Tobacco Treatment during Addictions Treatment or Recovery: A Review of the Literature

Transcription

1 Tobacco Treatment during Addictions Treatment or Recovery: A Review of the Literature Judith J. Prochaska, PhD, MPH University of California, San Francisco Research supported by NIDA #P50-DA09253 and #K23-DA018691, NIMH #R01-MH083684, and TRDRP #17RT-0077 and #13KT-0152

2 Death of a 56-Year-Old Man with SMI & Polysubstance Dependence A 56-year-old, gay-identified Caucasian man >15 psychiatric hospitalizations over a 10-year span Severe depressive symptoms, suicidal ideation, and auditory hallucinations criticizing him and/or commanding him to commit suicide Tested positive for stimulants Diagnosed with schizoaffective disorder, major depression with or without psychotic features, posttraumatic stress disorder, and polysubstance or stimulant dependence Prochaska, Schane et al., (2008). Am J Psychiatry

3 Death of a 56-Year-Old Man with SMI & Polysubstance Dependence Smoked 2 packs of cigarettes/day for 25 years 10 attempts to quit smoking, 2 in the past year Each attempt was unassisted, without clinical support or use of FDA-approved cessation medications Longest period of being tobacco-free was 7 days No advice to quit smoking in the past year by a mental health or general medical provider Prochaska, Schane et al., (2008). Am J Psychiatry Died 20 years prematurely from complications of pulmonary emphysema due to smoking

4 Objectives 1. Prevalence & causes of smoking in persons with alcohol or illicit drug use disorders 2. Literature review of tobacco cessation interventions during addictions treatment or following recovery 3. Organizational change factors with implementation of tobacco cessation guidelines in addiction treatment settings

5 PREVALENCE & ETIOLOGY

6 SMOKING RATE by PSYCHIATRIC HISTORY Panic Disorder 77% to 98% of clients in 90% methadone treatment 80% use tobacco -- >3 xs the 70% US average 100% 60% 41.0% Overall PTSD GAD Dysthymia Major Depression Bipolar Disorder 50% 40% 30% 20% 22.5% 34.8% Nonaffect Psychosis ASPD Alcohol Abuse/Dep 10% 0% None History Active Drug abuse/dep National Comorbidity Survey Source: Lasser et al., 2000 JAMA

7 Post-Mortem Study with Young Adults in Finland (N=1623) 100% 75% % Co nine+ (Recent Tobacco Exposure) 70% 72% 78% 75% 85% 50% 25% Finland Smoking Prevalence 18.6% 0% An psycho cs An depressants Anxioly cs Hpno cs/seda ves Illicit Drug Launiainen et al. (2011) NTR

8 SMOKING & SUBSTANCE USE Tobacco-related diseases account for 50% of deaths among individuals treated for alcohol dependence (Hurt et al., 1996) Death rate 4-xs greater for cigarette smoking vs. nonsmoking long-term drug abusers (Hser, 1994) Health consequences of tobacco and other drug use synergistic: 50% greater than sum of each individually (Bien & Burge, 1990)

9 FACTORS ASSOCIATED with TOBACCO and Co-Occurring ADDICTIVE DISORDERS Biologic & Pharmacologic Genetic predisposition Alleviation of withdrawal Pleasure effects Weight control Tobacco Use Psychological/Behavioral Conditioning effects Coping tool Social interactions Boredom Systemic & Treatment Use of cigarettes for reinforcement Failure to treat

10 DOPAMINE REWARD PATHWAY Prefrontal cortex Dopamine release Nucleus accumbens Amygdala Ventral tegmental area Stimulation of nicotine receptors Nicotine enters brain

11 NEUROCHEMICAL and RELATED EFFECTS of NICOTINE N I Dopamine Norepinephrine Pleasure, reward Arousal, appetite suppression C Acetylcholine Arousal, cognitive enhancement O Glutamate Learning, memory enhancement T -Endorphin Reduction of anxiety and tension I GABA Reduction of anxiety and tension N Serotonin Mood modulation, appetite suppr. E Benowitz. Nicotine & Tobacco Research 1999;1(suppl):S159 S163.

12 Dysphoric or depressed mood Insomnia and fatigue Irritability/frustration/anger Anxiety or nervousness Difficulty concentrating Impaired task performance Increased appetite/weight gain Restlessness and impatience Cravings* NICOTINE WITHDRAWAL EFFECTS * Not considered a withdrawal symptom by DSM-IV criteria. Most symptoms peak hr after quitting and subside within 2 4 weeks. American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48: Hughes & Hatsukami. (1998). Tob Control 7:92 93.

13 Henningfield Ratings of Different Substances 1 = Most serious 6 = Least serious Substance Withdrawal Reinforcement Tolerance Dependence Intoxication Nicotine Heroin Cocaine Alcohol Caffeine Marijuana

14 LD An Act to Exempt Substance Abuse and Psychiatric Patients from the Prohibition against Smoking in Hospitals

15 Source: Legacy Tobacco Documents

16 Persons with mental illness or addictive disorders comprise 44% to 46% of the US tobacco market RJ Reynold s Project Sub (Lasser Culture et al., 2000; Grant et Urban al., 2004) Marketing Equates to 175 billion cigarettes and $39 billion in annual sales (USDA, 2004)

17 LITERATURE REVIEW

18 US TOBACCO TREATMENT CLINICAL PRACTICE GUIDELINES Literature base of more than 8,700 research articles < 50 randomized clinical trials treating tobacco dependence in smokers with mental illness or addictive disorders Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

19 TOBACCO CESSATION DURING ADDICTIONS TREATMENT or RECOVERY Meta-analysis of 19 trials +15 (N=34) 28 with alcohol disorders; 6 with illicit drugs EOT Tobacco Cessation In Addictions Treatment: RR=1.73 (1.19, 2.53) In Recovery: RR=1.54 (1.21, 1.96) Cessation Pharma: RR=1.59 (1.23, 2.06) Behavioral Tx Alone: RR=2.02 (0.88, 4.67) Alcohol Use Disorders: RR=1.70 (1.31, 2.20) Illicit Drug Use Disorders: RR=1.22 (0.55, 2.71) Prochaska, Delucchi & Hall (2004) JCCP

20 Long-term Outcomes (6+ months) No long-term effect for tobacco cessation No long-term effect for abstinence from alcohol/illicit drugs: RR=1.02 (0.81, 1.20)

21 Conclusions Significant short-term smoking cessation effects that are not maintained long-term Most interventions targeted tobacco separately from other substances Future directions: more extended tobacco treatment integrated within alcohol and drug treatment services Effect of tobacco treatment on sobriety needs further study

22 TOBACCO CESSATION DURING ADDICTIONS TREATMENT or RECOVERY Systematic review of 17 studies Smokers with current and past alcohol problems: More nicotine dependent Less likely to quit in their lifetime As able to quit smoking as individuals with no alcohol problems Hughes & Kalman (2006) Drug Alc Dep

23 PREVENTION Drug Abuse Treatment Settings Prospective study, N=649 At 12-month follow-up, 13% of the 395 baseline smokers reported quitting smoking and 12% of the 254 baseline nonsmokers reported starting/relapsing to smoking Kohn et al. (2003) Drug Alc Dep

24 ORGANIZATIONAL CHANGE

25 Systems Level Changes 1. Identify and record smoking status 2. Provide education, resources and feedback to Audit promote of US staff drug intervention and alcohol treatment to support facilities: quitting Systems to facilitate consistent, evidence-based 3. Dedicate staff to provide tobacco treatment tobacco treatment and implement quality 4. improvement Promote organizational were NONEXISTENT policies (Hunt that et support al., 2012) and provide tobacco dependence services * Denormalization of smoking Fiore et al. (2007) AJPM

26 DAT Counselors Implementation of Tobacco Treatment CPGs Ask about Tobacco Advise Cessation Assess Readiness 18% 18% Quit Plan if Ready Correctional 13% 15% facility Quitline Referral 13% Most Times Always +Implementers: 20% 17% 22% 24% 48% Methadone maintenance setting Greater personal earnings -Implementers: Lower personal earnings 0% 10% 20% 30% 40% 50% 60% 70% MERITS I Project N=615 (Rothrauff & Eby, 2011)

27 Organization Development (OD) Methods for Dissemination Organization-centered" engage practitioners at all levels Needs-focused" address concerns of the particular organization Flexible responsiveness to readiness for change Relatively affordable Amodeo et al., (2006), Am J Drug Alcohol Abuse

28 Addressing Tobacco through Organizational Change (ATTOC): 12 Step Model 1. Acknowledge challenge of addressing tobacco 2. Establish a tobacco leadership group 3. Create a change plan & implementation timeline with measurable goals & objectives 4. Start with easy system changes 5. Conduct staff training & ongoing supervision 6. Provide treatment for staff who smoke Ziedonis et al. (2007). J Psychoactive Drugs

29 ATTOC: 12 Step Model 7. Require better tobacco assessments & chart doc 8. Incorporate tobacco treatment materials into patient education curriculum 9. Provide NRT medications 10. Integrate tobacco treatment groups into program 11. Develop onsite Nicotine Anonymous meetings 12. Develop written policies addressing tobacco use Ziedonis et al. (2007). J Psychoactive Drugs

30 12 Easy Policy Changes to Better Address Tobacco Use Use the phrase alcohol, tobacco, and other drugs Modify assessment forms to include tobacco use and motivation to change Identify smokers in the clinical chart Make sure tobacco dependence is on the problem list and a diagnosed Axis I disorder Provide educational materials on tobacco Re-label smoke breaks to just breaks Ziedonis et al. (2007). J Psychoactive Drugs

31 12 Easy Policy Changes to Better Address Tobacco Use Ban sales of cigarettes Do not allow staff to smoke with patients Limit hours and places for smoking Obtain tool kit files from the Internet Require smoke-free grounds or create less visible places where smoking is permitted Smoking staff should not give the appearance of smoking (e.g., smelling of smoke) Ziedonis et al. (2007). J Psychoactive Drugs

32 ATTOC Intervention Study 6 mo ATTOC intervention in 3 US DAT centers Pre- to post-intervention Staff and client beliefs about treating tobacco significantly more favorable NRT use increased Tobacco-treatment practices increased Guydish et al. (2007) Drug Alc Dep

33 SUMMARY High prevalence of tobacco use in persons with alcohol/illicit drug use disorders Multiple etiologies Systemic/treatment factors cannot be ignored Supporting literature: Significant post-tx tobacco cessation effects, though not sustained long-term ATTOC model useful framework for guiding organizational changes in DAT settings

34 CIGARETTES ARE MY GREATEST ENEMY Statewide social marketing campaign in California by Billy DeFrank Lesbian and Gay Community Center, the Center OC, and the American Legacy Foundation Real-life triumphs over adversities to quit smoking

35 ACKNOWLEDGEMENTS Grant funding: California Tobacco Related Disease Research Program (#17RT-0077) National Institute on Drug Abuse (#K23 DA018691, #P50 DA09253) National Institute of Mental Health (#R01 MH083684) Flight Attendant Medical Research Institute (FAMRI) Pfizer, Inc. Investigator Initiated Research Award Contact Judith J. Prochaska, PhD, MPH University of California, San Francisco Ph: (415) Website: