PHARMACOTHERAPY FOR TOBACCO DEPENDENCE
The updated PHS guideline discusses numerous medications for treating tobacco dependence. Clinicians should encourage patients to consider using medication when attempting to quit, except when the use of these drugs is medically contraindicated or there is insufficient evidence of their effectiveness (for example, patients who are pregnant, smokeless tobacco users, light smokers, or adolescent). Tobacco-dependence medications have been shown to significantly improve abstinence rates. Choice of specific pharmacotherapy should be guided by factors such as clinician familiarity with the drug, contraindications, patient preference, the patient's previous experience with pharmacotherapy, and the patient's characteristics (eg, history of depression or concerns about weight gain). Table: First-line pharmacotherapy for smoking cessation (in the online version of this article) lists the therapies that are FDA-approved for treating tobacco dependence.
Combination medications The updated guideline also identifies which first-line therapies are effective as combination therapy. Combination therapies are especially helpful for highly dependent smokers and patients who have a history of experiencing severe withdrawal symptoms. Effective nicotine replacement therapy combinations include the patch (for more than 14 weeks) plus gum or spray; the patch plus an inhaler; and the patch plus bupropion, sustained release (Zyban, generics), which is the only combination therapy that has received FDA approval for smoking cessation.
LIFE-LONG ADDICTION
Clinicians should remain aware that relapses are common and expected because of the chronic nature of this addiction. For this reason, repetitive brief counseling is so important. Relapses can occur early in the cessation process or years later. Most smokers who ultimately quit have experienced relapses along the way. It is imperative for clinicians to explain to the patient that multiple quit attempts may be necessary before permanent success is achieved, and patients should be encouraged to use a lapse as a learning experience. Minimal relapse prevention consists of congratulating success, encouraging continued abstinence, and discussing the benefits of quitting as well as the challenges of achieving success.
REIMBURSEMENT CODES
The ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnostic billing code for treatment of tobacco dependence is 305.1 (tobacco use disorder [tobacco dependence]). The CPT (current procedural terminology) codes are 99406 (smoking cessation counseling for 3-10 minutes) and 99407 (smoking cessation counseling for more than 30 minutes). Clinicians should note that reimbursement for smoking cessation therapy varies by payor and/or benefits package. In the interest of time, these diagnostic codes can be preprinted on the billing and diagnostic coding sheets and checked off as appropriate. Counseling by itself is a reimbursable activity and can be billed based on the number of minutes of counseling. A complete list of counseling codes can be found in the ICD-9-CM manual in the sections that correspond with the patient's diagnosis. Health care providers should be familiar with the codes that are not included with a related condition.
CONCLUSION
Whether to use the 5As model or the brief clinical intervention strategy is the clinician's choice. A more important note is to remember that one of the PAs' most important duties involves counseling patients. This role becomes even more vital when treating patients with chronic diseases. As clinicians, we should never underestimate the power of our words. Now that tobacco dependence is accurately defined as a chronic disease, it is imperative that we, as clinicians, become familiar with and accurately apply evidence-based treatment guidelines for treating our patients who are tobacco users. Being vigilant about identifying tobacco users is a necessary first step. A brief 3-minute clinical intervention session, including ask, assist, and refer those patients who use tobacco, in conjunction with evidence-based pharmacotherapy should be part of every clinician's armamentarium. JAAPA
Jean Covino is Associate Clinical Professor of PA studies and Coordinator of PA graduate education at PACE University-Lenox Hill Hospital, New York, New York. The author has indicated no relationships to disclose relating to the content of this article.
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