Download NAVMEDCENPTSVAINST 6200.5A NAVMEDCENPTSVA

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NAVMEDCENPTSVAINST 6200.5A
NAVMEDCENPTSVA INSTRUCTION 6200.5A
Subj: TOBACCO CESSATION PROGRAM POLICY
Ref:
(a) OPNAVINST 6100.2, Health Promotion Program
(b) NAVMEDCENPTSVAINST 6280.1 E, Smoking and Tobacco Use
Policy
(c) Firoe MC, Bailey WC, Cohen SJ, et al: Treating
Tobacco Use and Dependence. Clinical Practice
Guideline, Rockville, MD: U.S. Dept. of Health and
Human Services. Public Health Service. June 2000.
(d) Office of Surgeon General, Tobacco Cessation
Guidelines, Treating Tobacco Use and Dependence,
www.surgeongeneral.gov/tobacco
(e) American Cancer Society, Tobacco And Cancer,
www.cancer.org
(f) American Psychiatric Association: Practice Guidelines
for the Treatment of Patients with Nicotine Dependence,
American Journal Psychiatry 1996;
153:1-31.
(g) American Lung Association: Not On Tobacco (NOT)
Program, www.lungusa.org
(h) Center for Disease Control: Tobacco Information and
Prevention Source, www.cdc.gov/tobacco
(i) Health Promotion, Navy Environmental Health Center
(NEHC): Tobacco Cessation, wwwnehc.med.navy.mil/hp/tobacco/index.htm
(j) DoD Survey of Health Related Behaviors, 1998
(k) Navy Tobacco Metrics, www- nehc.med.navy.mil/
downloads/hp/TobaccoMetrics
Encl: (1) Standard Form 600 Overprint, Tobacco Cessation Program
Overprint, Zyban/Nicotine Replacement Therapy
Screening Form
(2) NMCP Tobacco Cessation Prescription Policy
(3) Provider Guidelines for Prescribing Tobacco Cessation
Medications
NAVMEDCENPTSVA INSTRUCTION 6200.5A
1. Purpose:
To provide an ongoing Tobacco Cessation Program that will:
(a) Promote operational readiness and a healthier lifestyle
by providing active duty military personnel the
opportunity, information and support to become
tobacco free.
(b) Promote a healthier lifestyle for eligible beneficiaries
by providing the opportunity, information and support to
become tobacco free.
(c) Provide medication support, as applicable, for
participants who are authorized to receive medication
from military treatment facilities.
2. Cancellation: NAVMEDCENPTSVA INSTRUCTION 6200.5
3. Scope. This instruction applies to the core hospital and
Branch Medical Clinics, which comprise the Naval Medical
Center (NAVMEDCEN), Portsmouth command and regional commands
as applicable.
4.Background: As stated in reference (d), tobacco use is the
single greatest cause of disease and preventable death in America
today, and is responsible for more than 430,000 deaths each year.
The following six systems strategies are recommended by U.S.
Public Health Services as part of a coordinated effort to provide
consistent and effective tobacco interventions:
(a) Implement a Tobacco-user Identification System in every
clinic
(b) Provide education, resources and feedback to promote
provider information
(c) Dedicate staff to provide tobacco dependence treatment and
assess the delivery of this treatment in staff performance
evaluations
(d) Promote hospital policies that support and provide tobacco
dependence services
(e) Include tobacco dependence treatments (both counseling
and pharmacotherapy) as paid or covered services for all
subscribers or members of health insurance packages
(f)
Reimburse clinicians and specialists for delivery of
effective Tobacco Dependence treatments and include them
among the defined duties of clinicians.
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NAVMEDCENPTSVA INSTRUCTION 6200.5A
5.Goals:
a. Support Force Health Protection and promote operational
readiness by reducing the number of tobacco users in the
military.
b. Promote and provide Tobacco Cessation Programs, educational
resources, counseling, support and relapse management to
eligible beneficiaries in a manner that considers cultural
language and educational diversity.
c. Educate and train designated personnel to become Tobacco
Cessation Facilitators and offer tobacco cessation classes
for military and eligible beneficiaries.
d. Collect Tobacco Cessation Program Metrics and identify
methods of improving the program
6.Procedures:
a. Wellness Department Head (WDH)
(1)
Directs the development and implementation of the
Tobacco Cessation Program according to
reference (a) through (k)
(2)
Collaborates with the Preventive Care and
Wellness Service Line Leader, NEHC Tobacco
Cessation Program Director, and other agencies
involved with Tobacco Cessation, to enhance the
program and improve outcomes for the region.
(3)
Directs ongoing Performance Improvement measures,
including Tobacco Cessation Program Metrics;
Directs reviews/updates of policies and procedures
periodically, as needed.
b.Program Manager, Tobacco Cessation
(1)
Coordinates the development, implementation,
management and evaluation of the NMCP Tobacco
Cessation Program, using guidelines listed in
references (a) through (k).
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NAVMEDCENPTSVA INSTRUCTION 6200.5A
b.Program Manager, Tobacco Cessation (cont)
(2)
Coordinates and collaborates with the Program
Manager, Adolescent Health for the development,
Implementation, management and evaluation of
the Adolescent Tobacco Cessation Program using
American Lung Association Not On Tobacco
(N.O.T.) Program guidelines per reference (g).
(3)
Coordinates the development and implementation
of Clinical Guidelines for Prescribing Tobacco
Cessation Medication.
(4)
Coordinates the development, implementation
and evaluation of the NMCP Tobacco Cessation
Facilitator Training Program using references
(a) through (k).
(5)
Collects and utilizes feedback from program
evaluations to perform periodic Needs Assessments
and update Performance Improvement standards.
(6) Coordinates the development and maintenance of
the database identifying current area
facilitators. Organizes periodic meetings to
provide feedback and updates.
(7) Coordinates the collection of NMCP Tobacco
Cessation Program outcome measurements and
communicates findings to the WDH and NEHC.
c.Tobacco Cessation Program Facilitator
(1)
Achieves satisfactory completion of the Tobacco
Cessation Program Facilitator Training per local
guidelines. Meets the required standard of
facilitating a minimum of two classes per 12
month period to maintain an active status with
NMCP Pharmacy.
(2) Coordinates and/or implements the Tobacco
Cessation Program at Medical Treatment
Facilities (MTF), Branch Medical Clinics and/or
Fleet and shore Commands. Follows appropriate
Guidelines listed in references (a) through (k).
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NAVMEDCENPTSVA INSTRUCTION 6200.5A
c. Tobacco Cessation Program Facilitator (cont)
(3) Facilitator participating in classes offering
medications must meet the following guidelines:
(a) Medical background experience that includes
knowledge of patient assessment and screening
techniques.
(b) If no medical background, Facilitator must
coordinate directly with the site Tobacco
Champion and/or co-facilitate another
facilitator who meets qualifications
(c) Maintains knowledge of the local pharmacy
policies and Clinical Practice Guidelines for
using prescription medication with the
Tobacco Cessation Program, as applicable.
(d) Communicates with the pharmacy and site
provider champion to coordinate the
prescription process for the class
participants.
(e) Assesses participants including current
tobacco use amount, medication side effects,
effectiveness of medications, and
motivation to change behaviors.
This includes documentation on appropriate
forms and reporting significant
findings/concerns to provider champion.
(4) Coordinates the scheduling of the classes and
provides on-going participant support for class
participants during and after class is completed.
(5) Submits registration forms, class roster and
participant satisfaction survey to NMCP Program
Manager, Outcomes and Marketing or clinic site
as indicated. Provides appropriate documentation
to ensure that the 3 and 6 month follow–up is
completed per local site guidelines.
(6) Coordinates, as indicated, with Primary Care
Manager/Medical provider concerning participant
health concerns and relapse management
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NAVMEDCENPTSVA INSTRUCTION 6200.5A
c. Tobacco Cessation Program Facilitator (cont)
(7) Follows NMCP and Tobacco Cessation Program
guidelines for reporting Adverse Effect(s)
d. Designated Primary Care Manager(s)/Provider(s)
(Tobacco Champion)
(1)
Promotes, implements and participates in (MTF),
Clinic, Fleet and/or Shore Command Tobacco Cessation
Programs according to references (a) through (k).
(2)
Completes NMCP Tobacco Cessation Program Provider
Guidelines for Prescribing Tobacco Cessation
Medications.
(3)
Ensures all adverse reactions are reported per
NMCP protocol.
(4)
Initiates, coordinates and participates in assessment
and medication management of participants, before,
during and after the Tobacco Cessation class sessions,
including relapse management and follow-up.
(5)
When facilitating Tobacco Cessation classes or
1:1 patient management, follows appropriate
guidelines for measuring outcomes required by NEHC.
7.Responsibilities: All NMCP Personnel and facilitators assigned,
attached or facilitating the NMCP Tobacco Cessation Program
classes will be directed by this instruction, including references
(a) through (k) and enclosures (1) through (4).
_________________________
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Subj: NMCP TOBACCO CESSATION PRESCRIPTION POLICY
Ref: (a) NAVMEDCENPTSVA INST 6200.5A
POLICY STATEMENT: Medical Officers who are prescribing Tobacco Cessation (TC)
Medications for eligible beneficiaries will follow the guidelines in reference a. NMCP and Branch
Medical Clinics dispensing the approved Tobacco Cessation medications will require the following
procedures be followed.
1. Tobacco Cessation Class Enrollment - The member must be enrolled in a Tobacco Cessation
class at the site where the provider is dispensing the prescription and/or be eligible to receive
the medication per reference a.
2. Approval - The provider writing the prescription must be on the current list of providers
who are approved to write Tobacco Cessation Medications.
a. The Wellness Department Tobacco Program Manager will coordinate with the Tobacco
Cessation Provider Educator and the NMCP Pharmacy Tobacco Cessation Liaison (PTCL)
to maintain an updated list of qualified Tobacco Cessation Providers and Facilitators.
b. The NMCP PTCL will ensure that the Branch Medical Clinics (BMCs) and Tricare
Prime Clinics (TPCs) receive a current copy of this list monthly.
3. Facilitator Responsibility -The Facilitator of the TC class will provide a list of participants to
the Pharmacy at the site where the class is being held, on the NMCP Pharmacy Tobacco
Cessation Medication Request form, in person, by e-mail or, if indicated, Fax the information to
the Pharmacy. (If NMCP – Fax to 953-0865)
4. Provider Responsibility -The provider will enter the medications directly into CHCS and put
in the comment section, “Enrolled in Smoking Cessation Program (dd/mm/yy).” The provider
will enter “ Zyban” and the pharmacy staff will be responsible for changing this to Wellbutrin
SR 150mg when the patient comes to pick up their medication.
5. Medication Guidelines -The Zyban should be written for a quantity of no more than thirty (30)
tabs. The NRT patch should be written for no more than one dosage level at a time. The
Nicorette Gum should be written for no more than 2 boxes at a time (one box contains 108
pieces).
Enclosure (2a)
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Subj: NMCP TOBACCO CESSATION PRESCRIPTION POLICY (cont)
6. Ship Guidelines & MDR Responsibilities – The Medical Officer and/or Senior Medical
Department Representative is responsible for following all Tobacco Cessation Program
guidelines per reference (a).
(a) The Tobacco Cessation Facilitator will provide a list of class participants to the NMCP
PTCL on the Pharmacy Tobacco Cessation Request Form by personal delivery, e-mail or
fax. The list will be submitted at least fourteen days prior to the date needed.
(b) The Ship’s provider will enter the medications directly into CHCS and put in the comment
section, “Enrolled in Smoking Cessation Program (dd/mm/yy).” The
provider will enter in Zyban and the pharmacy staff will be responsible for
changing this entry to Wellbutrin SR 150mg when the Ship’s Medical Department
Representative (MDR) comes to pick up the medication.
(c) Prescriptions will be written as follows: Zyban – a quantity of 60 per patient with one refill;
NRT patches – a quantity for the entire course of therapy for each patient; Nicorette Gum –
a quantity of 2 boxes with one refill
(d) The Independent Duty Corpsman, the Pharmacy Technician or the Medical Officer may
pick the Tobacco cessation medications from NMCP Pharmacy. Individual members will
not be able to pick up their medications.
(e) Deployment – if the Ship is deployed, NMCP Pharmacy will mail the medications directly
to the ship. The medications will be stored appropriately and dispensed in 1-2 week doses.
(f) Tobacco Cessation (TC) Patients will be assessed and monitored according to reference (a).
The TC patients will be monitored for at least four (4) weeks after the prescribed medication
is started. Blood Pressure checks will be done at least weekly and documented in the
patient’s medical record
Enclosure (2b)
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(Draft) Guidelines for Prescribing Tobacco Cessation Medication
1. Medications will be prescribed for persons attending Tobacco Cessation programs offered
or approved by Naval Medical Center Portsmouth and it Branch Medical Clinics as per
NAVMEDINST. 6200.5
2. If participant relapses within 12 months of completing Tobacco Cessation program that is
documented on SF 600 Tobacco Screening Overprint, a designated provider may screen and
prescribe additional medication and
provide one on one support. Otherwise, member may need to be referred
to another Tobacco Cessation Program.
3. Participant is screened for Zyban or NRT by using the SF 600, Tobacco Cessation
Screening Overprint, medical record, and/or appointment with designated provider.
Medication guidelines are:
Zyban, Wellbutrin, Bupropion HCL
¾ Information not all inclusive-refer to manufacturer’s package insert for complete prescribing
information.
¾ Contraindications:
o History of Seizure disorder
o Current treatment with Wellbutrin, Wellbutrin SR, or any other medications
containing Bupropion HCL. Incidence of seizure is dose dependent
o Current or prior diagnosis of bulimia or anorexia nervosa
o Concurrent administration of a monoamine oxidase inhibitor (MAO)
o Allergy to Bupropion
o Flight, diving, or other special active duty status
o Pregnant or breast feeding
¾ Warnings: Patient factors that may increase risk for seizure
o History of head trauma or prior seizure
o CNS tumor
o Severe hepatic cirrhosis
o Concomitant medication that lower seizure threshold
¾ Antipsychotics, antidepressants, theophylline, systemic steroids
o Excessive alcohol use or sedatives
o Addiction to opiates, cocaine, or stimulants
o Use of OTC stimulants and anorectics
o Diabetes treated with oral hypoglycemics or insulin
¾ No single dose should exceed 150mg or daily dose of 300mg
Enclosure (3a)
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Zyban, Wellbutrin, Bupropion HCL
¾ Adverse Effects and Recommendations (not all inclusive-refer to manufacturer’s package
insert for complete information)
o Hypertension-in some cases severe
o Tremors – recommend patient discontinue use and contact provider
o Most common side effects are dry mouth and difficulty sleeping –
may be dose dependent, usually disappears after a few days.
Dosage Guidelines:
¾ An initial 2-week supply (30 tablets should be ordered for each new patient.
(This may be ordered after the first session of the Tobacco Cessation class.)
¾ Order by typing “ZYB150” into CHCS
¾ Dosage: 150 mg/day for three days then, 150 mg bid up to 12 weeks
¾ Weekly assessment during the program will include a blood pressure check,
assessment of effectiveness and presence of any adverse/side effects
¾ Follow-up after the four week program, should include a blood pressure check and interview
for effectiveness and presence of any adverse/side effects
Nicotine Replacement Patches
Information not all inclusive-refer to manufacturer’s package insert for complete
prescribing information.
¾ Contraindications:
o Hypersensitivity to nicotine or any component of the transdermal system (e.g.
Adhesive tape)
o Use during the immediate post myocardial infarction period
o Life-threatening arrhythmias
o Severe or worsening angina pectoris
o Pregnancy-category D
¾ Warning:
o Systemic Hypertension-monitor for any increase in cardiovascular symptoms
¾ Adverse Effects and Recommendations:
o Atrial tachycardia or elevated blood pressure may occur with a combination of
patches and Zyban. Discontinue and contact medical for evaluation.
o Severe or persistent local skin reactions should be advised to discontinue use and
contact physician.
Enclosure (3b)
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Nicotine Replacement Patches
o Most common side effects: skin irritation at site of patch-rotate sites to decrease
irritation; headache, insomnia, abnormal dreams - removing patch at night may help.
¾ Dosage Guidelines:
o If smoking more than 10 cigarettes/day and/or using smokeless tobacco:
¾ Step 1: 21 mg for 2 - 4 weeks, then 14mg for 2 weeks,
then 7mg for 2 weeks
o If smoking 10 or less:
¾ Step 2: 14mg for 2 - 4 weeks, then 7 mg for 2 weeks
o (CHCS order)
Nicotine Gum
Not all inclusive-refer to manufacturer’s package insert for complete prescribing
Information.
¾ Contraindications:
o Oral lesions
o Hypersensitivity to nicotine
o Use during the immediate post myocardial infarction period
o Life-threatening arrhythmias
o Severe or worsening angina pectoris
o Pregnancy-category D
¾ Warning:
o Systemic Hypertension- monitor for any increase in cardiovascular symptoms
¾ Adverse Effects and Recommendations: (not all inclusive)
o Soreness or lesion in mouth or throat. Discontinue use and see medical.
o Most common side effect: Gastric distress. Recommend reviewing proper chewing
method and reduction of amount of gum used.
Dosage Guidelines:
¾ 2 mg for < 25 cig/day, 4 mg for > 25 cig/day
¾ Dispensed in boxes of 108
¾ Stop tobacco use completely before starting nicotine gum.
¾ Explain proper use:
o when the urge to use tobacco arises, chew one piece of gum slowly until a
‘tingle’ is felt.
Enclosure (3c)
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Nicotine Gum
Dosage Guidelines (continued)
¾ Explain proper use:
o ‘Park’ gum between cheek and gum
o When peppery taste is gone (approx 1 min), chew slowly
o When peppery taste returns, park gum in a different place
o Repeat until peppery taste is gone (usually ½ hour)
o Wrap in paper and dispose of properly
¾ Week 1-6: 1 pc every 1-2 hours
¾ Week 7-9: 1 pc every 2-4 hours
¾ Week 10-12: 1 pc every 4-8 hours
Enclosure (3d)
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