Varenicline for Nicotine Dependence

What are the 3 FDA approved medications for treating nicotine dependence (as of May 2022)? 
-Nicotine patches 
-Bupopripion (Wellbutrin) 
-Varenicline (Chantix) 

Which is the most effective treatment option for nicotine dependence? 
Varenicline (Chantix) is about 2x as effective as the other options. Combing it with nicotine patches or gum raises its effectiveness further. ‍

What is the mechanism of varenicline? 
It is a “partial agonist” at nicotine receptors. This means it can block nicotine from cigarettes from activating the receptors but it also activates the receptors itself. 
The nicotine receptors most important in addiction are the ones that interact with the structure of the brain called the nucleus accumbens via the mesolimbic dopamine tracks. 

Do I have to quite using nicotine before starting varenicline? 
No, varenicline should be started 7 days prior to the quit date so aim for a quit date of day 8. Some quit as late as 5 weeks or even taper down use over 3 months. Even without a quit date set there’s evidence this can be helpful b/c it decreases craving. 

How is varenicline dosed? 
Vareniclinet should be given at 0.5mg daily in the morning for 3 days and then increased to 2x per day for 4 days, then increased to 1mg 2x per day there on. 
It should be started 7 days prior to the quit date so aim for a quit date of day 8. Some quit as late as 5 weeks or even taper down use over 3 months. Even without a quit date set there’s evidence this can be helpful b/c it decreases craving. 

How long should varenicline be continued for? 
For 11 weeks or more (until not craving), then stop without tapering. Some patients continue for as long as 1 year. 

Is it safe to use varenicline along with nicotine patches? 
Yes it is. If someone is having trouble quitting with just varenicline it’s ok to add nicotine patches. 

What are the main side effects to varenicline? 
-Nausea: 15% of patients; tends to lessen over time
-Insomnia: 33% of patients; tends to lessen over time
-Nightmares: rare, but can be helped by clonidine if they do occur.
-Headaches & dizziness are also rare side effects.

What about the initial black box warning that it can lead to worsening depression or suicidal thinking? 
That was later proven to be false— a large meta-analysis found no association with varenicline and depression or suicidality.

What are some other helpful ideas to help quit using nicotine? 
-Get cigarettes (or vapes, chewing tobacco, cigars, etc.) out of the house
-Change the normal smoking areas around— if you have a favorite area on the porch or favorite smoking chair, move that to another location 
-Clean your ashtray right after smoking
-Contact 1800-QUIT-NOW which is a nationwide free resource to help quit using nicotine