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The Use of No20s™
In the Treatment of Nicotine Dependence
This one day module is aimed at staff who will provide No20s™
as part of a stop smoking programme, and includes training in
NeuroElectric Therapy™ (NET™), the use of the NET Model 902™
device and the NET Vue™ client management system.
This manual is based upon previously published as well as
current materials, including the No20s Treatment Manual and
the NET Model 902 Operation Manual. These materials may
be downloaded at www.No20s.com
TRAINING MANUAL
All rights reserved. No part of this
publication may be reproduced, stored
in a retrieval system, or transmitted,
in any form or by any means, electronic,
mechanical, photocopying, recording,
or otherwise, without the prior written
permission of NET Device Corp.
Copyright © 2010 by NET Device Corp
100 Technology Way
Mt. Laurel, NJ 08054 USA
www.No20s.com
EN.05.23.04 Release 002, Feb-17-2010
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Table of Contents
Learning Objectives .............................................................................................................................3
Using the Training Module ......................................................................................................4
No20sPractitionerCertication ..............................................................................................4
Session 1: Introductions and NET Overview .....................................................................................5
What are No20s and NeuroElectric Therapy (NET)? .............................................................6
What No20s is NOT ...............................................................................................................7
Detoxication ..........................................................................................................................8
Exercise One ..........................................................................................................................9
Session 2: The NeuroElectric Therapy Process ..............................................................................10
Inclusion/Exclusion Criteria .................................................................................................. 11
Safety ...................................................................................................................................12
Exercise Two ........................................................................................................................13
NET and Motivation ..............................................................................................................14
Client Preparation .................................................................................................................14
PreparingforNo20sdetoxication .......................................................................................15
Core Elements of a Behavioural Programme .......................................................................17
Change in Diet ......................................................................................................................18
Physical Activity ....................................................................................................................19
Session 3: Applying the No20s Stimulator ......................................................................................20
Client Preparation .................................................................................................................21
No20s Device Preparation ...................................................................................................23
Client Instructions .................................................................................................................24
Electrode Care .....................................................................................................................26
Session 4: Clinical Impact .................................................................................................................27
Nicotine and Withdrawal .......................................................................................................28
Observing, Communicating & Monitoring .............................................................................30
Withdrawal Severity Scale (WSS™) ....................................................................................31
Exercise Three .....................................................................................................................33
Completing No20s ................................................................................................................34
Client Worksheet ..................................................................................................................36
Relapse Prevention ..............................................................................................................37
Session 5: The Role of the No20s Practitioner ................................................................................39
RolePriortoNo20sDetoxication .......................................................................................40
RoleDuringDetoxication ....................................................................................................41
NET Treatment Process (Flow Chart) ...............................................................................................42
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Learning Objectives
No20s and NeuroElectric Therapy (NET)
4 To understand the nature, purpose and use of the NET intervention as a
non-pharmacologicaldetoxicationtool
4 To understand the process of NET and its application to nicotine cessation (No20s)
4 To understand the role of the No20s practitioner with this intervention
4 To understand the contraindications and safety issues associated with No20s
4 To be aware of the assessment, monitoring & recording responsibilities associated
with being a No20s practitioner
4 To be aware of how to approach No20s drop-out and relapse
No20s Stimulator Device (NET Model 902)
4 To gain a working knowledge of the use of No20s equipment
4 To be able to apply the No20s equipment to a client, supervise its use,
and ensure its proper working order
NET Vue
4 To gain a working knowledge of the use of the NET Vue client management software
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www.no20s.com
Learning Objectives
Using the Training Module
ThisTrainingModuleissetoutsothateachsectionrelatestoabriengsession.
The exercises should be completed in the order in which they are set out. All worksheets
and handouts are included in this Module; the trainer will distribute any other required materials
at the appropriate time during the session. There is also space in this portfolio for you to make
your own notes, if you should so wish.
To assist participants to increase their knowledge in this subject area it is highly recommended
that further reading be supported by use of the references/resources throughout this document,
and from the No20s web-site; www.no20s.com.
No20s Practitioner Certication
TobecomeacertiedNo20spractitioner,itisnecessarytopassamultiple-choicetest
following completion of this course. The test is based upon key information and guidelines
highlighted throughout this document.
InstructionsfortakingtheNo20scerticationtestwillbegivenattheendofthiscourse.
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Session 1: Introductions and NET Overview
The aim of this exercise is to introduce the participant group to each other
and to explore expectations of the training.
The trainer will ask each participant to introduce themselves to the group, explain why
they have come along to the training, and describe what they hope to gain from the course.
ThetrainerwillthenshowavideoofanNETdetoxicationandgiveanoverviewofNo20s.
Learning Objectives To introduce the participants
To understand use of the Training Portfolio
To understand the basic concepts of NET
To understand the use of this modality to-date in
thedetoxicationprocess
To understand what NET is not
Topics Covered Introductions and Welcome,
NeuroElectric Therapy (NET™) and No20s™
Learning Methods Individual work
Group discussion
Materials Required Training Portfolio
Introductory video
Timing 45 minutes
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www.no20s.com
Session 1: Introductions and NET Overview
What are No20s and NeuroElectric Therapy (NET)?
F NeuroElectric Therapy (NET) is a form of neuromodulation. Like Cranial Electrotherapy
Stimulation (CES), controlled waveforms and low levels of electrostimulation are used
across the head to stimulate a therapeutic response. Another form of neuromodulation,
Deep Brain Stimulation (DBS), uses electrodes implanted within the head to modulate
neurotransmitters. Both CES and DBS are approved for use in the EU and USA.
F NET is used to rapidly detoxify individuals from addictive substances and to reduce or
remove their acute and chronic withdrawal symptoms (including cravings). NET is used
by individuals addicted to heroin, cocaine, methadone, benzodiazepines, and many other
illegal and prescribed drugs.
F No20s uses NET to accelerate the normally slow withdrawal process from nicotine
into 3-5 days.
F By the end of No20s stimulation, the client will feel physically well, emotionally stable,
and mentally clear. No20s offers a particularly potent window of opportunity in which to
address the issues underlying and reinforcing the smoking behaviour.
F The No20s device being demonstrated in this training session is CE approved.
Its safety, performance and quality processes have been approved for use within
the EU and European Free Trade Area. NET is also being evaluated in randomized
clinical trials in the UK.
F No20s is a drug-free process. No replacement or ‘cushioning’ psychoactive medications
are used with this intervention. Since NET and psychoactive medications act to counter
theperformanceofoneanother,thechoiceofdetoxicationmethodisan‘either-orchoice.
F ThetheoreticalbasisforNETindrugdetoxicationisthatthespecic
waveforms used in this intervention re-establish or stabilise the natural levels
of neurotransmission by chemical messengers intractably disrupted by chronic
substance use. In particular, the endorphins (physical and emotional pain
neurotransmitter), dopamine (‘reward’ neurotransmitter) and serotonin
(mood, behaviour and sleep neurotransmitter) are modulated by NET.
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Session 1: Introductions and NET Overview
What No20s is NOT
F No20s is not a panacea or ‘miracle cure’. Rapidly feeling well is not a replacement
for making health and behavioural changes.
F No20sisnotastand-alonetreatment.Itisadetoxicationtooltobeusedaspart
of an integrated treatment programme.
F No20s is not a discomfort-free process. However, the reported low drop-out rate
suggests that most clients have found withdrawals under this modality to be tolerable
and of short duration.
F No20s is not ‘shock therapy’. The stimulator is powered by a 9 volt battery, and the
level of sensation is maintained at a level of comfort and controlled by the client.
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Session 1: Introductions and NET Overview
Detoxication
What constitutes effective detoxication?
Detoxicationisanaturalfunctionofthebody,primarilyinvolvingtheliver,kidneys,bowels,
and sweat glands. In drug treatments, this process can be enhanced through improved diet
and hydration, increased sweating through daily exercise and use of saunas, and light and
deep-tissue massage to release drugs and other toxins stored in the body.
The wider objectives of the NET approach are to:
F Signicantlywidenthecapacityofsmokingcessationtreatmentservices
F Signicantlywidenaccesstosmokingcessationtreatment
F Deliver quality care, safely
F Improve long-term nicotine-free outcomes
“De-toxication” denition:
The process by which the qualities of a poison or toxin are reduced or removed.
The detoxication objectives of NET are:
First: To provide sufcient withdrawal relief to retain the client in treatment
Second: By the end of NET treatment, to leave the individual feeling physically well,
mentally clear, and emotionally stable, and hence be as prepared as possible
to derive benet from follow-on health and behavoiur-change activities
My vision is that NeuroElectric Therapy
be available to all who wish to avail of it,
regardless of ability to pay: to see NET
used and used well.
Dr Meg Patterson (1922-2002) , www.drmeg.net
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Session 1: Introductions and NET Overview
Exercise One
Small Group Exercise:
List the main reasons you see for relapse in someone who has previously undergone nicotine with-
drawal.
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Session 2: The NeuroElectric Therapy Process
The aim of this exercise is to examine in-depth the process for use of this modality,
inordertobecomecondentinmakingclinicaldecisionsrequiredinitsnon-useaswellasuse.
The trainer will make a presentation based upon the step-by-step process in using this modality.
Witheachstepkeydecisionswillbeidentied,andtheguidingprinciplesforthedecision-making
process explained and discussed.
Learning Objectives
To understand the process and guidelines for
the use and non-use of NeuroElectric Therapy
To understand the key decisions that need to be
made within this process
To become familiar with the role of a No20s
practitioner
Topics Covered
Guidelines for using and not using NeuroElectric
Therapy in smoking cessation treatment
Safety issues
Wider health issues
Learning Methods
Presentation
Group discussion
Materials Required
Flipchart
Timing 60 minutes
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Session 2: The NeuroElectric Therapy Process
Inclusion/Exclusion Criteria
Is it safe to detox this individual from nicotine using NET?
Information required:
F Drug-using history, especially for prescribed medications and caffeine
F Health history, including psychiatric record if any
Conditions not to be treated with NET
(ie conditions where there may potentially be a safety risk with NET):
F Pregnancy (and breast-feeding mothers)
F Diagnosed epilepsy
F Diagnosed psychotic conditions
F History of brain injury / major brain illness (eg, stroke, meningitis)
F Serious heart disease
F Under 18 years of age
Temporary exclusion from NET detoxication:
F Healthissuesrequiringsignicanttreatmentbeforedetoxication,egdentalsurgery
Possible exclusion:
F Is the client on prescribed psychoactive medication (‘dual diagnosis’):
‘what?’, ‘why?’, and do they have their primary physician’s agreement to
come off this medication while they under-go NET?
F Other health issues of serious concern (eg cancer, lung diseases,
hypertension or other conditions that may require in-patient medical supervision)
Collect key information, and make a decision on NET exclusion / inclusion:
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Session 2: The NeuroElectric Therapy Process
Safety
Client safety is paramount. The parameters of safety when considering implementation of
NETtreatmentcanbedenedas:
F A decision not to treat a chemical dependent wishing or willing to enter into NET
treatmenthassignicanthealthimplications.Thevalueofevenpartialimprovement
in health and partial reduction in nicotine consumption associated health risk is
considered to be a valid treatment objective
F NET has been shown to be a safe treatment for chemical dependents, both in
the short-term and long-term
1
, and has been acknowledged to be a treatment
of‘non-signicantrisk’bytheUnitedStatesFoodandDrugAdministration
(IDENumber:G960240/S2)andthroughtheEuropeanCEcerticationprocess
F NEThasclearlydenedareasofpotentialriskwheretreatmentis
contra-indicated until further research has been conducted
(theseareasarespeciedabove)
1
Patterson MA, Firth J, Gardiner R. Treatment of drug, alcohol and nicotine addiction by
NeuroElectric Therapy: analysis of results over 7 years. J Bioelectricity 1984: 3:193-221
NET must be delivered in a manner that
is safe, professional and in a context of
best-meeting the needs of the Client.
Dr Meg Patterson (1922-2002) , www.drmeg.net
F Drug-using History:
Including caffeine and medications, dosages, routes of administration,
length of time taken, and treatment history
F Medical History:
Pregnancy test
Current illnesses / treatments
F Psychiatric History:
Any diagnosed psychotic history?
Current illnesses & treatment
Checklist 1:
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Session 2: The NeuroElectric Therapy Process
Exercise Two
Small Group Exercise:
Identify your client population. How would the safety criteria listed above affect your decision to
use or not use NET with your clients?
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Session 2: The NeuroElectric Therapy Process
NET and Motivation
Men and women become motivated enough to enter into treatment for a variety of reasons,
including external pressure, desire to avoid or reduce consequences of smoking, desire to
make improvements to their life, desire to ‘be there’ for family /partner, and desire to reclaim
a non-smoking life.
Motivation is frequently a complex mixture of motivations and circumstances, and may
not even be well understood or considered by the client.
Client Preparation
International evidence reviews consistently agree that nicotine dependence is most
effectively treated with a combination of supports. The role of the physician and health
centresareagreedtobecrucial.Aphysician’sadvicetoquitsignicantlyincreasesthe
likelihood of quitting and maintaining abstinence. ‘Moreover, person-to-person treatment
delivered for four or more sessions appears especially effective in increasing abstinence
rates… and therefore, if feasible, clinicians should strive to meet four or more times
with individuals quitting tobacco use’.
2
Inrecognitionoftheeffectivenessofthisclinicalapproach,NETdetoxicationisalso
centered within this model. Please note that nicotine replacement therapies cannot be
used along with NET.
What are the issues in relation to NET and Motivation?
F IfsomeonedesiresoriswillingtoacceptdetoxicationbyNET,theyhave
to be motivated enough to participate in a non-pharmacological process.
This is the fundamental level of motivation required for NET. NET is a
voluntary process, and can be discontinued at any point by the Client
simply by turning off the current.
F As long as the Client complies with the NET process, there will
be positive outcomes starting 15 to 20 minutes after stimulation
has commenced. However, during the days of NET, support and
encouragement is often required.
F As NET progresses, the capability to make decisions and take
responsibilityforlifedecisionssignicantlyincreasesencouragement
is often required.
2
Treating Tobacco Use and Dependence: 2008 Update.
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Session 2: The NeuroElectric Therapy Process
Preparing for No20s detoxication
It is important that the prospective client is given accurate information regarding
No20s prior to acceptance so that;
F The client is fully informed regarding No20s treatment and its processes
F The client has clear expectations regarding the treatment process
F The client understands the importance of making lifestyle and behavioral
changes before and after No20s treatment
All NET treatments (including No20s) require the immediate cessation of all psychoactive
pharmacologypriortodetoxication.Withsmokers,theseotherdrugstypicallyinvolvecaffeine
(coffee), alcohol, and prescribed psychoactive medications, especially anti-anxiety, anti-depressant and
sleeping pharmacologies. Health medications such as ventolin or antibiotics do NOT interfere
with NET.
Nicotine replacement therapies (NRT) cannot be used along with NET;
neither the NRT nor NET will function properly.
Apre-detoxicationprogrammeofbehaviourmodicationhasbeenincludedasan
integral aspect of overall NET nicotine treatment. The programme is based on the principle
of primary health care, and includes basic dietary and exercise health guidelines, as well as
behavioural changes to established smoking routines. This preliminary treatment should
commencepriortoNETdetoxication.
As standard procedure, stimulation is only commenced when the client presents in
acute withdrawal. With nicotine, this time-frame will vary from individual to individual.
While a general guideline of 4-6 hours is recommended, that decision is often taken
during the admission process and on a case-by-case basis.
AlthoughNETnicotinedetoxicationoccurswithina3-5dayperiodoftime,thereare
no easy solutions to addiction, whether chemical or behavioural. NET is a clinical tool
that quickly liberates the body from the physical symptoms of withdrawal, and consequently
allows the underlying issues involved in smoking and smoking behaviour be rapidly addressed.
The physical withdrawal from nicotine plays only a part in the overall withdrawal distress
experienced by a smoker trying to give up cigarettes, including dealing with stress, breaking the
powerful behavioural habits associated with smoking, dealing with weight gain, and coping with
health problems. In order to combat these other issues, a No20s treatment programme begins
priortoactualdetoxication.
By starting to the treatment programme prior to receiving No20s, the client starts dealing with
the underlying issues of their nicotine dependency without having to simultaneously undergo
thestressofphysiologicalwithdrawal.Bythetimedetoxicationcommences,theywillhave
learnednew,constructivehabitsthatwillnotonlyeasedetoxication,butalsobeinplace
tofunctionasrelapsepreventiontechniquespost-detoxication.
Session 2: The NeuroElectric Therapy Process
Preparing for No20s detoxication… (continued)
While general principles of a pre-treatment programme are given, each client’s
individualneedsandcircumstancesshoulddictatethespecicrequirementsof
their own individual programme.
Timeframe for No20s preparation
1. Assessment by the client’s own physician
F Base-line pulse, blood pressure, lung capacity, weight, any other clinical tests
to be carried out
F Start of health and good-nutrition programmes as recommended by physician
F Identicationofadditionalsupports:StopSmokingProgrammes
(these may be offered in the health centre itself), group (peer)
support such as Nicotine
2. 2-weeks prior to No20s
F Start behavioural programme – see guidelines below
3. 1-week prior to No20s
F Switch from coffee to de-caffeinated coffee (if appropriate)
4. Day of No20s start
F Last nicotine at least 4-6 hours before commencement of No20s
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Session 2: The NeuroElectric Therapy Process
Core Elements of a Behavioural Programme
A smoker will often light up in connection with a range of routine daily activities. Even after a
smoker has stopped smoking, the mere carrying out of these activities often triggers powerful
cravings. This is the smoking ‘habit` - learned behaviour that results in psychological and
sometimes physiological distress for the individual.
By changing the pattern of these routine activities, even on a temporary basis, the potency
of these ‘triggers` can be diminished or removed until the activity is no longer psychologically
associated with smoking. Put very simply, the client is replacing old habits with new ones.
The client should conduct a self-assessment to identify when, where, and under what
circumstances smoking regularly occurs.
Withcoffeerstthinginthemorning Drinktea,hotchocolate,orangejuiceinstead
While driving Change the type of music that plays while you drive.
Clean the car of cigarette ends and ash
While on the telephone Place doodle pad and pens by the phone t
o
occupy your hands
Waiting Have a book or other occupation available
At work – nervous tension Find alternate ways of keeping your hands busy.
Try a grip exercise ball or putty, use worry beads
Withtherstdrinkoftheevening Changethetypeofdrink(e.g.beertowine)
Routine activity associated with smoking Example of altered activity
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Session 2: The NeuroElectric Therapy Process
Change in Diet
When giving up nicotine, the client will experience metabolic changes as well as changes
ineatinghabits,withconsequentweightuctuation.No20swillassistthebodyindetoxifying
itself of nicotine and rapidly restore psychological and physiological stability. It will not, however,
replace nicotine as an appetite suppressant. A disciplined, eating and drinking lifestyle is
ultimately the only healthy way to control weight.
Nicotine is an appetite suppressant that increases metabolic activity. Research has found that
smokers weigh approximately 6-7 pounds less than non-smokers, and that weight-gain a recurrent
feature in relapse amongst women smokers (Kelesges et al., 1989). Nicotine withdrawal has also
beennotedtoproducesymptomsstrikinglysimilartohypoglycaemia,symptomatologyreected
in the ‘sweet-tooth’ eating habits of those trying to quit.
Itisstronglyrecommendedthatbasicchangesindietbeinstigatedpriortodetoxication,
inordertopreparethebodyforthetemporary‘rebound’uctuationsthatoccur.Theinclusion
ofVitaminC,whichassistsdetoxication,shouldbeconsideredinadietaryprogramme.
Morebre,lesscarbohydrates,starch,andfats
F Morebre,lesscarbohydrates,starch,andfats
F Have salads, or have fruit as desert
F Choose oral substitutes that are non-fattening
Note: Changes in taste occur rapidly and feature strongly in NET nicotine
detoxication. This has been found to be an important aspect in appreciating
food again as a non-smoker.
Session 2: The NeuroElectric Therapy Process
Physical Activity
Nicotine has a well-known detrimental effect on the cardiovascular and respiratory
systems. To help counteract these adverse effects, patients should be encouraged to
develop a more healthy lifestyle. Breathing exercises (high blood carbon monoxide
levels are a feature of smoking) and relaxation exercises are recommended.
Any new regimen undertaken by the client should meet the individual’s needs and
circumstances. Regular exercise is important. Brisk walks of a minimum of twenty
minutes, calisthenics, swimming, and cycling can all be integrated into an
everyday lifestyle without over-stressing the body.
19
When should we start No20s with this client?
F Has the client prepared their mind and body for change by starting a health
and behavioural programme, as directed by the client’s own physician?
F No concurrent psychoactive pharmacology can be utlised along with NET:
Has the client discontinued all psychoactive pharmacologies, and reduced
or regulated caffeine intake?
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www.no20s.com
Session 3: Applying the No20s Stimulator
The purpose of this exercise is to provide a practical demonstration of the use of the
No20s equipment, and to become aware of the expected clinical outcomes from appropriate
application of using this treatment.
The participants will be informed how to prepare a client for No20s treatment with a practical
demonstration of how to use the equipment. Each participant will also be given a copy of the
Device Operation Manual and Treatment Manual for the purposes of this exercise.
Learning Objectives To be able to correctly apply the NET equipment
To understand the operation of the NET equipment
Topics Covered Operation of equipment
Application processes and checks
Clinical considerations, including further safety
considerations
Electrode management
Learning Methods Demonstration
Presentation
Group discussion
Materials Required Flipchart
NET Device Operation Manual
No20s Treatment Manual
Timing 60 minutes
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Session 3: Applying the No20s Stimulator
Client Preparation
Shave the Ear-Rim
If necessary, shave a small, half-inch rim of hair behind each ear. If the site is not
restrictedbythehair-line,thiswillnotberequired.Itisimportanttoclearsufcient
margin for both the electrode and the surrounding micropore tape. Loose hair under
the tape will almost always cause the electrodes to become loose during treatment.
Prepare the Skin
Clean the skin thoroughly with NuPrep EEG gel. If NuPrep gel is not available,
acetone or an alcohol solution (e.g. Sterets wipe) can be used. Please note that the
purpose of the gel is to clean the site, not to improve contact or conduction with its
continued presence. The recommended gel is very effective at removing oils and dead
skinfromthesite.Thiswillbothincreasethelengthoftimethatelectrodesremainrmly
attached, and improve skin conduction. Use water and a paper towel to clean the
site and remove the gel after application.
F Correct Equipment:
NET Model 902 device, 9V ‘square’ battery, leads, electrodes, micropore
paper tape, razor, skin preparation gel, paper towel, water.
F NET Vue:
Installed on PC with free USB port
Monitor (and video controller) is at least 1280 pixels wide
Broadband Internet connectivity
Registered as No20s clinician (user name and password)
F Hair Rim Behind The Ears:
Is there adequate space between the hairline and the ear for the electrode
to be placed, or is shaving required?
F Check Client Handedness:
Is the client right or left handed?
Checklist 2:
22
www.no20s.com
Session 3: Applying the No20s Stimulator
Client Preparation… (continued)
Applying Electrodes
Reusable self-adhesive NET electrodes are available from NET Device Corp
at www.no20s.com. The electrodes are approximately 1cm x 2cm with a pigtail.
For each of two electrodes, remove the electrode from the liner. Lightly wet the
adhesive surface with tap or other clean water. Wait for at least thirty seconds for the
surface to become tacky or sticky. On the head, feel for the slight indentation in the
upper half of the mastoid bone behind the ear. This ‘dip’ must be covered by the
electrode.Presstheelectrodermlyintoplace.
The electrode should be close to the back of the ear but not touching it
(about a 2 mm space). Contact between the edge of the electrode and the back
oftheearwillcauseanunpleasanttinglingduringstimulation.Thenalangleshould
be in the 1 o’clock to 7 o’clock position for the right ear (and a mirror-image for the left).
Applyastripofmicroporetapetoholdelectrodesrmlyinplaceandtoprovidestrain
relief for the pigtail.
Attach the Lead Wires (noting client handedness)
If the client is right handed, the red lead should be attached at the right ear (‘red to right’).
If the client is left handed, the red lead should be attached at the left ear. If the device is
connected backwards (with RED to the non-dominant side), the No20s treatment may
have little if any therapeutic effect.
Insert the pins of the leads fully into the electrode pigtail so that no metal is visible.
Note: RED to RIGHT. Check the client’s handedness.
The red lead should be attached to the dominant side.
It is helpful to explain this to the client; they may detach
and re-attach the device without telling you.
23
Session 3: Applying the No20s Stimulator
No20s Device Preparation
Note: Never under any circumstances place the electrodes over the carotid sinus;
on each side of the upper neck and below the ears.
Load a Treatment Programme
Please refer to the NET Vue online help facility for instructions on how to load the
selected No20s treatment programme.
Attach the Stimulator
Turn the intensity knob to the OFF position (fully counter-clockwise).
Plug the unattached end off the leads into the stimulator.
The device may be kept in a cloth carrying pouch during the day. At night, the client
should be instructed to place the device under their pillow to prevent strain on the leads.
Regarding the Intensity Control:
F Control of the intensity level should always be performed by the client.
Hand the device to them. Put them into control of their own treatment.
F The No20s practitioner should ensure that the Intensity control is ‘Off’
before connecting or disconnecting the device from the client.
F Aretheelectrodesplacedproperlyontheatbonebehindtheear?
F Are the electrodes secured with micropore tape?
F Is there any hair under the tape?
F Is the polarity correct? (red to right in right-handed clients)
Checklist 3:
24
www.no20s.com
Session 3: Applying the No20s Stimulator
Client Instructions
After handing the connected device to the client, provide the following instructions:
1. Turn up the intensity control until you start to feel a sensation behind one or both
of your ears. The No20s waveform is polarized, and it is not unusual to feel sensation
behind just one ear. If you are not connected properly, you will not feel sensation
behind either ear.
2. Adjust the stimulation intensity to a comfortable level. This level should be just
below or just above the point of sensation. This will give you feedback that you
are receiving treatment.
(Note: this also provides the client a feeling of control over their own treatment.)
3. Don’t be surprised if you feel the sensation change at various times during the day.
The No20s device provides different waveforms over the course of the day as part
of its programme.
4. You should maintain the output at a comfortable level. Turning up the intensity
does not speed up the treatment process. (Note: it is sometimes helpful to tell
the client that their brain responds to frequency, not to volume. Just as you can
recognize a song whether it is loud or soft, your brain responds to the frequencies
of the stimulation and not its intensity. As long as the intensity is just below or just
above the sensation point, their brain will be able to hear the No20s programme.)
5. You will wear the No20s device 24 hours a day except to wash or shower.
If you must shower:
a. Remember to turn OFF the device before disconnecting.
b. Disconnect the leads from the electrodes. Leave the electrodes in place,
and take care to not dislodge them during the shower.
c. Remember “RED to right”. (Note: please teach the client about the
importance of handedness. If the client removes or detaches the electrodes,
they should understand the importance of handedness when the re-attach.
Teach them “RED to Right”.)
d. Try not to have the device off for more than one hour.
25
Session 3: Applying the No20s Stimulator
Client Instructions… (continued)
6. Put the device under your pillow at night to prevent accidental disconnection.
7. If you see the “Low Battery” indicator, please replace the battery.
8. As long as you see the heartbeat, the device is working.
9. If you can’t feel any sensation and no lights are ON, it is likely that the battery
died and you did not notice the “Low Battery” indicator. Replace the battery.
10. If you can’t feel any sensation and the heartbeat
is still going, you may need to clean the skin and
reattach the electrodes. Please see your
No20s practitioner for assistance.
26
www.no20s.com
Session 3: Applying the No20s Stimulator
Electrode Care
F Electrodes are for single client use only. Dispose of electrodes after use.
F Do not apply electrodes to broken skin.
F The life of the electrodes varies, depending on a number of factors including skin
conditions, amount and toxicity of sweating, and amount of current used. Although
breakdown of electrodes is rare over the short duration of a No20s treatment,
if the electrodes are clearly dissolving, fresh electrodes should be applied.
F If the client is unable to feel any sensation, but the device heartbeat is visible,
it is likely that the client’s skin has become dry or oily under the electrodes. While this
is rare during the short duration of No20s treatment, the condition is easily remedied.
Remove the electrodes and tape together and set aside. Use NuPrep gel to clean the
skin and remove any oils and dead skin that have built up. Remove the gel with water
and a paper towel. Re-apply the original electrodes and tape, taking care to attach
RED to the dominant side.
Session 4: Clinical Impact
The purpose of this exercise is to provide a practical demonstration of the use of the
No20s equipment, and to become aware of the expected clinical outcomes from appropriate
application of using this treatment.
The trainer will review the main nicotine withdrawal symptoms as experienced under No20s.
Learning Objectives To learn how No20s can impact upon nicotine
withdrawal symptomatology
To learn how to chart and use the Withdrawal
Severity Scale (WSS)
Topics Covered Dependency
Withdrawal
Detoxication
Learning Methods Small group work
Group discussion
Materials Required Flipchart
Timing 45 minutes
27
28
www.no20s.com
Session 4: Clinical Impact
Nicotine and Withdrawal
Nicotine is a quick-acting drug, travelling from the lungs to the brain in
seven seconds (with nicotine from pipe, cigar, and chewing tobacco, absorbed
through the mucous membranes of the mouth). It has a half-life of about two hours.
The mechanism of action for nicotine is gradually becoming understood. The drug
mimics the action of the neurotransmitter acetylcholine by acting on nicotinic
acetylcholine receptors, concentrated heavily in just a few regions of the brain.
Although nicotine stimulates the Central Nervous System, the drug is
nevertheless described as having as relaxant effect.
Nicotine is also known to act on the dopamine ‘reward pathway’, the mesolimbic
dopaminergic nerve tract of the brain, enhanced and disrupted by nearly all the
major drugs of addiction, including cocaine, heroin, amphetamines, and alcohol,
andbelievedtobeasignicantcomponentinthephenomenonofcraving.
Glassman and Koob (1996) have demonstrated decreased levels of monoamine
oxidase in smokers, with MOA-B at 40% below normal levels. Moreover, the level
has been shown to return to normal in former smokers. MAO-A is involved in serotonin
oxidisation of serotonin, the neurotransmitter involved in behaviour and mood; whilst
MAO-B is involved in dopamine oxidisation, the neurotransmitter involved in the
pleasuremechanism(thisndingmaywellexplaininpartthedecreasedincidence
of Parkinson’s Disease found in smokers, a disease characterised by a decrease
of dopamine and loss of dopamine neurons). Neuronal brain alteration persists
for months after nicotine cessation.
Nearlyoneinveofalldeathsindevelopedcountriesaresmokingrelated,
the largest single cause. The combined cost of each pack to society and the
individual smoker and family is nearly $40 (Sloan, Osterman & Picone, 2004).
Withsmokingincreasinglyunderpublicandofcialdisfavour,muchemphasis
is now placed on nicotine treatments. Current approaches can be divided into
techniques of nicotine replacement therapies (NRT’s - patches, gum, spray),
psychologicalintervention(behaviouralmodication;stressmanagement;12-Step
self-support groups; aversion therapy), pharmacological intervention (antagonist;
anxiolytic and/or antidepressant), and alternative/complementary therapies
(acupuncture, staple, and laser treatments; herbalism, hypnosis).
Withdrawal symptoms usually start within a few hours of the last cigarette and peak
48 to 72 hours later when most of the nicotine and its by-products are out of the body.
However, symptoms, and especially craving and mood swings can last for weeks.
29
Session 4: Clinical Impact
Nicotine and Withdrawal… (continued)
Gradual withdrawal from nicotine underlies most treatment approaches,
ranging over periods of weeks to months, or even over years. Dependency and
craving are key factors in relapse (West et al., 1990), and not even NRT’s have
been found to impart reliable reduction in craving (West et al., 1984). Research has
indicatedthatupto50%ofrelapsersreturntosmokingwithintherstweekoftheir
last cigarette (Kotke et al, 1989). ). A number of reports have found that a long-term
success rate (ie. abstinence after one year) of greater than 20-25% to be rare
(eg. U.S. Department of Health and Human Services. Reducing Tobacco Use:
A Report of the Surgeon General, 2000;.Hajek 1994), and more commonly,
between 3-5% ( Hughes et al 2004).
No20s helps the client to maintain long term abstinence from nicotine by reducing
the client’s nicotine cravings, reducing their attendant anxiety, reducing their chronic
dysphoria and improving sleep.
F
Brief calming effect
(‘steady nerves’)
F
Dizziness
F
Euphoria
F
Increased heart rate
F
Increased blood pressure
F
Nausea / Vomiting
F
Stimulation/energy
F
Appetite suppression
F
Breathingdifculties
F
Cancer of mouth
and lungs
F
Death
F
Heart disease
F
Impaired sense of
taste & smell
F
Lung disease
F
Suppressed appetite
F
Tolerance, dependence,
addiction
F
Anxiety
F
Disturbed sleep
F
Intense craving
F
Irritability
F
Loss of appetite during
Acute Withdrawal phase,
followed by over-eating,
esp. of sweet, sugar food
& drinks
F
Nervousness
F
Nausea / vomiting
F
Poor concentration
F
Racing heart
F
Restlessness
F
Sweating
Short Term Effects Long Term Effects Withdrawal Symptoms
30
www.no20s.com
Session 4: Clinical Impact
Observing, Communicating & Monitoring
Observation is a core skill in delivery of a safe treatment. Amongst other things,
good observation ensures:
F Detection and response to improvement or deterioration in the client’s condition
F Detection of underlying physical or psychological health issues
F Detection of co-occuring use of psychoactive pharmacology
F Timely progression through the overall treatment process
Communication is essential for effective care. The daily Withdrawal Severity Scale (WSS)
is a useful mechanism for communicating with the client in addition to observing and monitoring
client compliance (proper use of the No20s equipment; no drugs or alcohol taken during No20s
treatment) and treatment progress.
Session 4: Clinical Impact
Withdrawal Severity Scale (WSS™)
The Withdrawal Severity Scale (WSS™) is a therapeutic scale that permits measurement of nicotine
and non-nicotine related withdrawal severity in both the acute and chronic phases in order to evaluate
treatment progress. The WSS consists of twenty two (22) questions that are answered by the client on
a scale of 0 to 3 (where 0 is low and 3 is high). The WSS is typically administered three (3) times daily.
The aggregate score (WSS score) is the summation of response values.
31
WSS scores should be maintained by the client on a NET Vue printed worksheet, and then entered
into NET Vue by the clinician.
32
www.no20s.com
Session 4: Clinical Impact
Withdrawal Severity Scale (WSS™)… (continued)
WSS scores provide useful information to the No20s practitioner in both their aggregate and individual
forms. Aggregate WSS scores provide insight into the broad progress of the client. Individual responses
can often provide an alert to concurrent use of psychoactive pharmacology. With smokers, this typically
involves caffeine (coffee), alcohol, anti-anxiety medications and/or sleeping pills. Patterns of withdrawal
symptomatology across the individual WSS questions can reveal such concurrent usage. The practitioner
should remain aware that concurrent use of psychoactive pharmacology diminishes the effectiveness of
both No20s treatment and the concurrent pharmacology.
WSS questions pertinent to nicotine withdrawal:
WSS questions pertinent to caffeine withdrawal:
WSS questions pertinent to anti-anxiety or sleeping medication withdrawal:
33
Session 4: Clinical Impact
Exercise Three
Detoxication:
Examine the photographs displayed by your trainer. For each of the three photographs,
describe what you see and what you think might be occurring with this individual.
34
www.no20s.com
Session 4: Clinical Impact
Completing No20s
FollowingcommencementofNo20sfollowing3daysoftreatmentdetoxication,thepatientwill
remain attached to the No20s stimulator 24-hours per day for between 3 to 5 days of treatment.
Clients may discontinue No20s when there is a marked decrease in withdrawal symptomatology.
Approximately80%ofclientswillreportasignicantimprovementinwellbeingandalackofcravings
within 48 hours. The renewed sense of well-being is a sign of reduction in acute withdrawal symptoms.
No20s treatment should be continued for approximately 24 hours from this point in order to effectively
address chronic withdrawal symptoms. This will aid in reducing long term relapse rates in the client population.
The No20s smoking programme will automatically terminate at the end of the 4th day of
treatment (where the start of treatment is considered to occur on Day 1). Treatment can
be extended by reloading the Nicotine program at its chronic stage through NET Vue.
Tolerance Warning: Prior to discharge or in instances or non-completion of No20s,
the client should be informed that their tolerance has been
signicantly reduced, and this may affect them if they use
prescription psychoactive medications or alcohol.
Typical withdrawal severity scale (WSS) scores following abrupt cessation of nicotine
and the start of treatment look as follows:
Abstinent patients should have their quitting success acknowledged,
and the clinician should offer to assist the patient with problems
associated with quitting.
Treating Tobacco Use and Dependence: 2008 Update
35
36
www.no20s.com
Session 4: Clinical Impact
Client Worksheet
The client worksheet is a personalized account of the client’s WSS, handedness (as a reminder in
the event of device removal), useful instructions and treatment schedule. This worksheet is typically
printed by the No20s practitioner at the start of treatment and given to the client to take with them.
This worksheet allows the client to record WSS scores between visits to the practitioner.
Patients who have relapsed should be assessed
to determine whether they are willing to make
another quit attempt. Patients who have relapsed
and are unwilling to quit at the current time
should receive a brief intervention designed
to increase future quit attempts.
Treating Tobacco Use and Dependence: 2008 Update
Session 4: Clinical Impact
Relapse Prevention
Potentialrelapsetosmokingisnotedtobeinuencedbyanumberofcritical
‘predictors’. These include morning smoking, strength of cravings, environmental
smoking cues, thenumber of cigarettes smoked, as well as motivation and the
effectivenessofthedetoxication.Inordertoreinforcethepositivechangesachieved
beforeandduringdetoxicationandtoreduceopportunitiesforrelapse,theclient
should be encouraged to continue with the supports they have put into place prior
todetoxicationuntiltheyarecondentthesearelongerrequired.
Many smokers gain some weight following nicotine cessation. As healthy eaten habits
have been adopted with the advice and support of the physician, this weight gain should
be small, and sometimes even temporary. However, women tend both to gain slightly more
weight than men, and to be more conscious of doing so. Weight-gain issues may thus be a
specicfactorthathastobeaddressedinwomeninordertopreventrelapse.
Our experience is that a frequent occasion for relapse is to be found in social situations
in combination with alcohol. Clients should be made aware of this high risk situation,
and warned of the disinhibitory effect of alcohol.
Brandon and colleagues remark that full relapse does not usually occur
immediately,andthatsignicanttime(‘ameanof9days’)passesbeforea
secondcigaretteissmoked,withafurthersignicantperiodbeforeareturn
to daily smoking. ‘This suggests that many subjects do not rapidly lose
control once they sample a cigarette, and that there is substantial
time to intervene if a lapse occurs’ (Brandon et al., 1990).
37
38
www.no20s.com
Session 4: Clinical Impact
Relapse Prevention… (continued)
Questions:
F Further information on No20s can be found at www.no20s.com.
F Further information on NET can be found at www.netdevice.net.
F Clinical queries relating to application should be addressed to Lorne Patterson
RMN, at lpatterson@netscotland.com, or your appointed NET Supervisor
F Issues relation to equipment performance should be addressed
to mail@netdevice.net.
After quitting cigarettes:
20 minutes
Heart rate and blood pressure drops.
12 hours
Carbon monoxide levels in the blood drop to normal.
2 weeks to 3 months Circulation improves and lung function increases.
1 to 9 months Coughing and shortness of breath decrease; cilia
(the tiny hair-like structures that move mucus out of the
lungs) regain normal function in the lungs, increasing
the ability to handle mucus, clean the lungs,
and reduce the risk of infection.
1 year Excess risk of coronary heart disease is half that
of a smoker’s.
5 years Stroke risk is reduced to that of a non-smoker
5 to 15 years after quitting
10 years Lung cancer death rate is about half that of a continuing
smoker’s. The risk of cancer of the mouth, throat,
esophagus, bladder, cervix, and pancreas decrease, too.
15 years Risk of coronary heart disease is the same as
a non-smoker’s
(Taken from US Surgeon General’s Report s)
39
Session 5: The Role of the No20s Practitioner
The purpose of this session is to detail and discuss the role of the No20s practitioner
through the No20s process as described in the morning sessions.
Timing 60 minutes
LearningObjectives ToreectonthekeyrolesundertakenbytheNo20spractitioner
To review the role and responsibilities of the No20s practitioner
Topics Covered Roles prior to No20s acceptance, during No20s application and
during No20s treatment, the tolerance warning
Learning Methods Group discussion
Materials Required Flipchart
40
www.no20s.com
Session 5: The Role of the No20s Practitioner
Role Prior to No20s Detoxication
Gathering & Reviewing Client information
F Ensuring drug-using information, medical and psychological histories are available
F Interviewing client, if required
Making Recommendations - Acceptance/non-acceptance for No20s
F Based on collected information, making recommendations to the clinical team in
regards to acceptance / non-acceptance/ further investigation of clients for No20s
Preparing the Client for No20s
F Advising the client on cessation of prescribed psychoactive medications
F Advising the client on reducing caffeine intake
F Advising and supporting the client with a health and behavioural programme
prior to No20s
F Advising the client about No20s
F Advising the client about the time-frame of the last cigarette prior to No20s
Applying No20s
F Ensuring all required equipment required is available and in good working condition
F Shaving behind ear (if required), applying electrodes, connecting leads correctly
(ie polarity), inserting battery, downloading appropriate treatment programme,
instructing client as to maintaining output at comfortable level.
F Ensuring client is educated regarding showering instructions.
41
Session 5: The Role of the No20s Practitioner
Role During Detoxication
Support
F General support
F Specicencouragementtokeepphysicallyandmentallyactive
F Support for positive decision-making
Assessment & Monitoring
F Regular contact, involving observation and communication
F Assessment of degree of acute and chronic withdrawal response under No20s
F Treatment compliance:
v Are there indications that the No20s equipment is not being used
properly (e.g. output turned to OFF, electrodes pulled off, wrong polarity)?
v Are there any indications of concurrent use of cafne, alcohol
or psychoactive medication?
F Is the No20s equipment functioning?
F Are the electrodes functioning adequately or do they need to be replaced?
F Evaluation of when it is appropriate to discontinue No20s treatment
Tolerance Warning: Prior to discharge or in instances or non-completion of No20s,
the client should be informed that their tolerance has been signicantly
reduced, and may affect them if they use prescription psychoactive
medications or alcohol.
42
www.no20s.com
No20s Treatment Process (Flow Chart)
NET Treatment Process (Flow Chart)… (continued)
43
Tolerance Warning:
Prior to discharge or in
instances or non-completion
of No20s, the client should be
informed that their tolerance
has been signicantly reduced,
and may affect them if they use
prescription psychoactive
medications or alcohol.
44
www.no20s.com
NET Treatment Process (Flow Chart)… (continued)