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Pharmacology · chapter 15 · Substance Use Disorder Treatment Drugs

Nicotine Use Disorder Drugs

The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 6 practice questions with the reasoning.

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Key points

  1. Other tobacco components cause the harm

    Nicotine itself is not necessarily that toxic in doses used in clients with NUDs, but it is often the other components found in tobacco products (e.g., formaldehyde, lead, arsenic, benzene, carbon monoxide) that the client is exposed to that lead to a variety of chronic health conditions such as cancer, respiratory disease, and cardiovascular disease.

  2. How nicotine drives craving

    Nicotine works as an agonist at the nicotinic acetylcholine receptor. At high doses, nicotine can stimulate dopamine release in the reward center of the brain, leading to many of the craving symptoms clients experience when attempting to treat NUD.

  3. Very high doses are an emergency

    Nicotine at extremely high doses (e.g., a child ingests unsecured vaping solution or swallows chewing tobacco) can cause significantly more toxic effects, including risks for dysrhythmia, seizures, and respiratory failure, and should be treated as a medical emergency.

  4. Vaping is just as addictive

    Some clients may harbor the idea that vaping devices do not contain nicotine or are safer than other sources of nicotine, but the health care provider should educate clients that these devices can be just as addictive as smoking.

  5. Signs of nicotine withdrawal

    Reactions that occur during nicotine withdrawal include anxiety, difficulty concentrating, irritable mood, and severe cravings for nicotine.

  6. Timing of withdrawal

    It usually begins within 24 hours after discontinuation of nicotine-containing products and can last from days to weeks, making relapse rates quite high without the assistance of behavioral and pharmacologic intervention.

  7. Bupropion is safe if the client relapses

    Since bupropion does not have any actions at the nicotinic receptor, it is safe if clients relapse and begin using nicotine-containing products while taking bupropion.

  8. Stop NRT after a relapse

    It is also important for clients who relapse and start using nicotine-containing products again to discontinue their NRT. This prevents the client from being exposed to even higher doses of nicotine than they were originally using and reduces the risk for adverse effects.

  9. Start varenicline before the quit date

    In fact, it is recommended that varenicline be initiated 1 week prior to the chosen quit date to ease the transition into nicotine abstinence.

  10. Bupropion and seizures, suicidal ideation

    Bupropion should be used cautiously in clients with a history of seizures, as this can be worsened in the presence of bupropion. Bupropion, like other antidepressant medications, can increase risk for suicidal ideation, so it is important to educate the client to monitor for depressed mood and suicidal thoughts.

  11. Bupropion with other norepinephrine drugs

    Bupropion should be avoided if the client is taking any other drugs that increase norepinephrine actions, such as selective norepinephrine reuptake inhibitors (SNRIs) (e.g., duloxetine, venlafaxine).

  12. Varenicline adverse effects and depression

    Common adverse effects seen with varenicline include nausea, vomiting, and abnormal dreams. Varenicline should be used cautiously in clients with a history of depression and suicidal ideation or suicide attempts, as it has been shown to increase these symptoms in some clients.

  13. Secure nicotine products from children

    Nicotine-containing products should also be secured in a manner to avoid accidental pediatric exposures, as nicotine exposures in young children can cause severe toxicity, including the risk for respiratory failure and death.

  14. Nicotine spray and asthma

    Avoid nicotine sprays in clients with a history of asthma, as this can lead to asthma exacerbations.

Terms to know

Nicotine replacement therapy (NRT)
Nicotine replacement therapy (NRT) is designed to replace the nicotine products that a client is currently using with products only containing nicotine.
Varenicline
Varenicline is a partial nicotine receptor agonist that has a greater affinity for the receptor than nicotine itself.

Practice questions

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Every question here, with the answer

  1. A client using a nicotine patch tells the nurse they started smoking cigarettes again last week. What should the nurse advise?

    1. Switch to nicotine gum while continuing to smoke.
    2. Double the patch strength to help stop smoking.
    3. Keep the patch on to reduce cravings while smoking.
    4. Remove the patch and stop nicotine replacement therapy.

    Answer: Remove the patch and stop nicotine replacement therapy.

    Clients who relapse should discontinue NRT so they are not exposed to higher doses of nicotine than before, which can cause toxicity such as tachycardia and dizziness. Continuing, switching or increasing nicotine replacement while smoking adds even more nicotine.

  2. A client is prescribed varenicline to quit smoking. When should the nurse teach the client to begin the medication?

    1. Only when cravings become severe.
    2. On the day after the last cigarette.
    3. One week before the chosen quit date.
    4. One month after the quit date.

    Answer: One week before the chosen quit date.

    Varenicline is recommended to be started 1 week before the chosen quit date to ease the transition into nicotine abstinence. Waiting until after quitting or until cravings are severe misses that transition period.

  3. A client asks for bupropion to help quit smoking. Which finding in the history should the nurse report to the provider before the drug is started?

    1. A history of seizures
    2. Use of chewing tobacco
    3. A history of mild anxiety
    4. Smoking one pack a day

    Answer: A history of seizures

    Bupropion should be used cautiously in clients with a history of seizures because it can worsen them, and the nurse screens for this. Heavy smoking and chewing tobacco are the reason for treatment, and bupropion can actually be advantageous with anxiety.

  4. A nurse is caring for a client who stopped smoking two days ago. Which findings are expected signs of nicotine withdrawal? Select all that apply.

    1. Difficulty concentrating
    2. Respiratory failure
    3. Severe cravings for nicotine
    4. Irritable mood
    5. Anxiety

    Answer: Difficulty concentrating, Severe cravings for nicotine, Irritable mood, Anxiety

    Nicotine withdrawal includes anxiety, difficulty concentrating, irritable mood and severe cravings, usually starting within 24 hours of stopping. Respiratory failure is a risk of extremely high nicotine doses, not of withdrawal, which is not expected to be fatal.

  5. A nurse is teaching a client who is starting a nicotine patch. Which instructions should the nurse include? Select all that apply.

    1. Apply the patch to clean, dry skin.
    2. Keep smoking cigarettes while using the patch.
    3. Store nicotine products where children cannot reach them.
    4. Remove the patch before an MRI.
    5. Leave the patch on during an MRI.

    Answer: Apply the patch to clean, dry skin., Store nicotine products where children cannot reach them., Remove the patch before an MRI.

    Patches go on clean, dry skin, are removed before MRI procedures, and nicotine products must be secured because children can develop severe toxicity. Clients should avoid nicotine products while on NRT, and the patch is not left on during MRI.

  6. A client taking varenicline reports vivid dreams and nightmares since starting the drug. What is the nurse's best response?

    1. This means the drug is not working and should be stopped today.
    2. Dream changes are a known effect and should be reported, as the therapy may need to change.
    3. Take an extra dose at bedtime to improve sleep.
    4. Nightmares are caused by nicotine withdrawal, not the drug.

    Answer: Dream changes are a known effect and should be reported, as the therapy may need to change.

    Varenicline is known to cause vivid dreams, including nightmares, and clients should report dream changes because therapy may need to change. The nurse does not stop the drug on their own, blame withdrawal, or add doses.

Where every quote comes from

Section 15.4 Nicotine Use Disorder Drugs of Pharmacology for Nurses by Tina Barbour-Taylor, Leah Mueller (Sabato), Donna Paris, Dorie Weaver, OpenStax, 2024. Read the whole section free at openstax.org.

The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.