Background
Patient information
Chief Complaint: 16-year-old African-American female patient admitted for substance use, cannabis and tobacco co-use
HPI:
- Patient states that their cravings for cannabis are still strong, and “about 6 times a day” they would like to leave SUD treatment center and going to meet friends to smoke marijuana.
- Patient self-reportedmild depression; reports previous history of suicidal ideation.
Family History: history of anxiety, and drug use in family, otherwise unremarkable
Allergies: NKDA
Social Hx: Gender Identity: non-binary; Pronouns: they/them; reports history of drug/alcohol/tobacco use as coping mechanisms for anxiety. Lives with parents.
Ask
Screen for Tobacco Use With Every Youth Age 11+ at Every Clinical Encounter
* Products used may vary between communities. Visit the Considerations for Clinicians page to view illustrations of common products.
Create a Space for Confidentiality & Trust
Case Study Sample Dialogue: Part 1 of 5
Clinician: Have you ever tried tobacco or vaping products, like cigarettes, e-cigarettes, pods, vapes or dip?
Patient: By itself? No. I smoke spliffs* with my sister and friends.
Clinician: How often do you smoke spliffs?
Patient: Everyday.
Clinician: I appreciate you being honest and sharing that with me.
*Spliff is rolled cannabis cigarette.
Counsel
Counsel All Patients Who Use Tobacco About Quitting, Regardless of Amount or Frequency of Use
Clinician: Can you tell me why you smoke?
Patient: It started as a way to help me deal with my stress from school but now I feel like I’m doing it just because.
Clinician: It sounds like you started smoking because of stress and maybe now you kind of do it as a habit. Does that sound right?
Patient: I think so
Clinician: As your doctor, I care about you and your health. Spliffs contain nicotine, is it OK we talk about that for a bit?
Patient: Ok
Clinician: Your brain continues to grow until your early 20s. Nicotine and tobacco can harm your brain as it is developing.
Patient: Oh wow-I didn’t know that.
Clinician: Have you ever tried quitting before?
Patient: Not really.
Clinician: What are your thoughts about quitting?
Patient: I guess I don’t have a choice, I’m here.
Treat
Link Youth to Appropriate Behavioral Supports
Behavioral Support & Additional Follow Up
Clinician: It sounds like you are thinking you can’t smoke while you are in treatment. One way to look at it is that it’s an opportunity to see how you feel while not using tobacco. There are several things we can do to help with quitting. First. Can you complete this quick form to help me understand how dependent your body is on nicotine.
Patient: Sure.
*Patient is determined to be severely dependent*
Clinician: Based on your assessment, you are showing symptoms of a severe tobacco use disorder. For this, we should considera combination of both medication and behavioral support to help you quit successfully. Is that something you’re interested in?
Patient: Sure.
Clinician: Let’s set a quit date in the next 2 weeks. What day would you like to start?
Patient: Today is fine.
Clinician: Amazing, I’m very proud of you. During our sessions we will continue to talk about your feeling and any support you need. Once you leave we’ll discuss additional support options through text, call or web-programs.
Patient: Okay-thank you.
Additional behavioral supports can be found at www.aap.org/help2quit
Nicotine Replacement Therapy (NRT) and Adolescent Patients
* A full fact sheet for NRT and Adolescent Patients can be found at www.aap.org/NRT
Nicotine Replacement Therapy (NRT) and Adolescent Patients
* Dosing guideline can be found in NRT and Adolescent Patients at www.aap.org/NRT
Clinician: I’m also going to prescribe nicotine gum as well as nicotine patch to help you reduce the urge to smoke.
Patient: How are they going to help me if they both have nicotine in it?
Clinician: They both will give you a controlled amount of nicotine to stop the cravings but won’t give you the rush you get from the vape pen. The patch provides a steady level of nicotine to the body to help lessen withdrawal. The gum can be used to relieve cravings as they happen.
Patient: How do I use them both?
Clinician: Let’s talk about the gum first. The proper way to use this gum is called the “chew and park” method. Place a piece of gum in your mouth and bite slowly until you taste a strong peppery taste or feel a tingling sensation. This means the nicotine is being released. Then, stop chewing and “park” the gum between your cheek and gums. When you don’t feel the sensation anymore, begin to chew until you notice the peppery taste, and then park again. You will repeat this for about 30 minutes, or until the peppery taste and tingling sensation are gone.
Patient: Okay, that makes sense.
Clinician: Its important you don’t forget to park the gum. If you continuously chew without parking, you may feel a stomachache, hiccups, or heartburn.
Patient: Okay thank you.
Clinician: Okay let's talk about the patch. Remember the purpose of the patch is to keep a steady amount of nicotine in your body to help avoid withdrawal. You’ll apply a patch to clean skin and then change your patch every 24 hours. In 6 weeks, we’ll lower the dose in the patch. You’ll wear that patch for 2 weeks, changing every 24 hours.
Patient: Okay, that makes sense.
Clinician: Its important you change your patch every 24 hours. Your skin may feel a little irritated and your might experience changes to your sleep. If any of those side effects start to become a problem, give me a call and we’ll figure out another solution.
Patient: Okay, thank you
Clinician: I’m proud of you for making the decision to quit. Quitting can be difficult, but I know you can do it. Let’s continue to talk about how you feel at your next appointment
Patient: I would like that. Thanks
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Additional case studies were developed to show the variations in clinical settings, common products, screening techniques, motivational interviewing, patient response, and clinician considerations. Please return to the home page to see additional case studies.
Last Updated
05/07/2024
Source
American Academy of Pediatrics