Addressing NRT Barriers • Assess the severity of symptoms (Is it tolerable?). • Assess Hx: onset, duration and any troubleshooting that has already taken place. If indicated, get history of these symptoms when not taking these medications. You may also ask how Pt. would normally treat these symptoms. • If symptoms are tolerable àdevelop troubleshooting plan with Pt. Inform Pt. that many symptoms will go away after a few days. Reassess at next visit, but ask Pt. to call if symptoms persist/worsen or become intolerable before next call/visit. • If symptoms are not tolerableàconsider changing products or dosages as applicable. Consult study physician, as needed. Refer Pt. to their personal physician, if needed (e.g., prescription strength creams). • All potential cardiac symptoms should be promptly reported to study physician. Advise Pt. to discontinue NRT when indicated or instructed by study physician. Vivid Dreams/ Problems Sleeping: - Assess if sleep is being disrupted. Is night waking normal for Pt. – what is Pts.’ normal routine? - May try taking patch off at night, keeping in mind cravings may be stronger in the AM. After a couple of nights, try again to wear patch overnight. If using more than 1 patch, may consider only wearing 1 at night. - May try removing patch at night and putting on 2 hours before waking, especially when early morning waking is part of routine. Otherwise, can set an alarm, put on patch, and go back to sleep. - Regulate eating and sleeping patterns and use sleep hygiene tips (relaxation training, avoid caffeine). - Do not smoke or use short-acting NRT within 1-2 hours of bedtime (especially if sleep initiation is the major complaint.) Nausea/upset stomach: - Ask if nausea is only after using gum/lozenge or also after smoking a cigarette. - With short acting NRT, make sure gum/lozenge is parked in cheek or under tongue. (Don’t chew gum or suck on lozenge). Ask Pt. to show or tell you how he/she uses products and provide feedback. - Reduce number of cigarettes being smoked per day. - Wait to use 15 min after eating or have a large glass of water (don’t use on empty stomach). - If too much short-acting NRT is being used, limit use as needed. - Use OTC antacids or whatever Pt. would normally use/do to treat nausea. - Try other flavors of short-acting NRT Itching/Rash/ Irritation: - Use anti-itch or antihistamine cream around patch area. Let it soak in thoroughly before applying patch. If rash or irritation has occurred, let skin rest for several days and use OTC or Rx steroid cream for treatment. - Wear patch in a different location (e.g., lower body) to find a less sensitive area. - Rotate patch every day. - Talk to Pts.’ doctor / pharmacist; Consult with study physician. - Use distraction if itching only lasts for a few minutes after placing patch. - If blistering or swelling occur, discontinue patch. - If troubleshooting does not work and rashes are severe/intolerable, ask if Pt. is willing to try a new brand of patches (sample). If this also does not work, we may move Pt. to monotherapy. Consider 4 mg dose if Pt. smokes more than 20 per day or within 30 minutes of waking. Sore Throat: - Drink plenty of water – use normal “soothing” aides, such as hot tea, cough drops, etc. - Keep gum/lozenge parked in cheek or under tongue as much as possible. - Cut down smoking or e-cig use (if applicable); try different flavors of NRT Swelling/ Stinging Pain/Burning: - How long does swelling/ stinging last? In what areas is it the most severe? - Move patches to less sensitive areas. - Use over-the-counter pain relievers; consider applying a topical anesthetic (e.g. Benzocaine ointment or gel) to the area before applying the patch. - Talk to your doctor about anti-inflammatory cream or medications to take if it is long lasting. Jittery/Nervous or Irritability - Assess to gauge whether symptoms are related to toxicity or nicotine withdrawal – recommend either reducing dosage or increasing nicotine dosage base on assessment. - Discuss mood changes as part of other life changes and assess Hx of mood disorder – recommend mental health services or have Pt. talk with his/her doctor, if applicable. - Use relaxation techniques. Refer to Health Ed. Booklet for ideas. Headache: - Assess to gauge whether symptoms are related to toxicity or nicotine withdrawal – recommend either reducing dosage or increasing nicotine dosage base on assessment. - Drink plenty of water and eat regularly. - Assess whether there is any particular time of the day headaches occur? - Reduce smoking on the patch. - Use relaxation techniques (see educational booklet for ideas.) Other barriers: Forgetting to take Medication: Place NRT where it is most visible - by bedside or near/in cigarette pack; integrate into already established daily routines; set alarms and post reminders; track it on a calendar Patch not sticking: Use surgical tape or gauze; place under bra strap or waistband or sock; clean skin before putting on patch; shave area of skin if needed; do not put on within 15 minutes of shower or lotion application; place a jumbo bandage over patches; use a strip of panty hose to hold on arm Gum sticking to dentures/not tasting good: Mix piece of NRT gum with Freedent; swoosh cold water in mouth/mix with another flavor of regular gum .