Treating Tobacco Dependence: Interdisciplinary Perspectives

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1 Treating Tobacco Dependence: Interdisciplinary Perspectives ATTUD Interdisciplinary Committee October 16, 2013

2 ATTUD is an organization of providers dedicated to the promotion of and increased access to evidence-based tobacco treatment for the tobacco user

3 A Needed Care Continuum ATTUD represents over 40 disciplines and specialties engaged in treating tobacco addiction

4 Interdisciplinary Committee Represents the interests of the many disciplines that provide treatment Ensures the interests of all professions and disciplines are represented Ensures that members are treated with respect regardless of discipline

5 Interdisciplinary Committee The committee will foster bidirectional learning and information sharing by: Enhanced linkage to national professional organizations and Building resources for ATTUD members regarding the specialty roles various disciplines play in treating tobacco dependence and disseminating practical guidance

6 Patient Vignette Gloria

7 Patient Description Gloria is a 45-year-old, English speaking Latino Medicaid coverage GED-level education Married, and her husband also smokes Fear regarding withdrawal symptoms and weight gain Husband is supportive but not interested in quitting

8 Patient Description Began smoking at age 15, and has been a pack a day smoker for the last 15 years First cigarette is immediately upon awakening Has had at least five past quit attempts. All these attempts were cold turkey The longest abstinence was five months Her 18 year old daughter is now also smoking

Patient Description Has Type 2 diabetes History of depression, and at one time was hospitalized for severe depression and thoughts of suicide Currently taking trazodone at a stable dose

9 Patient Description Has Type 2 diabetes History of depression, and at one time was hospitalized for severe depression and thoughts of suicide Currently taking trazodone at a stable dose for the last year Reports shortness of breath with exertion but no chest pain Has periodontal disease Last dental exam also revealed the presence of leukoplakia on the right buccal mucosa

10 Multiple Case Perspectives Social Work Psychology Registered Nurse Dental Healthcare Respiratory Care

11 Social Work Donna Richardson

12 Social Worker Establishment of helping relationship is critical to our work Trust Cultural humility/ worth of every individual Self-determination Demonstration of competence/ ability to find resources Human kindness

13 Social Worker Person in Environment Mental Health Physical Health Social Roles in Relation to Others Social Environment Classic Family Therapy Question: Why now?

14 Social Worker Therapeutic Change 40% extra therapeutic factors such as safe & stable housing, secure employment, adequate $, positive interactions & supports in the community 30% Gloria s experience of therapeutic relationship (non-judgmental, respectful, honest, appears to care) 15% individual s sense of hope and expectations for growth 15% techniques & skill of helper Derived from Lambert & Barley, 2001

15 Psychology Chad Morris

16 Psychology Bio-psycho-social approach Assess psych history Current and past depression, suicidality Rule-out bipolar disorder Med levels affected by smoking Trazodone Bupropion for depression and cessation?

17 Psychology During quit attempt Monitor for depressive symptoms Differentiate between expected withdrawal and psych symptoms Caffeine use? Cognitive Behavioral Therapy

18 Psychology Education Whole health perspective e.g., Long-term association of smoking and greater depression and anxiety Support husband Has she found strategies to effectively manage her diabetes? Modeling for daughter

19 Registered Nurse Maria Feo

Nursing Nursing workforce is strategically situated to make an impact on the leading cause of preventable mortality and morbidity: tobacco use Most trusted healthcare professional (Gallup, 2012)

20 Nursing Nursing workforce is strategically situated to make an impact on the leading cause of preventable mortality and morbidity: tobacco use Most trusted healthcare professional (Gallup, 2012) Nurses have a long history of promoting health and preventing illness Evidence-based bio-psychosocial and holistic approaches, and cultural awareness to care delivery embedded in the nursing curriculum Extensive access to clients in a variety of settings across the continuum of care

Nursing Tobacco-Related Disparities and Cultural Care Ensure disparity issues remain primary concern in a strategic plan Remain culturally sensitive Advocate and support funding on all levels Refer

21 Nursing Tobacco-Related Disparities and Cultural Care Ensure disparity issues remain primary concern in a strategic plan Remain culturally sensitive Advocate and support funding on all levels Refer to Quitline (multiple language counseling options) Implement/ Support programs and interventions for behavioral health clients Collaborate closely with public health venues, coalitions, and community support groups Consider enlisting a (Latino) community outreach coordinator

22 Nursing Complete health history and physical assessment and a (possible)family pedigree Allow autonomy while encouraging self-management skills, lifestyle modifications, and tobacco cessation Referral to a Medicaid accepting PCP (preferably a PCMH) and other eligible services(dental/counseling/nrt) Plan of care to include patient/family education of tobacco-related disease processes and interactions with co-morbidities and medications Careful integration and monitoring of pharmacotherapy if indicated Recognize and validate Gloria s concerns regarding withdrawal symptoms, depression, triggers, and weight gain

23 Nursing Nurses are the largest workforce of healthcare providers and are advantageously poised to make a difference in ending a fatal epidemic Advocate for the tobacco-dependent population Recognize tobacco dependence as a chronic disease Nurses can influence change across the continuum of care via collaborative relationships, establishment of evidencebased protocols, policies, and population-health programs to benefit communities served

24 Dental Healthcare Provider Jill Loewen

Impact on oral health- more successful treatments and outcomes Health consequences

25 Dentistry Trusting relationships with our patients Convenience- not to be referred or have to go somewhere else Opportunities for encouragement, support and follow-up Impact on oral health- more successful treatments and outcomes Health consequences usually seen orally first Contributes to the quality of care and comprehensive care

Dentistry For oral health, our focus: Bad breath Gum/periodontal disease (indicated for this case) Sore throat/hoarseness Reduced smell/taste Unhealthy tissue (indicated for this case) Delayed

26 Dentistry For oral health, our focus: Bad breath Gum/periodontal disease (indicated for this case) Sore throat/hoarseness Reduced smell/taste Unhealthy tissue (indicated for this case) Delayed healing Oral cancer Throat cancer Teeth staining Poor response to dental treatment Oral lesions/ sores on mouth, lips, or tongue Additionally exposure to tobacco has been linked to Doubling a child s risk of caries in the primary dentition An association with delayed and irregular tooth formation

Dentistry Benefits to her oral health: Decrease stains on your teeth and gums Prevent bad breath Lessen the amount of tartar and build-up on your teeth Reduce your risk of oral cancer: Leukoplakia is

27 Dentistry Benefits to her oral health: Decrease stains on your teeth and gums Prevent bad breath Lessen the amount of tartar and build-up on your teeth Reduce your risk of oral cancer: Leukoplakia is a precancerous condition that most likely will disappear with no further tobacco use Improve healing after a tooth extraction or other oral surgery Better response to periodontal treatment and healthier gum tissue as an outcome Risk for tooth loss decreased, with improved periodontal condition (bone loss and tissue inflammation minimized)

28 28 Dentistry Dental practice in the 21st century will increasingly move from a restorative orientation to one of broader promotion of health and well-being. It is unconscionable to not include aggressive tobacco intervention in that new paradigm. Tomar 2001

29 Respiratory Care Practitioner Susan Ryan & Laura Van Heest

Respiratory Care Practitioner Working partnership with clients, with high degree of trust and mutual respect Comprehensive knowledge about health effects

and stamina in lay terms Have coping skills tool kits that also help improve work of breathing and ADLs for clients with pulmonary disease Able to provide

30 Respiratory Care Practitioner Working partnership with clients, with high degree of trust and mutual respect Comprehensive knowledge about health effects helping clients understand cause and effect related to their health concerns Able to explain concepts such as relationships between Carbon Monoxide (CO) and stamina in lay terms Have coping skills tool kits that also help improve work of breathing and ADLs for clients with pulmonary disease Able to provide social support for chronically ill clients by inclusion in support groups Trusted health team members- recognized expertise and good rapport with physicians.

31 Respiratory Care Practitioner For Gloria, counseling from an RC perspective would likely include exploring the importance of improving her breathing and stamina, and offering information and coping skills that help manage both smoking urges and SOB Offering information about possible added risk for alpha-1 antitrypsin deficiency and COPD in some Latinos might enhance Gloria s commitment to quit Social support via pulmonary rehab and support groups should Gloria have early COPD, asthma, etc.

32 Respiratory Care Practitioner Value-added knowledge related to health care problems important to the client. Tie to health-related goals and desires, even when faced with significant chronic health problems. RCPs can be especially effective working with clients concerned with: COPD, Lung CA, Asthma, Cystic fibrosis, Alpha-1 antitrypsin deficiency, Chronic bronchitis, Bronchiectasis, Secondhand smoke cardiac and vascular disease

33 Concluding Thoughts

Concluding Thoughts Healthcare has an increasing prevention and wellness focus Wellness is everyone s responsibility, and not the exclusive purview of any one discipline Tobacco

34 Concluding Thoughts Healthcare has an increasing prevention and wellness focus Wellness is everyone s responsibility, and not the exclusive purview of any one discipline Tobacco use is a complex social, environmental, and biological problem no single perspective is sufficient Comorbidity is the rule not the exception A Call for integrated systems of care

35 never lose an opportunity of urging a practical beginning, however small, for it is wonderful how often in such matters the mustard-seed germinates and roots itself. Florence Nightingale

36 Interdisciplinary Committee Angela Brumley-Shelton Maria Feo Frank Leone Donna Richardson Susan Ryan Laura Van Heest Jill Loewen Chad Morris

Oral Health: An Essential Component of Primary Care. Executive Summary

Oral Health: An Essential Component of Primary Care Executive Summary June 2015 Executive Summary The Problem Oral health is essential for healthy development and healthy aging, yet nationwide there is