Strategies for Integrating Smoking Cessation & Wellness into Psychiatric & Substance Abuse Treatment Settings

Transcription

1 Strategies for Integrating Smoking Cessation & Wellness into Psychiatric & Substance Abuse Treatment Settings Antoine Douaihy, MD Associate Professor of Psychiatry University of Pittsburgh School of Medicine Medical Director Addiction Medicine Services Western Psychiatric Institute and Clinic

2 Health & Wellness Overall health is essential to mental health Recovery includes wellness

3 Disturbing Statistics Persons with serious mental illness die, on average, 25 years earlier and suffer increased medical comorbidity At least 1 in 5 people has a diagnosable behavioral health disorder during eth course of any given year Persons with substance use disorders (SUD) and psychiatric disorders (PD): have tobacco use disorder at a rate 2 to 3 times higher represent over 44 percent of U.S. tobacco market consume over 34 percent of all cigarettes smoked in the U.S. NASMHPD, 2006 Kessler et al., 2006 Lasser et al., 2000

4 Tobacco Industry Study analyzed previously secret tobacco industry documents Monitored or directly funded research supporting the idea that individuals with schizophrenia: were less susceptible to the harms of tobacco needed tobacco as self medication Promoted smoking in psychiatric settings by: providing cigarettes supporting efforts to block hospital smoking bans Prochaska, Hall, Bero,

5 Responding to Clinical Needs 5

6 Debunking a Huge Myth Smoking cessation has no negative impact on psychiatric symptoms and smoking cessation may even lead to better mental health and overall functioning Participation in smoking cessation efforts while engaged in other substance abuse treatment has been associated with a 25 percent greater likelihood of long term abstinence from alcohol and other drugs Baker et al., 2006; Lawn & Pols, 2005; Morris et al., Unpublished data; Prochaska et al., 2008 Bobo et al., 1995 Burling et al., 2001; Hughes, 1996; Hughes et al., 2003; Hurt et al., 1993; Pletcher, 1993; Prochaska et al., 2004; Rustin, 1998; Saxon, 2003; Taylor et al.,

7 Another Myth Persons with PD and SUD are unable to quit smoking 24 studies: Recorded quit rates of patients with PD and SUD were similar to those of the general population Results not uniform to allow meta analysis el Guebaly N et al., 2002

8 Tobacco Cessation Works Seventy percent of smokers say they want to quit, 40 percent attempt to quit Quitting tobacco is difficult but absolutely feasible if assistance is provided quit rates with willpower alone four percent pharmacotherapy (NRT) alone 22 percent quitline counseling plus NRT 36 percent Varenicline 44 percent Smokers are more than twice as likely to quit with coverage el Guebaly et al.,

9 Smoking Cessation Results Most combine meds & psycho education +/or CBT Schizophrenia: 8 studies (n= 9 70) quit rates percent post treatment, twelve percent at 6 months Depression: 8 studies (n= ) quit rates percent post treatment percent at 12 months el Guebaly et al.,

10 Tobacco & Psychotic Disorders Comorbidity of cigarette smoking and severe psychotic disorders Patients drawn from the Genomic Psychiatry cohort (a multiethnic sample consisting of 9,142 individuals with severe psychotic disorders, and 10,195 population control individuals) Markedly higher" cigarette use than in the general population "at a rate that far exceeded previous estimates based on assessments in individuals with mild mental illness These findings highlight "the need for targeting substance use, specifically among individuals with severe psychotic illness, because protective influences may not carry over from the general population Hartz SM et al., 2014

11 Treatment Options A recent meta analysis found higher rates of smoking cessation associated with NRT (17.6% )and bupropion (19.1%) compared with placebo (10.6%) Varenicline (27.6 percent) and combination NRT (31.5%) were most effective for achieving smoking cessation. None of the therapies was associated with an increased rate of serious adverse events A recent re analysis of data from RCT (N=8027) and the DOD (N= 35,800) found no evidence that varenicline is associated with adverse neuropsychiatric events Current or past psychiatric illness increased the risk of neuropsychiatric events equally in all patients A British study of 119,654 patients treated with either bupropion or varenicline found no difference in risk of suicidal behavior in varenicline versus NRT products Ucar EY et sl., 2014 Cahill K et al., 2013, 2014 Gibbons et al., 2013 Thomas KH et al., 2013

12 Treatments & PD Varenicline as maintenance therapy for smoking cessation in patients with PD Maintenance varenicline versus standard treatment in achieving tobacco abstinence in patients with serious PD Abstinence at one year was three times higher among those assigned to maintenance varenicline treatment (60 percent) versus those assigned to placebo (19%) Varenicline maintenance treatment in adults with stably treated current or past depression Varenicline treated participants had higher continuous abstinence rates versus placebo at weeks nine to 52 (20.3% vs.10.4% respectively), with no clinically relevant differences between groups in suicidal ideation or behavior, and no overall worsening of depression or anxiety NRT has been found helpful in reducing agitation in patients with schizophrenia in the emergency department A meta analysis failed to find convincing evidence of its utility in longer term smoking cessation Anthenelli RM et al., 2013 Allen MH et al., 2011 Tsoi DT et al., 2013

13 Electronic Cigarettes Their use remains controversial. E cigarettes are likely safer than regular cigarettes and helpful to some smokers as a means of reducing or quitting smoking?? A prospective 12 month pilot study of e cigarettes in 14 patients with schizophrenia found sustained 50% reduction in the number of cigarettes smoked daily, and sustained smoking abstinence at week 52 was observed in 14.3% of participants "The use of e cigarettes substantially decreased cigarette consumption without causing significant side effects in chronic schizophrenia patients who smoke, not intending to quit Further research is necessary to determine the safety and utility of this treatment Meier E et al., 2013 Caponnetto P et al., 2013

14 Psychosocial Interventions Behavioral strategies University of California San Francisco. Smoking Cessation Leadership Center. Behavioral Health Resources. (2010) Available at: Morris C, Waxmonsky J, May M, et al. Smoking cessation for persons with mental illnesses: A toolkit for mental health providers. (2009) Available at: bacco%20cessation%20toolkit%20january% pdf

15 Conclusion Patients with PD and SUD are frequently willing and ready to quit Use an integrated approach using medications and behavioral interventions