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SUD Learning Community Journal Club
Greetings Colleagues,
What do you do when your patient who wants to quit nicotine accepts a prescription for NRT or varenicline and comes back in 6 weeks still smoking? Do you keep them on the same medication with a few behavioral tweaks? Do you add medication? Or something else? This study –punchline approaching --suggests you switch them to varenicline if they are using NRT or increase the current therapy dose (if it is NRT or varenicline). Hallelujah – it is wonderful to have a novel approach, as well as evidence that is beyond that first step of treatment. The concept of dosing to effect is consistent with lessons learned over the years of treating OUD -and from that, we know that the dose of the blockade/replacement can make all the difference.
Here are the caveats. First, there was a loss to follow which probably doesn’t but could lead to an overestimation of effect. Second, you’ll note that this study excluded patients with substance use disorders (other than nicotine use do), so in addition to these higher doses being off-label, we cannot easily weigh the risks and benefits in our patients with SUD. In those with OUD, quit rates are so low that there is no evidence that medication helps at all 1, making extrapolation to that group even less clear. Third, the benefits of a quit by twelve weeks were mostly gone by 6months. However, we know that it takes many quits for a sustained one, and all quits and returns to use are learning experiences that can set the stage for long-term improvement. So, despite the limitations, I think this data puts a new card up our sleeves for a difficult-to-treat use disorder.
Thank you for reading, details ahead…
Andrea
Andrea Truncali, MD, MPH
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