1 CHEM. 250 – Spring, 2015 Exam 1 Key Short Answer and Multiple

TAX INVOICE
Voucher for Nicotine Replacement Therapy
Quit for new life Program
Health worker to complete
Dear Pharmacist,
is receiving support to quit smoking as part of the Quit for new life Program.
Client is pregnant / breastfeeding
Client is in the postnatal period
or
or
LY
Client is a cohabitant who lives with a pregnant / postnatal woman
He/she smokes their first cigarette within
meets the definition of ‘nicotine dependent’.
minutes of waking and smokes ___ cigarettes daily, which
N
I have recommended Nicotine Replacement Therapy (NRT) to assist with client/cohabitant’s quitting.
O
I have discussed NRT options with the client. The client prefers to use _______________________
Please assess and if deemed suitable, provide an appropriate NRT product.
Redeem for:
2 weeks
6 weeks
8 weeks
10 weeks
12 weeks supply
Tel
PL
E
Health worker’s name
4 weeks
Job title _______________________________Local Health District _______________________________
Signature
Date
No
M
Client Record Number or DOB____________________ Previous voucher/s provided? Yes
Pharmacist to complete
SA
Pharmacy name
ABN
EFT Details: BSB
Email
/
Acc No.
Tel
Address
Date of issue of product
/
/
_
Name, dosage and quantity of product supplied
Total Retail Price (including GST) $
Full name of client:
Full name of Pharmacist:
Signature of client:
Signature of Pharmacist:
Give a copy of this form to the client and retain the original for your records
Pharmacist: See overleaf for payment details and notes on NRT
TAX INVOICE
Payment details (for pharmacist)
To enable payment:
Please FAX this form within 5 days to:
Pharmacy Guild of Australia, NSW Branch
Fax: 02 9467 7151
Payment will be made by Electronic Funds Transfer (EFT)
N
Notes on NRT for pregnant and breastfeeding women:
LY
For enquiries about vouchers payments: Please call the Health Services Manager, Pharmacy Guild of
Australia, NSW Branch Ph.9467 7140
For enquires about the Quit for new life program: Please contact the Statewide Coordinator, Rhonda
Matthews on [email protected] or 9391 9951
PL
E
O
The Quit for new life program is a NSW Health initiative supporting pregnant Aboriginal women (and their
families) to quit smoking. Up to 12 weeks free supply of NRT is available to each woman and their
household members (if clinically appropriate).
NRT is recommended for nicotine dependent pregnant and breastfeeding women where the likelihood and
benefit of quitting outweighs the potential harm of NRT and continued smoking.
Intermittent NRT is preferred as it more closely mimics nicotine levels from smoking. However, where
intermittent NRT is not tolerated, patches may be used (as per Therapeutic Guidelines: Psychotropic drug
use in pregnancy: non-prescribed psychoactive drugs). Pregnant women need to be made aware of the
need to remove patches at night to provide an 8 hour break.
Up to 12 weeks supply in total can be redeemed at the one time using one voucher.
The lowest cost product should be supplied.
Guidance on NRT dosages for pregnant women:
Dosage
M
NRT
Self titrate dose according to withdrawal
symptoms
When used as a single therapy: 8-12 gum/day
One gum should be chewed slowly until the taste becomes
strong (1 minute). Then stop and rest the soft gum against
cheek. When taste fades chew a few more times until taste
gets stronger. Use 20 to 30 minutes per gum, then discard.
Pregnant women will usually require 4mg gum
No eating or drinking while gum is in mouth.
Self titrate dose according to withdrawal
symptoms. When used as single therapy: 9-15
lozenges/day
One lozenge placed in the mouth, periodically moved from
one side of the mouth to the other until dissolved (20-30
minutes). The lozenge should not be chewed or swallowed
whole.
No eating or drinking while lozenge is in mouth.
SA
Gum
Lozenges
Pregnant women will usually require 4mg
lozenge
Inhalator
Patch
Directions for use
Self titrate dose according to withdrawal
symptoms.
When used as single therapy: 6-12
cartridges/day
Insert cartridge, close device to puncture. Inhale air through
device. Nicotine is absorbed through oral mucosa.
10 or more cigarettes/day, more than 45kgs: one
21mg/24hr or 25mg/16hr patch daily
Do not use on adhesive-sensitive skin. Place on clean, nonhairy site anywhere on non-fatty parts of the body. A new
patch should be placed on a different site each day to help
prevent a skin reaction.
If body weight is less than 45kgs: offer inhaler,
lozenge or microtab. Medical Officers (MO) may
prescribe 14mg patches to women less than
45kgs.
Pregnant women should remove the patch before sleeping
and apply a new patch in the morning.
Note: Quit for new life clients are only eligible for one form of free NRT at a time through Quit for new life.
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