Clinical Practice Guidelines: Treatment of Tobacco Use Disorder PDF

atom lackof information f 1 4.0 CLINICAL INTERVENTIONS FOR TOBACCO USE DISORDER There are two types of clinical intervention depending on the intensity of intervention and level of service provided. They are: i. Brief clinical intervention ii....

atom lackof information f 1 4.0 CLINICAL INTERVENTIONS FOR TOBACCO USE DISORDER There are two types of clinical intervention depending on the intensity of intervention and level of service provided. They are: i. Brief clinical intervention ii. Intensive clinical intervention 4.1 Brief Clinical Intervention for Tobacco Use Disorder Assist Arrange 4.1.1 For All Smokers Brief clinical intervention by the physician increases quit rates effectively14, Level I. It is vital to change clinical culture and practice patterns to ensure that every patient who uses tobacco is identified and offered treatment. The five major steps (5 A’s) for intervention are described below and summarised 00 in Table 1. The strategies are designed to be brief and minimal health care provider’s time is required15,16,17. These brief opportunistic advices typically involve asking patients about their current smoking, advising them to stop, offering assistance either by providing further advice, a referral to a specialist service or recommendation of or a prescription for pharmacotherapy or arranging a follow up wherever it is appropriate. The focus of this opportunistic advice is to increase smokers’ motivation to quit in improving success rate of quitting18. This brief intervention has been proven to increase overall tobacco abstinence rates regardless he or she is referred to an intensive intervention19,20 Level I,21 Level III. The steps involved in the delivery of brief intervention include: Step 1: Ask about tobacco smoking ALL patients should be asked about their smoking status and the findings should be documented in the patient’s notes. This should be delivered opportunistically during routine consultations to all smokers regardless whether they are seeking help to stop smoking. For people who smoke or have recently stopped smoking, the smoking status should be checked and updated at every visit to prevent relapse. Systems should be in place in all health care settings to ensure that smoking status is accurately documented at every visit (20, Level I; 6, Level I) 4  O Step 2: Advice to quit Advice to quit should be given clearly to all patients found to be smoking. Studies have shown that advise by health care providers (medical, dental, pharmacist, nurses etc.) increases rates of abstinence. There is a strong dose-response relationship between the session length of person-to-person contact and successful treatment outcomes20, Level I. Multiple efforts by health care providers can increase these rates further. Every tobacco user should be offered at least a brief intervention which consists of brief cessation advice from the health care providers. However, intensive interventions are more effective than brief interventions and should be used whenever possible as smokers’ motivation, beliefs and feeling about smoking and quitting is always conflicting18, Level III. Face to face treatment delivered for four or more sessions appears especially effective in increasing abstinence rates22, Level I. Therefore, if feasible, treatment providers should strive to meet four or more times with individuals quitting tobacco use. Health care workers should be provided with appropriate training to enable them to provide brief advice. This training should include providing the health care worker with information on available evidence-based smoking cessation treatments19. o Step 3: Assess willingness to make a quit attempt Health care providers involved with tobacco treatment should assess the willingness to begin treatment to quit. Though there is a lack of evidence for greater effectiveness of stage based approaches23, Level I, stages of change model provides a useful framework to help health care providers to identify smokers and assist smokers in quitting24, Level III. There is some evidence that the likelihood of success in an attempt to quit is unrelated to the smoker’s expressed interest in quitting in the period leading up to the attempt – unplanned attempts to quit are as likely (or even more likely) to be as successful as planned attempts25, Level III; 26, Level III. Thus, there is benefit in encouraging all smokers to consider quitting whenever the opportunity arises20, Level I. Step 4: Assist in quit attempt All patients should be assisted to quit. Brief advice as short as 30 seconds and self- help material have been shown to help14, Level I. Brief advice (3-5 minutes) is effective and there is a dose response in treatment provision. 5  Setting a quit date has been shown to be effective. Ideally the quit date should be within 2 weeks on assessment to quit. Individual, group and telephone counselling approaches are effective and  should be used in smoking cessation interventions. Smoking cessation interventions that are delivered in multiple approaches increase abstinence rates and should be encouraged. Studies have shown that individual counselling resulted in higher abstinence rates as compared to group or phone counselling and self-help27, Level II-1; 22, Level I. There are two forms of telephone telephone counselling which is the ‘proactive counselling’ and ʻreactive counseling counselling. In proactive counselling, smokers receive calls from healthcare providers according to a pre-agreed schedule. In ‘reactive counselling’, naivetreatctive smokers calls a helpline seeking help or advice. Proactive services, compared to reactive services, have been more widely evaluated as they can be more easily controlled. Studies have recommended that proactive plasma telephone counselling as one of the formats for delivering behavioural schedule counselling20, Level I; 28, Level I; 29, Level I. For hospitalised patients, a study has as shown that high intensive telephone follow-up (4 calls at 48 hours post discharge, 7, 21, 90 days)mm was more effective than low intensive follow-up (1 call at 48 hours post discharge) in addition to 30 minutes counselling30, Level I. continuous abstinence 6monthsnotsmoking 0 Step 5: Arrange follow up Health care providers wanting to do more intensive counselling will require further appropriate training. Health care providers who are not confident in providing counselling interventions can still assist patients wanting to quit by arranging referrals to services that can assist. Patients who are attempting to quit are at high risk of relapsing. Continuous O abstinence is achieved when the patient has not smoked for at least 6 months. The highest risk of relapse is within the first 8 days of quitting. Hence the support has to in Tara be given the utmost importance in the first week of quitting cigarette smoking. Evidence has shown that abstinence of 12 months follow up is a good indicator for long term abstinence31. on The evidence suggests that multiple treatment sessions increase smoking abstinence rate and its effectiveness. More intensive interventions (more than eight Intion sessions in six months) may produce enhanced abstinence rate. However, these interventions may have limited reach (affect fewer smokers) and may not be feasible 8sessions in some primary care settings20, Level I. in 6months The steps recommended by the NCSCT for evidence-based behaviour change techniques to assist health care providers in managing smokers who seek clinic help to quit smoking are32, Level I:- 6 Session 1: Pre-quit Assessment (1 or 2 weeks prior to Quit Date) Session 2: Quit Date Session 3: 1 week post Quit Date Session 4: 2 weeks post Quit Date Session 5: 3 weeks post Quit Date Session 6: 4 weeks post Quit Date (See Appendix 4 for details) rumonary go through Table 2: The “5 A’s” for brief intervention 1. Ask about tobacco use:  Identify and document tobacco use status for every patient at every visit, including the adolescents.  Where appropriate, ask the caretaker of the patient about tobacco use or exposure to tobacco smoke. What needs to be done? Expand the vital signs to include tobacco use or use an alternative universal identification system (e.g. stickers on patient charts). 2. Advise to quit: In a clear, strong and personalized manner urge every tobacco user to quit. Advice should be: 0  Clear—"I think it is important for you to quit smoking now and I can help you." "Cutting down while you are ill is not enough."  Strong—"As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you."  Personalised —Tie tobacco use to current health/illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household. 3. Assess willingness to make a quit attempt: Is the tobacco user willing to make a quit attempt at this time?  If the patient is willing to make a quit attempt at this time, provide assistance. 7   If the patient will participate in an intensive treatment, deliver such a treatment or refer to an intensive intervention.  If the patient clearly states he or she is unwilling to make a quit attempt at O this time, provide a motivational intervention built around the “5 R’s”: relevance, risks, rewards, roadblocks, and repetition. (Refer to section Smokers unwilling to quit, page 32) If the patient is a member of a special population (e.g., adolescent, pregnant smoker), consider providing additional information (refer to section Special Population, page 39). 4. Assist in quit attempt:  I For the patient willing to make a quit attempt, use counselling with 8 pharmacotherapy (when indicated) to help him or her quit. Preparations for quitting: (STAR)  Set a quit date. Ideally, the quit date should be within 2 weeks. Reduce the number of cigarettes gradually before the set date.  Tell family, friends, and co-workers about quitting and request understanding and support. Also, help patient obtain extra-treatment social support from self-help groups. Other smokers in the household. Patients should encourage household members to quit with them or not smoke in their presence to minimize risk of treatment failure and exposure to second-hand smoking.  Anticipate challenges to planned quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms. c Discuss challenges/triggers and how patient will successfully overcome them. Provide patients with problem solving/skills training.  Remove tobacco products from his or her environment. Prior to quitting, avoid smoking in places where a lot of patient’s time is spent (e.g., work, home, car).  Provide a supportive healthcare environment while encouraging the patient in his or her quit attempt.  Abstinence. Total abstinence is essential. Not even a single puff after the quit date.  Past quit experience. Identify what helped and what hurt in previous quit we attempts.  Alcohol. Since alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting. 8   Recommend the use of approved pharmacotherapies, if indicated. Explain how these medications increase smoking cessation success and reduce withdrawal symptoms.  Provide supplementary materials. 5. Arrange follow-up: Schedule follow-up, preferably within the first week after the quit date. Initiivers wee two  Timing. Follow-up should occur soon after the quit date, preferably during the first week. Subsequent follow-ups are recommended weekly41516 mont I within the first month, and then every two weeks for the 2nd and 3rd e month, and monthly after that up to 6mmmm months. n n  on follow-up, either in person or For those who successfully quit, schedule via telephone. Actions during follow-up: o Congratulate success o If tobacco use has occurred, review circumstances and elicit commitment to total abstinence. o Remind patient that a lapse can be used as a learning experience. Identify problems already encountered and anticipate challenges in the immediate future. o Assess pharmacotherapy use and problems. Consider using more intensive treatment, if not available, referral is indicated. Adapted from Fiore et al. 200820, Level I. Recommendation 1 Grade of Recommendation   Ask and document smoking status for all patients. Provide brief advice on quit smoking at every visit to all C smokers. Use individual, group and telephone counselling A approaches, or in combination for smoking cessation interventions. Arrange a minimum of six to eight face to face follow-up A sessions for smoking cessation interventions in six months. 9  ratherthan keep asking smokers toquit smoking Ask re should provide assistance forthem to quit ation 4.1.2 ABC for Smoking Cessation Alternatively, another approach is the ABC approach to help smokers to quit smoking (see Appendix 5). The steps are as follows: O A. Ask all people about their smoking status and document this. O B. Provide Brief advice to stop smoking to all people who smoke, regardless of their desire or motivation to quit. C. Make an offer of, and refer to or provide, evidence based Cessation treatment. O (Implementing the ABC Approach for Smoking Cessation Framework and work programme, 19) Physicians may be more effective in promoting attempts to stop smoking by offering assistance to all smokers than by advising smokers to quit and offering assistance only to those who express an interest in doing so6. 4.2 Intensive Clinical Interventions for Tobacco Use Disorders Evidence shows that intensive tobacco dependence treatment is more effective than brief treatment. This could be achieved by increasing the length of individual treatment sessions, the number of treatment sessions and specialized behavioural therapies. Intensive clinical interventions could be provided by any suitably trained doctors and other health care providers who have the resources available to give intensive interventions and are appropriate for any tobacco user willing to participate in them20, Level I. Table 3: Components of an intensive tobacco dependence intervention Assessment  Assessments should determine whether tobacco users are willing to make a quit attempt using an intensive treatment programme.  Other assessments can provide information useful in counselling (e.g., stress level, dependence). Programme  Multiple types of clinicians are effective and should be clinicians used.  One counselling strategy would be to have a medical/health care clinician deliver a strong message to quit and information about health risks and benefits, and recommend and prescribe medications recommended in this Guideline update. 10  atom lackof information f 5.0 FOR PATIENTS WHO ARE UNWILLING TO QUIT Motivational interviewing (MI) techniques may assist with smoking cessation when the health care providers are empathetic, promotes patient autonomy (e.g., choice among options), avoids arguments, and supports the patient’s self-efficacy (e.g., by identifying previous successes in behaviour change efforts)62, Level III; 63 , Level I. Table 10 highlights the strategies that can be used in motivational interviewing technique. Patients unwilling to make a quit attempt during a visit may be due to:  Lack of information about the harmful effects of tobacco,  May be demoralized because of previous relapse.  Lack the required financial resources  May have fears or concerns about quitting Such patients may respond to a motivational intervention built around the “5R’s”: Relevance, Risks, Rewards, Roadblocks and Repetition (Table 5). Express  Use open-ended questions to explore: cities Table 4: Strategy B1. Motivational interviewing strategies empathy o The importance of addressing smoking or other tobacco use (e.g., “How important do you think it is for you to quit smoking?”) o Concerns and benefits of quitting (e.g., “What might happen if you quit?”)  Use reflective listening to seek shared understanding: o Reflect words or meaning (e.g., “So you think smoking helps you to maintain your weight.”). o Summarize (e.g., “What I have heard so far is that smoking is something you enjoy. On the other hand, your boyfriend hates your smoking, and you are worried you might develop a serious disease.”).  Normalize feelings and concerns (e.g., “Many people worry about managing without cigarettes.”).  Support the patient’s autonomy and right to choose or reject change (e.g., “I hear you saying you are not ready to quit smoking right now. I’m here to help you when you are ready.”). Develop  Highlight the discrepancy between the patient’s present discrepancy behaviour and expressed priorities, values, and goals (e.g., inconsistent entourage 22 them  “It sounds like you are very devoted to your family. How do you think your smoking is affecting your children?”).  Reinforce and support “change talk” and “commitment” language: o “So, you realize how smoking is affecting your breathing and making it hard to keep up with your kids.” o “It’s great that you are going to quit when you get through this busy time at work.”  Build and deepen commitment to change: o “There are effective treatments that will ease the pain of quitting, including counselling and many medication options.” o “We would like to help you avoid a stroke like the one your father had.” Roll with Back off and use reflection when the patient expresses resistance resistance: o “Sounds like you are feeling pressured about your smoking.” Express empathy: o “You are worried about how you would manage withdrawal symptoms.” Ask permission to provide information: o “Would you like to hear about some strategies that can help you address that concern when you quit?” Support Help the patient to identify and build on past successes: self-efficacy o “So you were fairly successful the last time you tried to quit.” Offer options for achievable small steps toward change: o Read about quitting benefits and strategies. o Change smoking patterns (e.g., no smoking in the home). o Ask the patient to share his or her ideas about quitting strategies. Adapted from Fiore et al. 2008 20, Level I 23  Table 5: Enhancing motivation to quit tobacco—the “5 R’s” Relevance  Encourage the patient to indicate why quitting is personally relevant, being as specific as possible.  Motivational information has the greatest impact if it is relevant to a patient’s disease status or risk, family or social situation (e.g. having children in the home), health concerns, age, gender, and other important patient characteristics (e.g.m prior quitting experience, personal barriers to cessation). Risks The clinician should ask the patient to identify potential negative consequences of tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. The clinician should emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks. Examples of risks are: o Acute risks: Shortness of breath, exacerbation of asthma, increased risk of respiratory infections, harm to pregnancy, impotence, and infertility. Long-term risks: Heart attacks and strokes, lung and other cancers (e.g., larynx, oral cavity, pharynx, oesophagus, pancreas, stomach, kidney, bladder, cervix, and acute myelocytic leukemia), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), osteoporosis, long-term disability, and need for extended care. Environmental risks: Increased risk of lung cancer and heart disease in spouses; increased risk for low birth-weight, sudden infant death syndrome (SIDS), asthma, middle ear disease, and respiratory infections in children of smokers. Rewards The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. Examples of rewards follow: Improved health Food will taste better Improved sense of smell Saving money Feeling better about oneself Home, car, clothing, breath will smell better Setting a good example for children and decreasing the likelihood that they will smoke Having healthier babies and children Feeling better physically 24  Performing better in physical activities Improved appearance, including reduced wrinkling/aging of skin and whiter teeth Road- The clinician should ask the patient to identify barriers or impediments blocks to quitting and provide treatment (problem solving counselling, medication) that could address barriers. Typical barriers might include: Withdrawal symptoms Fear of failure Weight gain Lack of support Depression Enjoyment of tobacco Being around other tobacco users Limited knowledge of effective treatment options Repetition The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful. Adapted from Fiore et al. 200820, Level I. Recommendations 3 Grades of Recommendations Motivational intervention (incorporating 5R technique – Relevance, Risks, Rewards, Roadblocks & Repetition) A should be used for patients who are unwilling to make a quit attempt. 25  6.0 PATIENTS WHO HAVE RECENTLY QUIT (RELAPSE PREVENTION) For smokers who have recently quit, relapse prevention intervention may focus on identifying and resolving tempting situations or smoking cues64, Level I. Most interventions have tried a skills-based approach, where recent quitters are taught to recognise high-risk situations and acquire the skills to withstand the temptation to smoke. However, trained health care providers should provide targeted and effective relapse prevention interventions due to the chronic relapsing nature of tobacco dependence 65, Level III; 66, Level III; 67,Level III). When clinicians encounter a patient who has quit tobacco use recently, they should: a. Reinforce the patient’s decision to quit b. Review with patient the benefits of quitting c. Assist the patient in resolving any residual problems arising from quitting. Almost all lapses occur during the first 3 months after treatment and half of those who have their first lapse smoke their second cigarette within 24 hours of the first cigarette or immediately following treatment68, Level I. The annual incidence of relapse was around 20% to 25%69, Level I. Relapse prevention interventions can be delivered by means of scheduled clinic visits, telephone calls, use of quitline or any time the clinician encounters an ex- tobacco user. There are two practices of relapse prevention, either minimal or intensive. I_ 6.1 Minimal Practice Relapse Prevention This is appropriate for most recent quitters and can be addressed briefly during a coincident clinic visit or a scheduled follow-up visit. Similarly, the “5 R’s” strategy should be used to prevent relapse. Patients should be encouraged to report difficulties promptly (e.g. lapses, depression, medication side-effects) while continuing efforts to remain abstinent. The simple D.E.A.D. pointer technique can be applied to refrain oneself from smoking: Delay – Deliberately delay the act of lighting up cigarette by doing something else Escape – Escape any situation / environment that induce smoking Avoid – Plan to avoid situation / environment that induce smoking Distract – Distract the intention to smoke by doing relaxation techniques, housework, spending time with family, etc. 26  0 BAHAGIAN AMALAN & PERKEMBANGAN FARMASI KEMENTERIAN KESIHATAN MALAYSIA GARISPANDUAN FARMAKOTERAPI BERHENTI MEROKOK EDISI KEDUA 2019 GARISPANDUAN FARMAKOTERAPI BERHENTI MEROKOK EDISI KEDUA 2019  10 MODUL FARMAKOTERAPI BERHENTI MEROKOK Aliran Lawatan Pesakit Tugas Tanggungjawab Kerja Pra Lawatan 1 Promosi (1-2 kali lawatan) Pegawai Perubatan / Mempromosi program FBM dan Pegawai Farmasi / menjalankan saringan bagi pesakit yang Paramedik / layak mengikuti program ini. Penyelaras Program Pra Lawatan 2 Penyaringan dan Pendaftaran (1-2 kali lawatan) Membuat saringan pesakit. Pegawai Perubatan / a. Mendapatkan maklumat sejarah Pegawai Farmasi / merokok atau penggunaan produk Paramedik / nikotin. Penyelaras Program b. Memberi nasihat untuk berhenti merokok. c. Menilai tahap kesediaan untuk berhenti merokok berdasarkan Transtheoretical Model (TTM) of Stage of Change: i. Bagi pesakit yang bersedia untuk berhenti merokok (dalam fasa contemplation, preparation & action), rujuk kepada pendaftaran. ii. Bagi pesakit yang belum bersedia untuk berhenti merokok (dalam fasa pre- contemplation), gunakan Motivational Interviewing (MI). 5R Sekiranya pesakit bersedia untuk berhenti selepas MI, rujuk kepada pendaftaran. Membuat pendaftaran hanya bagi pesakit yang bersedia untuk berhenti merokok dan bersetuju dengan kriteria program yang ditetapkan. a. Tetapkan tarikh temujanji (dalam Penyelaras Program tempoh 2 minggu). b. Penyelaras Program perlu memaklumkan tarikh temujanji pesakit set.eu baru kepada Pegawai Perubatan dan Pegawai Farmasi. GARISPANDUAN FARMAKOTERAPI BERHENTI MEROKOK EDISI KEDUA 2019  11 Aliran Lawatan Pesakit Tugas Tanggungjawab Kerja Lawatan 1 Penilaian Awal Pertama (Bagi perokok yang bersetuju untuk mendapatkan rawatan) a. Ambil dan catatkan tanda-tanda vital Paramedik dalam Borang Rekod Pesakit FBM: tekanan darah, berat badan & tahap CO. b. Terangkan tahap CO dengan bantuan Pegawai Farmasi / carta yang sedia ada dalam Borang Paramedik Rekod Pesakit FBM. Lawatan 2 Konsultasi oleh Pegawai Perubatan Pertama a. Tetapkan tarikh berhenti merokok. Pegawai Perubatan / Pegawai Farmasi b. Bincangkan rintangan-rintangan yang bakal dihadapi oleh pesakit dan cara- cara mengatasi. c. Bincangkan dan tentukan farmakoterapi yang sesuai bersama Pegawai Farmasi. d. Tetapkan tarikh temujanji yang sesuai Penyelaras Program dengan Pegawai Perubatan. Lawatan 3 Sesi Kaunseling Pertama a. Dispen ubat mengikut kriteria yang Pegawai Farmasi ditetapkan dalam rekod pesakit FBM untuk tempoh masa 2 minggu. b. Berikan kaunseling mengikut Panduan Kaunseling FBM. c. Isikan maklumat lawatan pesakit berhenti merokok dalam Borang Rekod Pesakit FBM. GARISPANDUAN FARMAKOTERAPI BERHENTI MEROKOK EDISI KEDUA 2019  12 Aliran Lawatan Pesakit Tugas Tanggungjawab Kerja d. Tetapkan tarikh temujanji dengan Penyelaras Program Pegawai Farmasi dalam masa 2 minggu. e. Penyelaras Program menetapkan tarikh kaunseling modifikasi tingkahlaku (behaviour therapy) dengan Kaunselor / Pegawai Farmasi/ Pegawai Perubatan. Lawatan Susulan 1 Penilaian Awal (minggu ke-2, 4, 8, 12) a. Pendaftaran. Paramedik b. Ambil dan catatkan tanda-tanda vital dalam Borang Rekod Pesakit FBM: tekanan darah, berat badan & tahap CO. c. Terangkan tahap CO dengan bantuan carta yang sedia ada. d. Isikan maklumat lawatan pesakit berhenti merokok dalam Borang Rekod Pesakit FBM. Lawatan Susulan 1 Penilaian / Sesi Kaunseling (minggu ke-2) a. SMS atau telefon pesakit sebelum Pegawai Farmasi / tarikh susulan minggu ke-2 untuk Penyelaras Program SMS mengingatkan tarikh temujanji. pentaguan b. Cadangkan isu-isu penjagaan Pegawai Farmasi farmaseutikal farmaseutikal kepada Pegawai doctor Perubatan (sekiranya ada). ruguk pesakit be prn dispens ubut I c. Rujuk pesakit kepada Pegawai Perubatan (sekiranya perlu). Kaunseving d. Dispen ubat dan jalankan kaunseling relord farmasentikal mengikut modul yang ditetapkan dalam Kaunkling Panduan Kaunseling FBM untuk tempoh masa 2 minggu. e. Isikan maklumat farmakoterapi kaunseling dalam Borang Rekod Pesakit FBM. GARISPANDUAN FARMAKOTERAPI BERHENTI MEROKOK EDISI KEDUA 2019  13 Aliran Lawatan Pesakit Tugas Tanggungjawab Kerja Lawatan Susulan 1 Konsultasi oleh Pegawai Perubatan dan (minggu ke-4, kaunseling oleh Pegawai Farmasi. 8 & 12) a. SMS atau telefon pesakit sebelum Pegawai Farmasi / tarikh susulan minggu ke-4, 8 & 12 Penyelaras Program untuk mengingatkan tarikh temujanji. SMS nutangan b. Bincangkan rintangan-rintangan yang Pegawai Perubatan / bakal dihadapi oleh pesakit dan cara- Pegawai Farmasi tavilin tj cara mengatasi. counseling c. Tetapkan tarikh temujanji seterusnya Pegawai Farmasi / pada setiap bulan yang akan datang. Penyelaras Program record farmasentical d. Kaunseling susulan dengan Pegawai counseling Farmasi tentang ubat-ubatan Pegawai Farmasi menggunakan Panduan Kaunseling sesi Kaungering FBM. modifikasi value e. Isikan maklumat farmakoterapi Pegawai Farmasi fingurn kaunseling dalam Borang Rekod Pesakit FBM. f. Sesi kaunseling modifikasi tingkahlaku Pegawai Farmasi / (behaviour therapy) sekiranya ada. Kaunselor Susulan 1 Pemantauan keadaan pesakit. Melalui Telefon a. Berikan kaunseling mengikut Panduan Pegawai Farmasi (minggu ke- 6 Kaunseling FBM. dan 10) b. Isikan maklumat farmakoterapi kaunseling dalam Borang Rekod Pesakit FBM. GARISPANDUAN FARMAKOTERAPI BERHENTI MEROKOK EDISI KEDUA 2019  14 Aliran Lawatan Pesakit Tugas Tanggungjawab Kerja Lawatan 1 Sesi Kaunseling susulan setelah a. Hubungi pesakit sebelum tarikh Pegawai Farmasi / berhenti susulan minggu ke -16 & 24 untuk Penyelaras Program merokok mengingatkan tarikh temujanji. (minggu ke- 16 & 24) b. Kaunseling bersama Pegawai Pegawai Perubatan / Perubatan dan Pegawai Farmasi. Pegawai Farmasi c. Tetapkan satu sesi testimoni pesakit Kaunselor / yang berjaya (sekiranya perlu). Paramediks / Penyelaras Program d. Tetapkan tarikh temujanji dengan Pegawai Farmasi / pesakit untuk membuat penilaian Penyelaras Program abstinence pada bulan ke - 6 dan ke - 12. e. Sesi kaunseling behavioral therapy. Pegawai Farmasi / Kaunselor Nota: ɤ Master Rekod FBM perlu diwujudkan dan sentiasa dikemaskini untuk memudahkan proses pemantauan perkembangan rawatan pesakit. ɤ Borang Saringan Minda Sihat (Depression Anxiety Stress Scale, DASS) perlu digunakan bagi prosedur penilaian kesihatan mental pesakit FBM yang mengalami atau menunjukkan gejala masalah mental. GARISPANDUAN FARMAKOTERAPI BERHENTI MEROKOK EDISI KEDUA 2019  q 10 section 1 GARIS PANDUAN KAUNSELING METHADONE GARIS PANDUAN PENDISPENSAN DAN PEMANTAUAN RAWATAN TERAPI GANTIAN SIRAP METHADONE 1. ORIENTASI PESAKIT TERHADAP PERKHIDMATAN FARMASI DAN PROGRAM RAWATAN TERAPI GANTIAN Pesakit perlu diberi orientasi farmasi termasuk maklumat berkaitan Sirap Methadone. Pesakit perlu diberi peluang untuk bertanya soalan mengenai Sirap Methadone atau ubat-ubatan lain yang dipreskrib bersama. Maklumat bertulis yang berkaitan perlu disediakan termasuk waktu pendispensan di Farmasi. Maklumat yang perlu di maklumkan kepada pesakit sewaktu orientasi: namesrenren.mn www.renren 1.1 Sirap methadone adalah sejenis opioid di mana pesakit akan bergantung kepadanya secara fizikal dan sekiranya diberhentikan secara mengejut, kesan pengunduran akan berlaku. withdrawalsymptom 1.2 Pada peringkat awal rawatan, rasa mengantuk dan/atau kesan pengunduran C mungkin dirasai. Elakkan daripada memandu kenderaan atau mengendalikan mesin sewaktu dalam peringkat awal rawatan kerana mungkin boleh membahayakan pesakit. Kesan ini boleh juga dialami pada peringkat pengubahsuaian dos atau waktu-waktu ketidakstabilan. 1.3 Penggunaan dadah secara haram dan pengambilan alkohol boleh membahayakan diri pesakit. Semasa pengambilan Sirap Methadone, perbincangan dengan doktor C yang merawat perlu dilakukan sebelum menggunakan bahan-bahan lain termasuk ubat-ubatan preskripsi atau bukan preskripsi kerana dikhuatiri berlaku interaksi ubat. 1.4 Atas sebab-sebab keselamatan, dos Sirap Methadone boleh ditangguhkan selepas C perbincangan dengan doktor yang merawat sekiranya pesakit dalam keadaan intoksikasi. 1.5 Sebarang dos Sirap Methadone yang tidak terambil akan dilaporkan kepada doktor yang merawat. Selepas 3 dos tidak terambil, pesakit perlu dinilai oleh doktor sebelum Sirap Methadone dibekal semula. 1.6 CKesan sampingan pengambilan Sirap Methadone dalam terapi gantian adalah termasuk sembelit, berpeluh, keletihan berlebihan, kurang daya seks dan peningkatan berat badan. 1.7 Pesakit harus memaklumkan kepada doktor yang merawat sekiranya telah diberi/ dipreskrib sebarang bahan narkotik daripada doktor lain. T 2.Famanammammmmammammmm UJUAN KAUNSELING 2.1 0 Memastikan pesakit memahami Rawatan Terapi Gantian (RTG) dengan Sirap Methadone. 2.2 Meningkatkan kepatuhan pesakit terhadap pengambilan Sirap Methadone. understood 1 1 BAHAGIAN PERKHIDMATAN FARMASI, KKM 2 Danger e attest 4 5 Dosage GARIS PANDUAN KAUNSELING METHADONE 2.3 Memberi maklumat berkaitan kesan sampingan yang mungkin dialami pesakit sewaktu pengambilan Sirap Methadone. 2.4 Memberi maklumat kepada pesakit tentang bahaya pengambilan Sirap Methadone bersama-sama dengan ubat/ dadah lain. 2.5 Memberi penerangan kepada pesakit berkaitan dos bawa balik, dos tertinggal dan dos berlebihan. 2.6 Lain-lain penjagaan diri (self care) pesakit yang berkaitan. 3. TUJUAN RAWATAN UBAT METHADONE 3.1 Untuk menghilangkan pergantungan terhadap pengambilan semula opiod yang diambil. 3.2 Membantu pesakit berada dalam keadaan selesa dan bebas dari rasa gian terhadap opiod. 3.3 Menyekat kesan dadah (opiod) yang diambil secara haram. 4. APA ITU METHADONE? Methadone ialah ubat yang tergolong di dalam kumpulan opioid yang digunakan sebagai terapi gantian untuk merawat ketagihan heroin dan lain-lain ketagihan opioid. Opioid dikelaskan sebagai ubat-ubat penekan (depressant drugs) kerana ia memperlahankan sistem saraf. Kesan Methadone adalah lebih lama daripada heroin (kesan heroin hanyalah selama beberapa jam sahaja). 5. MEMULAKAN RAWATAN METHADONE? 5.1 Hanya boleh dimulakan oleh pakar psikiatri/doktor yang diberi kuasa untuk mempreskrib ubat. 5.2 Pegawai Farmasi akan mendispens Sirap Methadone kepada anda berdasarkan dos yang telah dipreskrib. Nota Pegawai Farmasi Farmakokinetik Methadone: Masa Tindakan (onset) : 30 minit Kesan puncak (peak effects) : ~ 3 jam Tempoh hayat (half-life) : ~ 24 jam Masa untuk penstabilan : ~ 3-10 hari 2 BAHAGIAN PERKHIDMATAN FARMASI, KKM  GARIS PANDUAN KAUNSELING METHADONE 5.3 Apabila mula-mula berhenti heroin, anda akan berasa agak sukar untuk menyesuaikan hidup. Oleh itu, selalulah berjumpa dengan kaunselor anda untuk membantu mengatasi kesukaran ini. Kaunselor boleh membimbing anda untuk mengatasi isu-isu atau masalah yang dihadapi. 6. KEBAIKAN RAWATAN DENGAN SIRAP METHADONE 6.1 Dos Sirap Methadone yang betul: 6.1.1 Berkesan dalam tempoh yang lebih lama di dalam badan berbanding heroin (ia hanya perlu diambil sekali sehari). 6.1.2 Membantu anda mengatasi proses pengunduran dengan lebih selesa. 6.1.3 Tidak dikontaminasi dengan bahan-bahan/dadah lain. comparetoheroine 6.2 Memberi kesan positif dari segi pengurangan risiko dalam membendung jangkitan HIV kerana ia tidak perlu disuntik seperti dadah heroin dan dengan ini dapat mengelakkan amalan perkongsian jarum. 7. CARA PENGAMBILAN SIRAP METHADONE 7.1 CDos D dos ini adalah bergantung kepada ciriciri individu pesakit permulaan Sirap Methadone ialah 15-30mg/hari (tidak melebihi 40mg/hari), walaubagaimanapun tersebut. Masa penstabilan dos biasanya adalah satu (1) minggu atau lebih tetapi penambahan dos biasanya diperlukan pada minggu dan bulan seterusnya. 7.2 Dos pengawalan (maintenance dose) adalah 60-80mg. Kekerapan dos Sirap Methadone ialah sekali sehari dan diberi secara oral (diminum). Sebaik-baiknya Sirap Methadone perlu diambil pada waktu pagi untuk memudahkan pemantauan sekiranya berlaku kesan sampingan yang teruk. 7.2 Sirap Methadone boleh diambil dengan susu sekiranya mengalami gangguan perut. 8. DOS TERTINGGAL (MISSED DOSE) Sila berhubung dengan doktor anda jika anda tertinggal lebih daripada dua dos. Nota Pegawai Farmasi Sekiranya seseorang pesakit tertinggal dos : Satu hari : tiada perubahan pada dos Dua hari : sekiranya tiada bukti berlaku intoksikasi,berikan dos asal Tiga hari : beri separuh dos dan bincang dengan preskriber Empat hari : rujuk pesakit kepada preskriber Hari ke lima dan seterusnya : dikira sebagai induksi baru (rujuk pesakit kepada preskriber) BAHAGIAN PERKHIDMATAN FARMASI, KKM 3 GARIS PANDUAN KAUNSELING METHADONE 9. DOS TERMUNTAH (VOMITTED DOSE) Jika pesakit didapati betul-betul termuntah selepas dos diberikan, langkah penggantian dos akan diambil. Preskripsi baru perlu diperolehi untuk gantian dos. Nota Pegawai Farmasi Sekiranya seseorang pesakit termuntah dos yang diberikan : Kurang 15 minit dari pengambilan dos : ganti dos penuh Antara 15 minit hingga 30 minit dari pengambilan dos : ganti 50% dos Jika muntah selepas 30 minit pengambilan dos : Tiada gantian dos 10. KESAN- KESAN YANG TIDAK DIINGINI 10.1 Simptom-simptom yang tidak diingini boleh berlaku pada permulaan rawatan. Sesetengah simptom yang dialami mungkin juga disebabkan oleh kesan sampingan Sirap Methadone. Antaranya ialah: Kesan sampingan Faktor penyebab Tindakan Mengantuk selepas Dos berlebihan Beritahu doktor atau pegawai farmasi pegambilan dos Penggunaan dadah depresi anda. sistem saraf pusat (alkohol, Elakkan dari memandu kenderaan atau benzodiazepine). mengendalikan mesin sekurang-kurangnya dalam masa dua minggu pertama. Rasa loya/muntah dan Sirap Methadone Elakkan dari pengambilan semasa dalam hilang selera makan perut kosong Gian (craving) kepada Dos tidak mencukupi Beritahu doktor atau pegawai farma si heroine anda Peningkatan berat Retensi cecair dalam badan Bincang dengan doktor/ pegawai farmasi badan untuk nilai semula dos. Berbincang dengan doktor atau pegawai farmasi mengenai pengubahsuaian diet. Banyakkan senaman. Sembelit Sirap Methadone Bincang dengan doktor/ pegawai farmasi Diet yang tidak betul untuk nilai semula dos. Gaya hidup Banyakkan mengambil buah-buahan dan sayursayuran berserat tinggi, elakkan minum alkohol Rawatan sembelit 4 BAHAGIAN PERKHIDMATAN FARMASI, KKM  GARIS PANDUAN KAUNSELING METHADONE Kesan sampingan Faktor penyebab Tindakan Gangguan tidur / Berlebih atau kurang dos Ubahsuai dos atau masa pengambilan ubat Insomnia Masa pengambilan dos Buat senaman ringan dan tetapkan waktu Kesan bahan/dadah lain e.g kopi, tidur yang rutin rokok, dadah perangsang seperti Kenalpasti bahan stimulan dan nasihati amphetamine dan pseudoephedrine. pesakit untuk mengelakkannya Masalah gigi Sirap Methadone mengurangkan Tingkatkan penjagaan kesihatan oral pembentukan air liur (masalah (kerap memberus gigi, elakkan mengambil dengan semua opioid) makanan/ minuman bergula, kunyah gula- Penjagaan gigi yang tidak betul gula getah (chewing gum) tanpa gula. Pengurangan libido Dos yang tinggi Bincangkan dengan doktor atau pegawai dan fungsi seks Faktor psikologikal/ masalah farmasi anda untuk tujuan nilai semula peribadi dos. Bincang dengan kaunselor anda. Keletihan. Faktor persekitaran Rehat yang secukupnya. Dos berlebihan Bincang dengan doktor atau pegawai farmasi. Berpeluh berlebihan Dos berlebihan Pakai pakaian yang tidak terlalu tebal. Bincangkan dengan doktor atau pegawai farmasi. Kulit lebam dan gatal Sirap Methadone Beritahu doktor atau pegawai farmasi anda Kadar denyutan Dos berlebihan Segera jumpa doktor jantung menjadi laju atau perlahan Susah bernafas Dos berlebihan Segera jumpa doktor 10.2 Simptom-simptom yang tidak diingini juga boleh berlaku sekiranya dos Sirap Methadone yang diambil adalah terlalu tinggi atau rendah. Oleh itu, doktor anda akan menilai respons anda dengan Sirap Methadone pada selang masa tertentu untuk memastikan dos yang anda ambil adalah betul untuk anda. Ini boleh membantu mengurangkan simptomsimptom yang tidak diingini berlaku. 10.3 Kebanyakan individu yang pernah mengambil heroin akan mengalami kesan sampingan dengan Sirap Methadone yang minimal. BAHAGIAN PERKHIDMATAN FARMASI, KKM 5 GARIS PANDUAN KAUNSELING METHADONE Nota Pegawai Farmasi Sembelit – Kebanyakan pesakit boleh menjadi tolerans terhadap kesan sembelit akibat opioid Gangguan tidur/Insomnia – Kebanyakan pesakit mengalami gangguan tidur/insomnia dengan pengambilan Sirap Methadone. Walau bagaimanapun penggunaan ubat hipnotik adalah tidak digalakkan kerana penggunaaan dadah hipnotik bersama Sirap Methadone boleh menyebabkan sleep apnoea (gangguan pernafasan semasa tidur) Masalah gigi – Semua opioid termasuk Sirap Methadone mengurangkan pengeluaran air liur. Oleh itu, pengambilan opioid secara haram beserta pengambilan pemakanan yang kurang berzat serta penjagaan gigi yang rendah boleh menyebabkan masalah kerosakan gigi. Pengurangan libido dan fungsi seks – Dos yang rendah mungkin boleh membantu mengatasi masalah ini. Walau bagaimanapun, dos yang dipreskrib mestilah diimbangkan dengan risiko pengambilan heroin. Keletihan – Perlu dipastikan terlebih dahulu punca keletihan. Dos Sirap Methadone mungkin perlu dikurangkan jika berkaitan. Berpeluh berlebihan – dos mungkin perlu dikurangkan untuk mengurangkan simptom. I 11. NTERAKSI UBAT 11.1 Jangan mengambil Methadone bersama ubat-ubat berikut sebelum berbincang dengan doktor atau Pegawai Farmasi :- 11.1.1 Alkohol 11.1.2 Ubat – ubat antiepileptik 11.1.3 Cimetidine 11.1.4 Ciprofloxacin 11.1.5 Efavirenz 11.1.6 Fluoxetine 11.1.7 Fluvoxamine 11.1.8 Nicotine 11.1.9 Rifampicin 11.1.10 Tricyclic Antidepressants 11.1.11 Pengasid urin contohnya Vitamin C 11.1.12 Pengalkali urin contohnya sodium bicarbonate 11.1.13 Zidovudine 6 BAHAGIAN PERKHIDMATAN FARMASI, KKM  GARIS PANDUAN KAUNSELING METHADONE 13.2 Antara simptom-simptom pengunduran: 13.2.1 Disforia 13.2.2 Rasa loya dan muntah 13.2.3 Rasa sakit badan (muscle aches)* 13.2.4 Hingus meleleh dan pengeluaran air mata 13.2.5 Pembesaran anak mata (Pupillary dilatation) 13.2.6 Cirit birit 13.2.7 Menguap berlebihan 13.2.8 Demam 13.2.9 Tidak dapat tidur (insomnia)* 14. PENYIMPANAN METHADONE 14.1 Sirap Methadone yang dibawa balik perlu disimpan: 14.1.1 Di tempat selamat (dalam kabinet atau laci yang dikunci) dan jauh daripada kanak-kanak. 14.1.2 Pada suhu bilik (tempat yang kering dan tidak panas) dan tidak di dalam peti sejuk. 14.2 Sekiranya anda terlupa untuk mengambil dos sirap Methadone anda, ambil dos tersebut secepat mungkin sebaik sahaja anda teringat. Sekiranya waktu untuk mengambil dos tersebut telah hampir dengan waktu untuk dos seterusnya, abaikan dos yang tertinggal tersebut dan ambil dos seterusnya seperti biasa. Jangan gandakan dos anda. 15. DOS BAWA BALIK (PENGAMBILAN UBAT DI RUMAH) 15.1 Pengambilan ubat di rumah hanya dibenarkan: 15.1.1 Selepas 6 minggu klien stabil mengikuti program RTG. 15.1.2 Penilaian yang teliti mengenai kestabilan dan tidak disalahguna. 15.2 Kesesuaian penilaian untuk pengambilan ubat di rumah mestilah direkod dengan jelas di dalam nota klinikal termasuk: 15.2.1 Petunjuk Kestabilan pesakit yang terperinci. 15.2.2 Tiada sebarang kontraindikasi terhadap rawatan. 15.2.3 Maklumat penggunaan ubat-ubat psikoaktif yang lain. 15.3 Bagi dos bawa balik : 15.3.1 Dos < 25 mg cairkan hingga 50 ml, 15.3.2 Dos > 25 mg cairkan hingga 100 ml. 15.3.3 Sediakan label yang lengkap dan tampal pada botol yang mengandungi dos bawa balik. BAHAGIAN PERKHIDMATAN FARMASI, KKM 11 RTG METHADONE 6.6.4 Catatan rekod masuk/penerimaan bekalan hendaklah dilakukan dengan menggunakan dakwat merah dan rekod pengeluaran/pembekalan dengan menggunakan dakwat hitam. 6.6.5 Sebarang rekod dengan menggunakan dakwat biru atau hijau adalah tidak digalakkan. 6.6.6 Pembatalan dan pindaan boleh dilakukan dengan catatan sewajarnya. Contoh format rekod sila rujuk BR3 (m/s 16) 7. TANGGUNGJAWAB PEGAWAI FARMASI 7.1 Pendispensan dan pembekalan ubat RTG hendaklah dijalankan oleh Pegawai Farmasi dan tidak boleh diturunkuasa kepada Penolong Pegawai Farmasi atau anggota lain. 7.2 Semua Pegawai Farmasi yang terlibat dalam program ini perlu mendapat pendedahan dan mempunyai pengetahuan yang cukup mengenai penggunaan ubat dalam RTG. 7.3 Pegawai Farmasi dikehendaki menjalankan tugas-tugas berikut:- 7.3.1 Memastikan preskripsi adalah sah dan lengkap. Senarai contoh tandatangan preskriber terkini perlu diperolehi untuk rujukan. 7.3.2 Memastikan ubat yang betul didispens kepada pesakit yang betul dengan merujuk kepada gambar pesakit yang telah disahkan oleh preskriber. 7.3.3 Memeriksa catatan yang dikeluarkan oleh preskriber. 7.3.4 Memastikan dos yang disediakan seperti yang dinyatakan oleh preskriber. 7.3.5 Memastikan dos yang diberi adalah selamat. 7.3.5.1 Jika pesakit terlupa atau tidak mengambil 4 atau lebih dos ubat RTG, tangguhkan rawatan dan rujuk kepada preskriber serta- merta. 7.3.5.2 Menilai pesakit jika berlaku tanda-tanda keracunan atau terlebih dos. 7.3.6 Memastikan tiada penyelewengan berlaku semasa ubat diambil 7.3.6.1 Perhatikan dan pastikan pesakit betul-betul mengambil/menelan ubat tersebut, kemudian galakkan pesakit berbual. 7.3.6.2 Pastikan pesakit tidak membawa bekas sendiri/membawa balik bekas minum. 7.3.7 Memantau pesakit yang tidak hadir untuk meningkatkan kadar pengekalan 7.3.7.1 Selidik sebab-sebab pesakit tidak hadir. 5 BAHAGIAN PERKHIDMATAN FARMASI, KKM  RTG METHADONE 7.3.7.2 Ambil tindakan pencegahan yang sesuai untuk meningkatkan kehadiran pesakit. 7.4 Menggalakkan komunikasi di antara Preskriber dengan Pegawai Farmasi:- 7.4.1 Memastikan preskriber diberitahu mengenai ketidakhadiran pesakit mengambil ubat, tingkah laku dan keadaan pesakit. 7.4.2 Menghubungi preskriber dan mencatitkan segala komunikasi yang berlaku. 7.4.3 Mengambil tindakan yang proaktif dalam berinteraksi dengan preskriber. 7.5 Memastikan maklumat mengenai RTG disampaikan kepada Pegawai Farmasi yang terlibat dalam pendispensan dan rekod-rekod pesakit, rekod administrasi ubat dan segala komunikasi dengan preskriber disimpan dengan baik. Juga pastikan garispanduan RTG adalah terkini sebagai rujukan. 7.6 Memastikan pesakit yang memerlukan maklumat tambahan diberi kaunseling ubat secara berterusan. 7.7 Memastikan peluang anggota mendapat latihan berkaitan RTG. 7.8 Memastikan anggota mendapat kerjasama dan sokongan secukupnya. 7.9 Memastikan stok bekalan antidot Inj. Naloxone sentiasa mencukupi. 8. TANGGUNGJAWAB PRESKRIBER 8.1 Perlu menjalani latihan tertentu dan ‘clinical attachment’ sebelum diberi kuasa mempreskrib ubat RTG. 8.2 Proses penilaian yang berterusan melalui jawatankuasa induk RTG untuk memastikan piawai rawatan dikekalkan. 8.3 Preskriber dikehendaki: 8.3.1 Menerima kuasa untuk mempreskrib dari KKM. 8.3.2 Menilai penggunaan dadah untuk menetapkan kesesuaian rawatan. 8.3.3 Menggunakan preskripsi sirap methadone yang sah. 8.3.4 Menarik balik atau menamatkan program rawatan pesakit apabila perlu. 9. TANGGUNGJAWAB PESAKIT 9.1 Pesakit adalah dikehendaki: 9.1.1 Mematuhi syarat-syarat atau peraturan dalam kontrak program RTG. 9.1.2 Berkelakuan baik terhadap kakitangan yang memberi rawatan dan pesakit lain dengan rasa hormat. 9.1.3 Memberitahu mengenai sebarang pengambilan ubat-ubatan lain semasa RTG. BAHAGIAN PERKHIDMATAN FARMASI, KKM 6