Known history of or newly presenting adverse effects, drug sensitivity or allergy
Recent MI, CVA, angina or arrhythmias. This is not an absolute contraindication; recent studies have shown
that using NRT is safer then smoking. Any patient with a recent CVA or MI, or any arrhythmias should be
initiated on NRT ONLY after discussion with the physician. The pharmacist or RN can then continue these
patients on NRT and reduce dosages accordingly. Any increase in dosage should also be done only after
discussion with physician.
Consent:
Appendix Attached:
Yes
1. Patients of HFHT Family Physicians
2. HCP obtains verbal patient consent prior to the implementation of care
3. HCP fully explains risks, benefits or nicotine replacement therapy
No
Title:
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Guidelines for Implementing the Order /
Procedure:
Appendix Attached:
Yes
No
Title:
Documentation and Communication:
Appendix Attached:
Prescription
Yes
No
Title: Appendix D Example
1. Documentation of the patient’s current medications, clinical findings and the plan of care will be included in the
medical record. Response to the procedure or directions provided by the pharmacist, RN or RPN will also be
documented.
2. If a prescription or samples are given, include the prescription given or the quantity of samples given including
the date, drug, form, dosage, and number of refills. “Medical Directive HFHT 02” should also be indicated on the
prescription as well as the signature of the implementer of the Medical Directive and the name of the delegating
physician. See example prescription.
3. The Physician will refer to documentation in the medical record by the pharmacist, RN or RPN.
Review and Quality Monitoring Guidelines:
Appendix Attached:
Yes
No
Title:
QUALITY CONTROL/MONITORING PROCESS




Educational requirements: a current or updated list of those certified to implement this medical
directive must be maintained by the respective program managers.
The pharmacist, RN or RPN is also expected to maintain competency by regular use of the medical
directive once a month or more.
This medical directive will be monitored by the respective HFHT program managers.
The pharmacist, RN or RPN implementing this medical directive will seek consultation from the
physician regarding individual patient issues/care as needed.
Administrative Approvals (as applicable):
Appendix Attached:
Yes
No
Title:
Approving Physician(s)/Authorizer(s):
Appendix Attached:
Implementers
Yes
No
Title: Appendix C Authorized
See attachment
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APPENDIX A
DECISION TREE TO ADDRESS NICOTINE WITHDRAWAL
Assess patient’s smoking status:
 Pattern of smoking: daily/non-daily/ex-smoker/never smoked
 Amount smoked: cigarettes smoked per day
 Withdrawal when stopping and how soon after stopping in the past
 Any signs of withdrawal at time of assessment
 Goals (reduction, cessation, withdrawal management)
 Inpatient status: voluntary or involuntary
 Previous experience with NRT: cessation/reduction
 Med. Hx: Recent/previous MI, unstable angina, arrhythmia, TMJ dysfunction, dentures,
pregnant
 Non daily smoker, or
 No withdrawal on
stopping smoking
No
Daily Smoker
Withdrawal Symptoms: Cravings to smoke, irritability, frustration, anger,
anxiety, difficulty concentrating, restlessness not accounted for by any other
mental health or physical condition.
Yes
Yes
Hold NRT, contact doctor, patient can still be started on
NRT but only after discussion with the physician.
Presence of recent heart attack,
angina, arrhythmias
No
No
Medication
Yes
Try alternative brand. If patient has topical
reaction to all brands, discontinue patch and
provide nicotine gum, lozenges, or inhaler
instead
Allergic to nicotine patch?
No
Smokes ___ cigarettes per day
Less than or equal to 14 cigarettes per day
Greater than or equal to 15 cigarettes per day


Start with 14mg patch per day plus gum
q1hr prn for cravings
OR
 Consider gum or lozenge 2 or 4mg q1h alone
 Use inhaler if gum not suitable or if
preferred by patient

Start with 21mg patch/day plus 4mg gum or
lozenge, q 1hr prn
Use inhaler if gum not suitable or if preferred by
patient
If patient has dentures, TMJ dysfunction or is unable to chew nicotine gum, provide the inhaler or lozenge
instead of gum.
Start with 4mg gum or lozenge, if patient cannot tolerate 4mg (finds it is too strong) then reduce to 2mg
gum or lozenge.
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APPENDIX B
DECISION TREE TO ADDRESS NICOTINE WITHDRAWAL
INCREASING DOSAGE BEYOND 21MG PATCH
Smoking while
using NRT



No
Support patients quit attempt
Relapse prevention
Continue with prescribed NRT, reduce down
according to patients therapeutic response
Yes







Assess for nicotine toxicity
Advise patient not to smoke
Assess amount smoked: cigarettes per day
Assess any signs of nicotine withdrawal
Assess dose of NRT
Assess if correctly using NRT
Assess goals (reduction, cessation, withdrawal
management)
Signs of nicotine toxicity
Yes


Signs/symptoms of nicotine toxicity:
nausea and/or vomiting, diaphoresis,
vertigo, tremors, confusion, weakness,
racing heart, light-headedness
Advise patient not to smoke
Reduce NRT by 7mg if patient continues to smoke
No


Increase dosage of patch by 7mg
Reassess patient in 1 week
OR


Add nicotine inhaler, nicotine gum or lozenge to treatment regime
If already using gum or inhaler, increase amount used per day
If patient requires greater than 35 mg dosage, discuss first with the physician. The RN or RPN can
then continue patients on dosages of 35 mg or higher. Any additional increases beyond 35 mg should
be discussed first with the physician.
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APPENDIX C
List of Authorized Implementers
Name of Registered Nurse/
Registered Practical
Nurse/Pharmacist
Name of Authorizing
Physician
Date of initial
authorization
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APPENDIX D
Sample Prescription
Dr. J.D. Authorizer, MD, CCFP.
Hamilton Family Health Team
10 George Street
Hamilton, ON
905 667-4848
Date: August 14, 2014
Patient: Christa Jones, 100 Main Street, Hamilton
Nicotine Patch 14mg
Apply 1 patch every 24 hours
Dispense: 28 patches
Nicotine (choose one) Gum, Lozenge or Inhaler 2-4mg q1h prn nicotine cravings
(Signature)
Jane Smith RN
Medical directive Hamilton FHT
02
Dr. J.D. Authorizer, MD, CCFP