Session 8: Tobacco Interventions for Patients with Mental Health Issues

Transcription

1 Tobacco Cessation Interventions Lunch and Learn Seminar Series for Physicians, Family Health Teams, and other Health/Allied Health Practitioners Session 8: Tobacco Interventions for Patients with Mental Health Issues Faculty: Alexandra Andric, RN, BScN, CPMHN(C)

2 Housekeeping Please sign-in Please ensure you have completed Learning Assessment 1 A link to Learning Assessment 2 will be sent by Both Learning Assessments are required for the Letter of Completion If you haven t already, please dial-in via audioconference Conference #: Participant Code: # The Adobe Connect webinar will remain ON until 1:00 pm 2

3 Alexandra Andric, RN, BScN, CPMHN(C) (416) ext Alexandra Andric is a Registered Nurse who has worked at CAMH since Alexandra has worked in a variety of Psychiatric settings such as the General Psychiatry Program and the Addiction Medicine Clinic. As a Registered Nurse in the Nicotine Dependence Clinic, she provides counselling, support and education to clients. She also monitor clients responses to cessation medications, prescribes nicotine replacement therapy and co-facilitates therapeutic groups. Alexandra has co-facilitated presentations for clients as well as other health care professionals regarding smoking cessation, reduction, and group counselling. Lastly, Alexandra dispenses cessation medication to clientele at the clinic. 3

4 Disclosures Alexandra Andric No Disclosures 4

5 5 The recipient of the funding is in compliance with the CMA and the CPA guidelines / recommendations for interaction with the pharmaceutical industry.

6 Disclaimer These materials (and any other materials provided in connection with this presentation) as well as the verbal presentation and any discussions, set out only general principles and approaches to assessment and treatment pertaining to tobacco cessation interventions, but do not constitute clinical or other advice as to any particular situations and do not replace the need for individualized clinical assessment and treatment plans by health care professionals with knowledge of the specific circumstances. 6

7 TEACH Curriculum Development The TEACH Curriculum and slides were developed and compiled with funding from the Government of Ontario, Ministry of Health Promotion. Content of slides are primarily based on evidence based guidelines including: CAN-ADAPTT Canadian Practice Guidelines Initiative developed in collaboration with national experts in tobacco cessation and health behaviour change ( US Guidelines Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 Update. US Department of Health and Human Services, Public Health Service Rethinking Stop-Smoking Medications: Treatment Myths and Medical Realities OMA Position Paper, January The development and delivery of the TEACH curriculum is not influenced or funded in any part by tobacco industry. TEACH has not received funding from the tobacco industry. The development of the TEACH curriculum has not been influenced by pharmaceutical industry. TEACH project received a $ unrestricted grant from Pfizer, to develop video vignettes that are used in our training. Information presented on pharmacotherapy refers to generic products only, and recommendations are based on existing research, including the CAN-ADAPTT and US guidelines. An algorithm is provided to help practitioners determine if and which pharmacotherapy is appropriate for a smoker. 7

8 Session 8: Learning Objectives 1. Identify the prevalence rates of tobacco addiction in persons across the spectrum of mental illness. 2. List the currently available treatment opportunities, as they relate to cessation in this sub-population. 3. Link the emerging neuropsychiatric considerations related to tobacco addiction and cessation with implications for practice. 8

9 Tobacco in Mental Health and Addiction (MH&A) Settings Historically neglected Significant barriers to treatment exist Understanding remains incomplete Association between smoking and mental illness: Robust Reproducible Clinically significant 9

10 Relevance of Tobacco to Persons with MH&A: More likely to smoke and less likely to quit. Poorer physical health Consume 44% of all cigarettes smoked. Persons with schizophrenia die 25 years younger than the general population. Kalman et al (2005) Am J Addict 14(2): Lasser et al. (2000) JAMA 284: Phelan et al. (2001) BMJ 322: Colton & Manderscheid (2006) Prev Chron Dis 3:A42. Miller et al. (2006) Psychiatr Serv 57:

11 Prevalence of Smoking: 100 Substance use disorders Smoking prevalence (%) Psychiatric disorders 0 SZ BPD MDD PD OCD PTSD Alcohol Cocaine Opioid Gen US pop Kalman et al (2005) Am J Addict 14(2):

12 Prevalence Rates: Summary Tobacco use is disproportionately affecting the mentally ill population. Rates remain high despite ongoing tobacco control. Rates have not reduced similar to reductions in the general population. Unless we address this challenge, the prevalence rates may continue to plateau. 12

13 13 Etiological Theories and Pathophysiology

14 14 14 Nicotine

15 The seat of tobacco addiction: Benowitz NL Nicotine addiction NEJM 362:2295,

16 Why do mentally ill persons smoke? Normalizes psychophysiological deficits P50 auditory evoked potential deficits Prepulse inhibition deficits Smooth-pursuit eye movement deficits Blinking rates Impairments selectively improved: Spatial working memory Sustained attention Reduces antipsychotic induced EPS Ameliorates negative symptoms George T. Medication for Nicotine Dependence (2007) Taylor & Francis, CRC Press. 16

17 Self-Medication with Tobacco: Remedies a range of core symptoms of schizophrenia and medication-induced sideeffects. However, overreliance on the self-medication hypothesis and an unbalanced focus on patients so-called right to smoke may result in neglect of the leading preventable cause of death and disease. 17

18 18 Treatment: General Principles

19 Withdrawal versus Cessation These represent two different DSM diagnoses. Nicotine withdrawal is often neglected or undertreated in persons with mental illness & addiction. Withdrawal management does not equate cessation. Successful withdrawal management can increase odds of success with cessation. 19

20 Nicotine Withdrawal Symptoms Symptom: Irritability/aggression Depression Restlessness Poor concentration Increase appetite Light headedness headedness Night time time awakenings Constipation Mouth ulcers Urges to smoke Duration: Prevalence: < 4 weeks 50% < 4 weeks 60% < 4 weeks 60% < 2 weeks 60% > 10 weeks 70% < 48 hours 10% < 1 week 25% > 4 weeks 17% > 4 weeks 40% > 2 weeks 70% Hughes et al. Addiction ;89:

21 Nicotine Delivery by Cigarettes and NRT Products Cigarette (nicotine delivery, 1-2mg) Plasma Nicotine Concentration (μg/l) Time Post-administration (minutes) 21 Sweeney CT et al. CNS Drugs. 2001;15:

22 Nicotine Delivery by Cigarettes and NRT Products Plasma Nicotine Concentration (μg/l) Cigarette (nicotine delivery, 1-2mg) Transdermal patch Time Post-administration (minutes) 22 Sweeney CT et al. CNS Drugs. 2001;15:

23 24 h Plasma Nicotine Subject smoking 1 cigarette per hour 4 mg Gum Nicotine 21mg patch Comfort zone Plasma nicotine (ng/ml) AM Noon Midnight AM 23

24 Without Treatment, Expect: Irritability Aggression Difficulty concentrating Nausea Diarrhea/constipation Shakiness Clumsiness Diaphoresis Dizziness Appetite changes Cravings Fatigue Sleep disturbances Headaches Ward milieu changes Risk of harm 24

25 Combination therapy works better than monotherapy. Hughes, J (2010): HealthCPR and ATTUD blog (ahead of print) 25

26 Projected Outcomes of Preventive Interventions Intervention Lives Saved NNT Smoking cessation 328,400 9 Lipid lowering 132, BP control 63, ß-blockers (MI) 17, ASA (MI) 10, Coumadin (A. fib) 3,418 2,014 Woolf AH. JAMA 1999; 282(24):

27 Smoking Cessation: Persons with Severe Mental Illness Eight trials pooled meeting criteria. Results suggest: Treating tobacco addiction is effective, Treatment demonstrated to work in the general population works in persons with SMI, Treatment is approximately equally effective, Treating tobacco addiction does not worsen mental state. Banham & Gilbody (2010) Addiction

28 28 Smoking and Psychiatric Disorders: Schizophrenia, Mood and Anxiety Disorders

29 Smoking prevalence rates in Schizophrenia Composite: 72.5% (but could be up to 90%) depending on setting. Half are heavy smokers (>15cpd). More likely to smoke and less likely to quit Biological & social variables = robust determinants. Self-medication of symptoms may drive smoking: Negative symptoms Cognitive symptoms Medication side-effects. Kalman et al (2005) Am J Addict 14(2): Lasser et al. (2000) JAMA 284:

30 Approach to Management in Mental Illness Els C, Sutherland G. GHA meeting, Athens,

31 Treatment in persons with Schizophrenia Nicotine replacement therapy: Dose and duration considerations. Putative therapeutic benefit to illness itself. Bupropion: Theoretical risk of increased psychosis. Caution with alcohol-addicted persons. Caution in clozapine treated persons. Varenicline: Particular value in bypassing CYP450 Combination therapy. 31

32 Prevalence of Smoking in: Depressed patients General population Current smokers 56% 26% 44% Non-smokers 74% Farrell et al (2003) Int Rev Psychiatry 15(1-2): 43-49; 49; Mackay et al (2006) The Tobacco Atlas 2nd ed., World Health Organization. 32

33 Treatment in persons with Mood Disorders Nicotine replacement therapy. Bupropion: Serves as an antidepressant due to DA / NE reuptake inhibition. Caution with alcohol-addicted persons. Nortryptyline Varenicline. Not causally related to depression / suicide. Combination therapy. 33

34 Characteristics of Smoking in Anxiety Disorders Rates of smoking 2x greater then general population. Smoking may predispose persons to developing selected anxiety disorders. Increased sensitivity, bodily sensations, and agoraphobic avoidance. Associated with greater levels of impairment. Little gender variation. Lasser et al. (2000) JAMA 284: McNally, R. J. (2002). Biological Psychiatry, 52, Zvolensky,, M. J., Forsyth, J. P., Fuse, T.., et al. (2002). Cognitive Behaviour Therapy, 31,

35 Nicotine is an anxiogenic drug Nicotine, as a stimulant drug, leads to increased anxiety. But often subjectively perceived as anxiety-relieving by smokers. Withdrawal symptoms between cigarettes worsen anxiety. Anxiety is lower within 2 weeks of abstinence. Lasser et al. (2000) JAMA 284: Zvolensky,, M. J., Forsyth, J. P., Fuse, T.., et al. (2002). Cognitive Behaviour Therapy, 31,

36 Treatment Options for persons with Anxiety Disorders Nicotine replacement therapy (4 options) Combination therapy may be more efficacious. Bupropion: Limited evidence in sub-population. May be panicogenic in some persons. Caution with alcohol-addicted / seizure risk persons. Varenicline. Combination therapy. 36

37 37 Smoking and Psychiatric Disorders: Summary

38 Basic Departure Points: Mentally ill persons want to quit smoking. Mentally ill persons CAN quit smoking. Multi-modal and longitudinal interventions yield best outcomes: Psychosocial interventions Pharmacotherapy For as long as it takes. 38

39 Psychosocial Interventions Cognitive behavioural therapy, Meditation, Behavioural activation therapy, Motivational interviewing, Aerobic exercise Ziedonis et al, (2008) Nicotine Tob Res 10: (12)

40 Case Example: Angela Angela is a 48 year old, single, Caucasian female with a history of bipolar I disorder, currently in remission from any mania symptoms presents requesting help to quit smoking. She is prescribed lithium 300mg, and is currently seen for medication management only at a local mental health center. Angela reports that she wants to quit smoking because she can t afford it (she spends $100 month on cigarettes). She also states that she d like to quit for health reasons. Even though she reports no known medical problems, she worries about developing a smoking related illness (e.g. cancer or heart disease). Angela reports smoking 15 cigarettes/day and reports as many as 11 previous quit attempts. She reports using the patch and gum, with no success. Her only reported period of abstinence was for 2 weeks, when she went cold turkey. Angela reports smoking since age 19, and cannot even remember life without cigarettes. Angela lives alone, and supports herself with Disability collecting $500 month. She volunteers as a warm line operator a few times a week. She states that although she enjoys helping others, she feels that it s stressful at times, and she also finds that she smokes more after a stressful night at work. 40

41 Case Discussion: Angela 1. Assessment what is her level of dependence and motivation to quit? 2. What are her barriers to quitting? 3. What treatment approach would you take? 4. Predicted Outcome... 41

42 For reflection/discussion What will you take away from this session? How will your learning impact your clinical practice? What is one thing you will commit to trying with patients in the coming week? 42

43 Resources

44 Canadian Journal of Psychiatry, 2009

45 Cormac, I., Brown, A., Creasey, S., Ferriter, M., & Huckstep, B. (2010). A retrospective evaluation of the impact of total smoking cessation on psychiatric inpatients taking clozapine. Acta Psychiatr Scand, 121: Ferron, J. C., Brunette, M. D., Xiaofei, H.E., Xie, H., McHugo, G. J., & Drake, R. E (2011). Course of smoking and quit attempts among clients with co-occurring severe mental illness and substance abuse disorders. Psychiatric Services, 62 (4), Lowe, E.J., Ackman, M.L. (2010). Impact of tobacco smoking cessation on stable clozapine or olanzapine treatment. Ann Pharmacother, 44(4): Morisano, D., Bacher, I., Audrain-McGovern, J., & George, T.P. (2009). Mechanisms underlying the comorbidity of tobacco use in mental health and addictive disorders. Canadian Journal of Psychiatry, 54(6): Moss, T.G., Vessicchio, J.C., Weinberger, A.H., Cushing, S., Kitchen, K., Callaghan, R., Selby, P., George, T.P. (2010). A Tobacco Reconceptualization in Psychiatry (TRIP). Am. J. Addictions, in press. Schroeder, S.A. & Morris, C.D. (2010). Confronting a neglected epidemic: Tobacco cessation for persons with mental illness and substance abuse problems. Annual Review of Public Health, 31: Tondstad, S., Davies, S., et al. (2010). Psychiatric adverse events in randomized, double-blind placebo-controlled clinical trials of varenicline: a pooled analysis. Drug Safety 33 (4): Further Reading

46 Remember A link to the Online Course Evaluation will be sent by . A link to Learning Assessment 2 will also be sent by e- mail. This must be completed by November 30 th in order to receive your Letter of Completion Next session: December 14, 2011: Working with Pregnant Women who use Tobacco **Application period will open Monday November 28 th ** 46

47 Thank you!

48 Copyright Copying or distribution of these materials is permitted providing the following is noted on all electronic or print versions: CAMH/TEACH No modification of these materials can be made without prior written permission of CAMH/TEACH. 48