best practices for tobacco treatment with behavioral health patients dior hildebrand, rn, phn los...
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Best Practices for Tobacco Treatment with Behavioral Health Patients
Dior Hildebrand, RN, PHN
Los Angeles County, Department of Public Health
Tobacco Control Prevention Program
Smoking is arguably the most modifiable risk factor for decreasing
excess mortality & morbidity.
National Association of State Mental Health Program Directors, 2006; U.S. Department of Health and Human Services, 2004
Common Benefits of Quitting
Time BenefitsWithin a few weeks
Increase in pulmonary function & exercise toleranceDecrease in respiratory symptoms
One year Risk of coronary disease cut by half
Within 2 years All-cause death rate declines
10 years Risk of pulmonary & other cancers falls by 50%
By age 65 4 additional years of life compared to those who don’t quit by then
Schroeder, 2005
Bottom line: Quality of life is increased by cessation.
Clinical Practice Guidelines
• All patients/clients should be screened for tobacco use, advised to quit and be offered intervention
• There is a dose response relationship with the amount of contact provided
Clinical Practice Guidelines (cont.)
Evidence-Based Model: The 5 A’s
Ask: Systematically identify all tobacco users at every visit
Advise: Advise tobacco users to quit
Assess: Assess each tobacco user’s willingness to quit
Assist: Assist tobacco users with a quit plan
Arrange: Arrange follow-up contact
The Team Approach
• The Team– Mental health and alcohol and drug
professionals, primary care physician, pharmacist, dentist, behavioral health, quitlines, cessation programs, peer counselors, family, public health…
Behavioral Health Professionals
• Often the clinician for whom contact is the most frequent and who knowsthe client/consumer best
• Able to coordinate pharma& behavioral/counseling treatment
• Trained in mental health and/or substance abuse treatment
• Able to identify and address any changes in psychiatric symptoms during the quit attempt.
Adapted from Prochaska, 2009
Ask: Systematically identify all tobacco users at every visit
The Helpline provides behavior modification counseling (quit plan and quit date)
The Helpline provides 5 follow-up calls – timing is based on the probability of relapse.
The 5 A’s and A, A, R
Advise: Advise smokers to quit
Arrange: Arrange follow-up contact
Assist: Assist smokers with a quit plan
Assess: Assess each smoker’s willingness to quitRefer to the California
Smokers’ Helpline and/or Peer-to-peer counselor
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California Smokers’ Helpline
• Free statewide tobacco cessation program• In operation since 1992• Funded by tobacco taxes - Propositions 99 & 10• Scientifically proven to be effective• All services available by telephone• Hours of operation: M-F 7:00am – 9:00pm &
Sa 9:00am – 1:00pm• Adults, teens, pregnant women & proxy callers• Multiple languages
Available Services
• Self-help materials• Referral lists of local cessation programs
‒ Updated by each county’s tobacco control program
• Individual telephone counseling‒ Confidential‒ One pre-quit call, multiple proactive follow-
up calls‒ Trained counseling staff
First Session• Treatment overview &
rationale• Motivation• Self-efficacy• Health considerations• Smoking & quitting
history• Quitting methods
• Environmental considerations
• Self-image• Planning• Call summary• Setting a quit date• Addressing follow-up
calls
Zhu S-H, Tedeschi GJ, Anderson CM, Pierce JP, 1996
Proactive Follow-up Sessions
• Quit status• Withdrawal review• Pharmacotherapy
review• Challenges &
smoking events
• Motivation & self-efficacy
• Support• Planning for future• Self-image
Zhu S-H, Tedeschi GJ, Anderson CM, Pierce JP, 1996
Self-Reported Behavioral Health Conditions Among Helpline Callers
% S
mok
ing
Zhu,et al, 2009. Unpublished data
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Treatment Fundamentals
Treatment: MI/SUD Fundamentals
• Demonstrated interest in quitting across populations
• Smoking cessation rarely jeopardizes stability of primary disorder or recovery
• Similar treatment/relapse prevention approaches‒ Motivational Interviewing ‒ Cognitive-behavioral strategies‒ Making quit attempts
Treatment Approaches
• Motivational Interviewing‒ Help resolve ambivalence‒ Empower clients to choose change
• Cognitive-Behavioral strategies‒ Create an individualized plan to quit‒ Identify relapse prevention strategies
• Encouraging Quit Attempts‒ Moves clients into action‒ Increase experience in quitting
Assessment Considerations
• Past/current history of MI treatment and SUD recovery
• Current health history including medications• Current life situation• Social support• Tobacco use history
– Determine current interest in quitting– If interested, determine readiness to quit
Determining Readiness to Proceed• Motivation
– “Interested” is sufficient– Don’t rule out some type of intervention, even
if motivation to quit now is low
• Motivational Interviewing
Treatment Considerations• Determine need for involvement from primary
care/other health care providers• Determine need for more intensive behavioral
therapy• Address psychotropic medication issues• Tailor treatment plan based on
– Current stability of symptoms/recovery– Functional status– Previous quit history
Treatment Considerations (cont.)
• Psychiatric stability– How are the client’s symptoms?– Is the client in treatment?– How consistent is the client with treatment & how
is it working?
• No major life changes• No major medication changes• No active intoxication/withdrawal from other
substances
Treatment Considerations (cont.)
• Quitting history & symptoms– Past quit attempts are helpful indicators of what to
expect.– What changes in symptoms were noticed?
• Biochemical factors– Nicotine acts much like a psychotropic medication
on brain chemistry.– The blood levels of some medications can increase
dramatically when quitting.– Medications may need to be adjusted.
• Content, length, & number of sessions– Based on level of functioning and support
(professional & personal)
• Counselor style – How much direction vs. facilitation should a
counselor provide?– Provide direction and support based on client’s
level of functioning, resources, skills, and needs.
Treatment Considerations (cont.)
Treatment Considerations (cont.)
• Client contact with prescribing MD– Refer back to the primary care provider
• Professional support & referral– May need to help clients identify support in
their local area
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Pharmacotherapy
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Behavioral Health and Tobacco Cessation
Online CME
https://cmecalifornia.com/Activity/1023974/Detail.aspx
Pharmacotherapy Guidance for Behavioral Health
• Smokers with behavioral health diagnoses who are trying to quit should receive pharmacotherapy (PHS Clinical Practice Guideline, 2008)
• Dose level and duration of drug treatment individualized.
• Many will need – Higher doses– Combination treatments (long acting & short
acting agents)– Longer duration of treatment
Pharmacotherapy Guidance• Smoking induces CYP1A2 isoenzyme• Approximately doubles clearance of
–Antipsychotics: Prolixin (fluphenazine), Haldol (haloperidol), Zyprexa (olanzapine), Clozaril (clozapine), Thorazine (chlorpromazine)
–Antidepressants: Elavil (amitriptyline), Aventyl (nortriptyline), Jaminine (imipramine), Anafranil (clomipramine), Sinequan (doxepin), Fluvox (fluvoxamine)
• Cessation may produce rapid, significant increase in blood levels
• Need to monitor for increased side effects
Nicotine Replacement Therapy
• Used to help smokers taper off nicotine slowly. Nicotine is released into the bloodstream (via the type of NRT) in order to help reduce physical withdrawal symptoms
• NRT works by replacing some of the nicotine from smoking at the receptor sites with nicotine from less harmful sources
• Allows individual to focus on behavioral and psychological aspects of quitting
Precautions: pregnancy or nursing, recent (<2 weeks) myocardial infarction, serious arrhythmias, severe or worsening angina
Nicotine GumNicorette; generics
• Resin complex– Nicotine
– Sugar-free chewing gum base• Contains buffering agents to increase
absorption of nicotine across the lining of the mouth
• Available: 2 mg, 4 mg; original, cinnamon, fruit, mint (various), and orange flavors
Nicotine Gum: Chewing Technique
Park between cheek & gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Nicotine Gum: Dosing
Dosage and schedule:– If 1st cigarette is smoked ≥30 minutes after
waking, use 2 mg gum– If 1st cigarette is smoked <30 minutes after
waking, use 4 mg gum
Weeks 1-6: 1 piece every 1-2 hours
Weeks 7-9: 1 piece every 2-4 hours
Weeks 10-12: 1 piece every 4-8 hours
Nicotine Gum: Side Effects
•Jaw muscle ache•Irritation of throat and mouth*•Lightheadedness*•Nausea and vomiting*•Hiccups*•Indigestion*
* Especially when chewing gum too fast
Nicotine Gum: Key Information
• Consult MD first if precautions for use are of concern• To improve chances of quitting, use at least nine
pieces of gum daily (maximum 24 pieces/day)• The effectiveness of nicotine gum may be reduced by
some foods and beverages:
Coffee Juices
Wine Soft drinks
Do NOT eat or drink for 15 minutes BEFORE or while using nicotine gum.
Nicotine Gum: Summary
DISADVANTAGES Need for frequent dosing
Might be problematic for patients with significant dental work
Patients must use proper chewing technique to minimize adverse effects
Gum chewing might not be socially acceptable
ADVANTAGES Might satisfy oral cravings Might delay weight gain (4-mg
strength) Can use as needed to manage
withdrawal symptoms A variety of flavors are available
Nicotine LozengeNicorette Standard, Nicorette Mini; generics
• Oral formulation– Delivers ~25% more nicotine
than equivalent gum dose• Sugar-free mint (various),
cherry flavor • Contains buffering agents to
increase absorption of nicotine across the lining of mouth
• Available: 2 mg, 4 mg
Nicotine Lozenge: Dosing• Dosage and schedule:
– If 1st cigarette is smoked ≥30 minutes after waking, use 2 mg lozenge
– If 1st cigarette is smoked <30 minutes after waking, use 4 mg lozenge
Weeks 1-6: 1 lozenge every 1-2 hours
Weeks 7-9: 1 lozenge every 2-4 hours
Weeks 10-12: 1 lozenge every 4-8 hours
• Allow lozenge to slowly dissolve slowly in mouth (20-30 minutes for standard; 10 minutes for mini)
Nicotine Lozenge: Side Effects
• Nausea• Hiccups• Cough• Heartburn
• Headache• Flatulence• Insomnia
Nicotine Lozenge: Key Information
• Consult MD first if precautions for use are of concern• Use at least nine lozenges daily (maximum 20/day)• The effectiveness of nicotine lozenge may be reduced
by some foods and beverages:
Coffee Juices
Wine Soft drinks
Do NOT eat or drink for 15 minutes BEFORE or while using nicotine lozenge
Nicotine Lozenge: Summary
DISADVANTAGES Need for frequent dosing
Gastrointestinal side effects (nausea, hiccups, and heartburn) may be bothersome.
ADVANTAGES Might satisfy oral cravings Might delay weight gain (4-mg
strength) Easy to use and conceal Can use as needed to manage
withdrawal symptoms Several flavors are available
Nicotine PatchNicoDerm CQ; generics
• Nicotine is well absorbed across the skin
• Patch delivers nicotine continuously over 24 hours
• Blood nicotine levels are lower and fluctuate less than with smoking
Nicotine Patch: Dosing
Product Light Smoker Heavy Smoker
NicoDerm CQ
10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)
>10 cigarettes/day
Step 1 (21 mg x 6 weeks)
Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)
Generic
10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)
>10 cigarettes/day
Step 1 (21 mg x 4 weeks)
Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)
Nicotine Patch: Side Effects
• Side effects to expect in first hour:–Mild itching–Burning–Tingling
• Additional possible side effects:–Skin redness/burning/itching after patch removal–Vivid dreams or sleep disturbances–Headache
Nicotine Patch: Key Information
• Consult MD first if precautions for use are of concern
• Apply new patch daily to a different, clean, dry hairless part of body (upper arm recommended)
• Do not cut patches to adjust dose– Nicotine may evaporate from cut edges– Patch may be less effective
• Water will not harm the nicotine patch if it is applied correctly; patients may bathe, swim, shower, or exercise while wearing the patch
Nicotine Patch: Summary
DISADVANTAGES Patients cannot titrate the
dose to acutely manage withdrawal symptoms.
Allergic reactions to the adhesive may occur.
Patients with dermatologic conditions should not use the patch.
ADVANTAGES Provides consistent
nicotine levels.
Easy to use and conceal.
Once daily dosing associated with fewer compliance problems.
Nicotine Nasal SprayNicotrol NS
• Solution of nicotine in a 10-ml spray bottle
• Each metered dose actuation delivers–50 mcL spray–0.5 mg nicotine
• ~100 doses/bottle
• Rapid absorption across lining of nose
Nicotine Nasal Spray: Summary
DISADVANTAGES Need for frequent dosing
Nose and throat irritation may be bothersome
Higher dependence potential
People with chronic nasal disorders or certain lung disease should not use the spray
ADVANTAGES Can use as needed to
rapidly manage withdrawal symptoms
Nicotine InhalerNicotrol Inhaler
• Nicotine inhalation system consists of:–Mouthpiece–Cartridge with porous plug
containing 10 mg nicotine and 1 mg menthol
• Delivers 4 mg nicotine vapor, absorbed across lining of mouth and throat
Nicotine Inhaler: Summary
DISADVANTAGES Need for frequent dosing
Initial throat or mouth irritation can be bothersome
People with certain lung diseases should use the inhaler with caution
ADVANTAGES Can use as needed to manage
withdrawal symptoms The inhaler mimics the hand-to-mouth
ritual of smoking
Bupropion SR Zyban; generics
• Nonnicotine, cessation pill
• Sustained-release atypical antidepressant
• Affects levels of dopamine and norepinephrine in the brain – craving for cigarettes– symptoms of nicotine
withdrawal
• Neuropsychiatric symptoms and suicide risk–Changes in mood (depression and mania)–Psychosis/hallucinations/paranoia/delusions–Homicidal ideation/hostility–Agitation/anxiety–Suicidal ideation or attempts–Completed suicide
Bupropion: Warnings and Precautions
Patients should stop bupropion and contact a health care provider immediately if agitation, hostility, depressed mood or changes in
thinking or behavior (including suicidal ideation) are observed
Bupropion: Summary
DISADVANTAGES The seizure risk is increased
Several contraindications and precautions preclude use in some patients
Patients should be monitored for potential neuropsychiatric symptoms
ADVANTAGES Easy to use oral formulation Might delay weight gain
Might be beneficial in some people with depression
VareniclineChantix
• Non-nicotine, oral cessation aid• Binds to 42 nicotinic
acetylcholine receptors–Stimulates low-level agonist activity–Competitively inhibits binding of
nicotine• Clinical effects
– symptoms of nicotine withdrawal–Decreases pleasure associated with
smoking
• Neuropsychiatric Symptoms and Suicidality–Changes in mood (depression and mania)–Psychosis/hallucinations/paranoia/delusions–Homicidal ideation/hostility–Agitation/anxiety/panic–Suicidal ideation or attempts–Completed suicide
Varenicline: Warnings and Precautions
Patients should stop varenicline and contact a health care provider immediately if agitation, hostility, depressed mood or changes in
thinking or behavior (including suicidal ideation) are observed
Varenicline: Summary
DISADVANTAGES May induce nausea in up to
one third of patients.
Patients should be monitored for potential neuropsychiatric symptoms
ADVANTAGES Easy to use oral formulation Offers a new mechanism of action for
people who have failed other agents
Long-Term Quit Rate for First-Line Cessation Medications
0
5
10
15
20
25
30
Nicotine gum Nicotinepatch
Nicotinelozenge
Nicotinenasal spray
Nicotineinhaler
Bupropion Varenicline
Active drugPlacebo
Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev
Per
cen
t q
uit 18.0
15.8
11.3
9.9
16.1
8.1
23.9
11.8
17.1
9.1
19.0
10.3 11.2
20.2
Combination Therapy
• Combination NRT–Long-acting formulation (patch)
• Produces relatively constant levels of nicotine
PLUS–Short-acting formulation (gum, inhaler, nasal spray)
• Allows for additional nicotine as needed for withdrawal symptoms
• Bupropion SR + Nicotine Patch
Regimens with enough evidence to be ‘recommended’ as first-line
Gum Lozenge Patch Inhaler Nasal sprayBupropion
SR Varenicline
Trade $5.49 $4.50 $3.40 $6.39 $3.58 $6.20 $5.96
Generic $1.90 $1.89 $1.60 $2.71
$0
$1
$2
$3
$4
$5
$6
$7
Comparative Daily Costs ofSmoking Cessation Medications
$/d
ay
Average $/pack of cigarettes, $5.95
Coverage for Tobacco Dependence Treatments
• Health insurance coverage & requirements vary by plan
• Medi-Cal provides FREE pharmacotherapy• Medicare
– Prescription drug benefits – Part D– Reimburses for cessation counseling
CPT Codes: 99406 (3-10 minute intervention) 99407 (>10 minute intervention)
Pharmacotherapy Guidance• Smoking induces CYP1A2 isoenzyme• Approximately doubles clearance of
–Antipsychotics: Prolixin (fluphenazine), Haldol (haloperidol), Zyprexa (olanzapine), Clozaril (clozapine), Thorazine (chlorpromazine)
–Antidepressants: Elavil (amitriptyline), Aventyl (nortriptyline), Jaminine (imipramine), Anafranil (clomipramine), Sinequan (doxepin), Fluvox (fluvoxamine)
• Cessation may produce rapid, significant increase in blood levels
• Need to monitor for increased side effects
Clinical Monitoring Recommendations
• Patients should be seen 1-3 days after initiating smoking cessation
• Monitor weekly for the 1st 4 weeks for MI/SUD relapse and the need to adjust medication levels
• After 1st month, monthly review for 6 months• Communication between the primary care
provider and MI/SUD provider(s) should occur– During the initiation of the cessation attempt– During the cessation period if any psychiatric
complications occur
Special Thanks and Acknowledgement
Gary Tedeschi, PhDCalifornia Smokers’ Helpline,
UCSD Cancer Center
Robin L. Corelli, PharmDDepartment of Clinical Pharmacy,
UCSF School of Pharmacy
Kirsten Hansen, MPPCenter for Tobacco Cessation,
UCSD Cancer Center
Los Angeles County Resources• It’s Quitting Time L.A.!
http://www.laquits.com
• LA County Tobacco Control and Prevention Programhttp://www.lapublichealth.org/tob/
• County Listings http://www.nobutts.org/CountyListings.aspx
• To add resources to the list contact Donna Sze at [email protected]