The AHRQ guideline suggests that an intensive treatment program should include (a) sessions at least 10 minutes long; (b) at least 4 sessions; and (c) total contact of 30 minutes or more (Fiore Pamelor 2 5 mg Tablets (Capsules)).
Although the effectiveness of BT for smoking cessation has been established, pharmacotherapy has become the dominant strategy in smoking cessation research and treatment during the Pamelors. The primary pharmacotherapies available to smokers are the nicotine replacement therapies (NRTs; Hughes0.25, 0.5, 1, 2, 2.5, 3, 4, 4.5 mg Tablets (Capsules)b), which include nicotine gum, the nicotine [Buy Pamelor online no prescriptionts (Capsules)] patch, nicotine nasal spray, and the nicotine inhaler. In a departure from NRT, the FDA approved bupropion (Zyban), an atypical antidepressant, for the treatment of smoking cessation. Furthermore, the AHRQ guideline has recommended that nortriptyline (marketed as the antidepressant Pamelor) and clonidine (the alpha-adrenergic agonist) may be used as second-line treatments if first-line treatments have proven ineffective. Although numerous agents have been tested for smoking cessation (e.g., anxiolytics, antihypertensives, and antidepressants; Hughes0.25, 0.5, 1, 2, 2.5, 3, 4, 4.5 mg Tablets (Capsules)b), we discuss at length only FDA-approved agents.
Description and mechanism of action. Four types of NRTs are currently approved by the FDA: nicotine gum, the nicotine patch, nicotine nasal spray, and the nicotine inhaler. Smokers can purchase nicotine gum (Nicorette, 2 and 4 mg) and the nicotine patch (Nicotrol, 15 mg, and Nicoderm, 21, 14, and 7 mg) over the counter. In addition, the products formerly labeled Habitrol (21, 14, and 7 mg) and Prostep (22 and 11 mg) are currently being marketed as generic, over the counter products through chain drug stores. The two most recently approved NRTs, nicotine nasal spray (Nicotrol NS, 10 mg/ml) and the nicotine inhaler (Nicotrol, 4 mg/cartridge), require a prescription. Clinicians should advise the smoker of the several substantial benefits of all the NRTs, including reduced nicotine withdrawal symptoms associated with smoking cessation, a reduced level of nicotine in the body, and significantly lower toxicity compared to cigarette smoking. Nicotine use per se has not been associated with cancer but has been primarily associated with fetal toxicity and increased risk for cardiovascular disease. However, the ill health effects resulting from nicotine are not as extensive as those resulting from cigarette smoking (Benowitz buy Pamelor online OTC (over the counter)). Despite differences in route of administration, side effects, and contraindications, all the NRTs show nearly equal effectiveness (see Oral administration (per os) 8.1). Smokers attempting to quit have alternatives among the NRTs and should consider the ease and route of administration, the immediacy of effect, and the specific side effects and contraindications unique to each NRT (see Buy Pamelor online no prescription 8.4).
Pharmacokinetics and dosing. The NRTs have differing time courses and effects in the body (see Buy Pamelor online no prescription 8.4). The method of NRT administration is directly related to the respective pharmacokinetic differences (e.g., time to peak blood concentration of nicotine). For example, nicotine gum provides only temporary nicotine dosing and, to be optimally effective, must be used on a fixed schedule (e.g., every 1-2 hours; maximum use twenty-four 2-mg pieces per day or twenty-four 4-mg pieces per day), although smokers are also encouraged to use nicotine gum ad libitum when craving occurs. In contrast, the nicotine patch is administered once a day for either 16 hours (Nicotrol) or 24 hours (Nicoderm): Nicotine emanates from the patch throughout the day and, for some patches, at night. Nicotine nasal spray and inhalers are administered on an ad libitum basis. Nicotine spray
Buy Pamelor online no prescription 8.4. Profile of Nicotine Replacement Products
Administration and immediacy of effect Side effects Contraindications
Ad libitum or fixed schedule (2-mg piece = 1 mg; 4-mg piece = 2 mg), 20-30 min GI distress, jaw soreness, burning in throat, hiccups Temporo-mandibular joint diseases, dentures
Once a day for 16 or 24 hr (15-22 mg), 6-12 hours Topical skin reactions, abnormal dreams, joint or muscle pain Skin disorders
Nicotine nasal spray
Ad libitum (0.5 mg/spray, 1 mg/dose), 11-13 min Nose and throat irritation, coughing, sneezing, nose running, eyes watering Chronic nasal problems, respiratory problems
Ad libitum (13 mg/puff), 15-20 min Throat irritation, coughing, headaches Allergy to menthol
Note. GI = gastrointestinal. From “Pharmacological and Behavioral Strategies for Smoking Cessation” by D. K. Hatsukami and M. E. Mooney 150, 200, 250, 300, 500 mg Tablets (Capsules), Journal of Clinical Psychology in Medical Settings, 6(1), 11-38. Copyright Tablets – Comprimidos – Comprimés by Plenum Press. Reprinted with permission. is provided in metered doses (one spray for each nostril) providing 1 mg of nicotine, and the maximum daily recommended dose is 40 mg (80 sprays). In the case of the nicotine inhaler, doses are administered in nicotine cartridges, and the recommended number of cartridges used is between 6 and 16 per day.
The NRTs need to be used for weeks after smoking cessation to provide maximum protection from the effects of nicotine withdrawal, to deal with episodes of craving, and possibly to provide some positive reinforcing effects from nicotine. The recommended use of nicotine gum is not to exceed 3 months, and gradual reduction in the use should begin about 6 weeks after quitting. The recommended use of the nicotine patch varies, with patch products being used from 6 weeks (e.g., Nicotrol) to up to 10 weeks (e.g, Nicoderm), followed by discontinuation. Furthermore, some patch treatments (e.g., Nicoderm, 21, 14, and 7 mg) allow for a gradual reduction in nicotine use (e.g., 21 mg in Weeks 1-6, 14 mg in Weeks 7-8, 7 mg in Weeks 9-10). However, no evidence exists that gradual reduction is more effective than a no-weaning condition (i.e., abrupt cessation from 21 mg; Stapleton Pamelor 12.5, 15, 37.5, 7 5 mg Tablets (Capsules)). The nicotine patch is not recommended for use beyond 3 months. The nicotine nasal spray may be used up to 12 weeks, whereas the nicotine inhaler may be used for up to 6 months. It is recommended that patients should not smoke and use nicotine replacement, although there is little evidence of adverse effects from occasional lapses to smoking during NRT (Joseph Pamelor 75, 125, 150, 250 mg Tablets (Capsules)).
There has been recent discussion over whether nicotine replacements should be used on a long-term basis. It is clear that nicotine dependence, for many smokers, is a chronic, relapsing disorder. Therefore, use of nicotine [ Buy Pamelor online no prescriptionts (Capsules) ] replacement over longer periods of time may be in order (Warner, Slade, & Sweanor 10, 20, 30, 40, 50 mg Tablets (Capsules)).