Practical Skills for Working with your Patients who Smoke. Daryl Sharp, PhD, APRN, BC, FNAP University of Rochester

Transcription

1 Practical Skills for Working with your Patients who Smoke Daryl Sharp, PhD, APRN, BC, FNAP University of Rochester 1

2 Epidemiology: Smoking and Mental Illness People with serious mental illness die, on average, 25 years younger than the general population Poorer health care A 10 year study of elevated coronary heart disease risk in schizophrenia: tobacco use identified as the major causal factor after controlling for BMI/weight 59% of public mental health facilities permit smoking 2

3 Epidemiology: Smoking and Mental Illness Overall smoking in the United States has decreased but the proportion of smokers with psychiatric disorders has increased 75% of those with either addictions or mental illness smoke compared to 21% in the general population Nearly ½ the cigarettes smoked in the U.S. are smoked by those with psychiatric disorders 3

4 Epidemiology: Smoking and Mental Illness Smoking Prevalence among People with Mental Illnesses Major Depression 50-60% Anxiety Disorder 45-60% Bipolar Disorder 55-70% Schizophrenia* 65-85% ADHD 40% *20% of those with schizophrenia started smoking at college age and many began smoking in mental health settings, receiving cigarettes for good behavior 4

5 Social factors to consider Limited education Poverty Steinberg, Williams, & Ziedonis (2004) found that smokers with schizophrenia spent at least 1/4 of their monthly disability on cigarettes Unemployment Abundance of smoking peers Underground market for cigarettes Loosies Indian Reservations 5

6 Clinician factors to consider Psychiatric clinicians have responded slower than other health professionals Cigarettes as behavioral reinforcement Belief that smoking reduction/cessation is not a realistic goal Patients only pleasure & least of their worries Contributes to normalizing 6

7 Common Patient Perspectives Smoking helps me calm down. Smoking helps me concentrate. I smoke because I m bored. Smoking is one of the few things I do that I enjoy. Sticking to a cessation plan is too hard. 7

8 Yet many smokers with psychiatric illnesses do want to quit People with mental illnesses want to stop smoking and often seek information about how to stop smoking They (and we) often lack confidence, however, in their ability to be successful They often lack social support, which predicts better cessation rates 8

9 The same interventions that help the general population are likely to help our clients if provided at greater intensity and for longer periods of time 9

10 The nature of nicotine addiction Of all the substances of abuse, nicotine has the highest probability of causing dependency when one has tried it at least once; nicotine may be the most addicting substance known. 10

11 Nicotine Pharmacodynamics (Taylor, 2006) Nicotine binds to receptors in the brain and other sites in the body Central nervous system Cardiovascular system Gastrointestinal system Exocrine glands Adrenal medulla Other: Neuromuscular junction Sensory receptors Other organs Peripheral nervous system Nicotine has predominantly stimulant effects. 11

12 Nicotine Pharmacodynamics Central nervous system Pleasure Arousal, enhanced vigilance Improved task performance Anxiety relief Other Appetite suppression Increased metabolic rate Skeletal muscle relaxation Cardiovascular system Heart rate Cardiac output Blood pressure Coronary vasoconstriction Cutaneous vasoconstriction 12

13 Prefrontal cortex Dopamine Reward Pathway (Schwartz-Bloom: Dopamine release Nucleus accumbens Ventral tegmental area Stimulation of nicotine receptors Nicotine enters brain 13

14 Chronic Administration of Nicotine: Effects on the Brain Human smokers have increased nicotine receptors in the prefrontal cortex. Hig h Low Nonsmoker Smoker Image courtesy of George Washington University / Dr. David C. Perry 14

15 Neurochemical and Related Effects of Nicotine Dopamine Norepinephrine Acetylcholine Glutamate Serotonin β-endorphin GABA Pleasure, appetite suppression Arousal, appetite suppression Arousal, cognitive enhancement Learning, memory enhancement Mood modulation, appetite suppression Reduction of anxiety and tension 15

16 Nicotine Addiction Cycle 16

17 Nicotine Pharmacodynamics: Withdrawal Effects Depressed mood Insomnia Irritability Anxiety Difficulty concentrating Restlessness Increased appetite & eating Craving for tobacco Hedonic dysregulation Although symptoms may peak hr after quitting and subside within 2 4 weeks, there is considerable individual variation in withdrawal symptoms so it is very important to listen to what your patients tell you! 17

18 Potential neurobiological benefits of nicotine for those with psychiatric disorders Effects on neurotransmitters postulated to: Reduce negative (deficit) symptoms of the schizophrenic syndrome Improve working memory, attention, & motor speed Normalize impaired sensory gating function Reduce antipsychotic drug side effects, e.g. akathisia 18

19 Nicotine Pharmacology & Addiction Nicotine dependence is a form of chronic brain disease. Tobacco use is a complex disorder involving the interplay of the following: Pharmacology of nicotine (pharmacokinetics and pharmacodynamics) Environmental/social factors Physiologic factors Treatment of tobacco use and dependence requires a multifaceted treatment approach 19

20 Tobacco Dependence Treatment Tobacco Dependence Physiological The addiction to nicotine Treatment Behavioral The habit of using tobacco Treatment Medications for cessation Behavior change program Treatment should address the physiological and the behavioral aspects of dependence. 20

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22 PHS Guideline for Treating Tobacco Use & Dependence Highly significant health threat Disinclination among clinicians to intervene consistently Presence of effective interventions 22

23 Types of Interventions Lower intensity 3-10 minutes Targets smokers who are willing, unwilling, and those who recently quit Higher intensity Session length > 10 minutes 4 or more sessions Tend to be coordinated by tobacco dependence specialists Multiple clinician types 23

24 Recommended Clinical Approaches 4 The 5 A s for patients willing to make a quit attempt 4 The 5 R s for patients unwilling to make a quit attempt at this time 4 Relapse prevention for patients who have recently quit 4 Intensive interventions should be provided when possible (there is a strong dose-response; more intensity = better quit rates) 4 Health care administrators, insurers, and purchasers should institutionalize guideline findings 24

25 Lower Intensity Interventions: The 5A s for Patients Willing to Quit ASK about tobacco use 4ADVISE to quit 4ASSESS willingness to make a quit attempt 4ASSIST in quit attempt 4ARRANGE for follow-up 4 VARIATIONS include (per SCLC): 4 Ask-Advise-Refer* (*our first targeted goal) 4 Ask & Act 25

26 Lower Intensity Interventions: The 5R s for Patients Unwilling to Quit 4 RELEVANCE: Tailor advice and discussion to each patient 4 RISKS: Discuss risks of continued smoking 4 REWARDS: Discuss benefits of quitting 4 ROADBLOCKS: Identify barriers to quitting 4 REPETITION: Reinforce the motivational message at every visit 26

27 PHS Guideline: Format & Process of Higher Intensity Treatment Format: Multiple types of clinicians Session length: Longer than 10 minutes Number of sessions: 4 or more Individual or group; can supplement with telephone counseling Clinician approach (process):* Support autonomy Empathic *Recommended for both lower and higher intensity interventions 27

28 PHS Guideline: Components of Higher Intensity* Treatment (*our second targeted goal) Pharmacotherapy Risks/benefits Educate regarding withdrawal/toxicity Practical counseling Problem solving Skills training (coaching re: coping) Supplement with QUITNOW Intratreatment social support Positive, encouraging, & compassionate 28

29 Pharmacotherapeutic Interventions All patients attempting to quit smoking should be encouraged to use effective pharmacotherapy except under special circumstances 29

30 2008 Meta-Analysis Effectiveness & Abstinence Rates 6 months post-quit (N = 86 studies) Medication Estimated Odds Ratio Estimated abstinence rates Placebo % Varenicline (2 mg/day) % Nicotine nasal spray % High dose nicotine patch (>25mg) % LT nicotine (>14 wks) % Varenicline (1 mg/day) % Nicotine inhaler % 30

31 2008 Meta-Analysis Effectiveness & Abstinence Rates 6 months post-quit (N = 86 studies) Medication Estimated Odds Ratio Estimated abstinence rates Placebo % Clonidine % Bupropion SR % Nicotine patch (6-14 wks) % LT nicotine patch % Nortriptyline % Nicotine gum (6-14 wks) % 31

32 How Nicotine Replacement Therapies (NRT) Work Smoking stimulates α4β2 receptors Receptors become desensitized within minutes (~one cigarette) Receptors re-sensitize after 45 minutes WITHDRAWAL symptoms NRT alleviates re-sensitization of nicotinic α4β2 receptors responsible for withdrawal 20 cig/pack 32

33 NRT: Products Polacrilex gum Nicorette (OTC) Generic nicotine gum (OTC) Lozenge Commit (OTC) Generic nicotine lozenge (OTC) Nasal spray Nicotrol NS (Rx) Inhaler Nicotrol (Rx) Transdermal patch Nicoderm CQ (OTC) Generic nicotine patches (OTC, Rx) 33

34 A Patient-Centered Approach to NRT Dosing Estimate amount of nicotine patient is getting from smoking Generally mg. of nicotine/cigarette Cover with comparable NRT (often helpful to use a continuous + intermittent form of NRT) mindful that NRT is more slowly absorbed than nicotine from cigarettes; higher peak levels of nicotine result in higher subjective effects of nicotine; often need higher doses of NRT to achieve same effects Review signs/symptoms of potential side effects including information that combination NRT is not FDA approved/discuss risks & benefits 34

35 A Patient-Centered Approach to NRT Dosing Teach patient signs/symptoms of nicotine withdrawal & nicotine toxicity On a scale of 0-3 (0=none; 1=mild; 2= moderate; 3= severe) Signs of withdrawal: Anxiety Irritability Difficulty concentrating Cravings for cigarettes Signs of toxicity Nausea Sweating Palpitations 35

36 Nicotine Patch Advantages: Easy to use, private, one per day, helps with early morning cravings Disadvantages: Skin reactions, not orally gratifying, vivid dreams, insomnia Dosage: 4 weeks - 21mg/24hrs. then 2 weeks - 14mg/24hrs. then 2 weeks - 7mg/24 hrs. Costs: $4.25/day 36

37 Nicotine Gum Advantages: Orally gratifying, useful to offset cravings Disadvantages: Poor taste, mouth soreness, dyspepsia, hiccups Dosage: Maximum dose: 24 pieces/day patient smokes < 25 cigs/day: 2mg patient smokes > 25 cigs/day: 4mg *must use correctly: chew & park Costs: $6.25/day (about 10 pieces) 37

38 Nicotine Inhaler Advantages: Mimics smoking, keeps hands & mouth busy Disadvantages: Mouth & throat irritation, coughing, rhinitis, Less effective below 40 F Dosage: 6 16 cartridges/day One cartridge lasts 20 min. continuous puffing Good for 24 hours if not used completely Costs: $ /day 38

39 Nicotine Nasal Spray Advantages: Higher nicotine levels, fast relief for heavy smokers, rapid delivery of nicotine Disadvantages: Nasal irritation, sneezing, coughing, runny nose Dosage: 1 2 doses/hour (in each nostril) minimum dose: 8 doses/day maximum dose: 40 doses/day Costs: $ /day 39

40 Nicotine Lozenge Advantages: Keeps mouth busy, easy to use in social situations Disadvantages: Mouth/throat irritation, heartburn, indigestion, hiccups & nausea Dosage: minimum dose: 9 lozenges/day 2mg: smokes 1 st cigarette after 30 min. of waking 4mg: smokes 1 st cigarette within 30min.of waking Costs: $4.50/day 40

41 Additional NRT Guidelines Combining the nicotine patch & ad libitum NRT (nicotine gum/nicotine nasal spray) is more efficacious than a single form of NRT FDA has not approved combination NRT strategy Certain groups of smokers may benefit from extended use of NRT Continued use of medication is clearly preferable to a return to smoking with respect to health consequences Risks/benefits analysis and patient preferences should inform pharmacotherapy choices 41

42 NRT: Precautions Patients with underlying cardiovascular disease; package inserts recommend caution: Recent myocardial infarction (within past 2 weeks) Serious arrhythmias Serious or worsening angina There is no evidence of increased cardiovascular risk with NRT Other precautions Active temporomandibular joint disease (gum only) Pregnancy/Lactation 42

43 Bupropion SR Advantages: Antidepressant, less weight gain, FDA approved for maintenance therapy (6mos) Disadvantages: May disrupt sleep, possible headaches, & dry mouth, seizure risk Dosage: Begin 1-2 weeks prior to quit date 150mg q am for 3 days Increase to 150mg b.i.d. (at least 8 hours apart) Costs: $3.25/day 43

44 Varenicline Partial agonist selective for the nicotine acetylcholine receptor Advantages: Dual mechanism of action: agonist and antagonist effects Disadvantages: Nausea, insomnia, vivid dreams, headaches; use with caution in patients with renal dysfunction Dosage: Begin 1 week prior to quit date to minimize nausea/insomnia Days 1 3: 0.5 mg qd Days 4 7: 0.5 mg bid Days 8 28: 1 mg bid An additional 12 wks recommended for those who quit Adjust dose for real insufficiency 0.5 mg/d for GFR < 30 *Should be taken after eating and with full glass of water Costs: $3.30/day 44

45 Varenicline: Public Health Advisory FDA WARNINGS and PRECAUTIONS (February 2008) Serious neuropsychiatric symptoms Changes in behavior Agitation Depressed mood Suicidal ideation Attempted and completed suicide Developed during Chantix therapy and during withdrawal of Chantix therapy May cause recurrence or exacerbation of psychiatric illness 45

46 Combination Pharmacotherapy Bupropion SR + NRT can be safely combined; considered a first line medication combination NRT should NOT be combined with Varenicline The safety of combining Bupropion & Varenicline has NOT been established 46

47 Second-Line: Clonidine* *NOT FDA APPROVED FOR SMOKING CESSATION Alpha-2 agonist used primarily as an antihypertensive; decreases nicotine withdrawal symptoms Advantages Available as transdermal patch Disadvantages SE: sedation, dry mouth, hypotension, dizziness Abrupt discontinuation: HA, agitation, tremor, rapid rise in BP Dosage mg/day (dosing regimen in smoking cessation not established) 47

48 Second-Line: Nortriptyline* *NOT FDA APPROVED FOR SMOKING CESSATION Tricyclic antidepressant; decreased urges to smoke Advantages Efficacy: doubles chances of long-term abstinence; inexpensive Disadvantages CV effects: orthostatic hypotension; arrhythmias; dry mouth; sedation; weight gain; blurred vision; urinary retention Dosage mg/day 48

49 When patients stop smoking May be at risk for medication toxicity The tar in smoke enhances P450 enzyme system Increased 1A2 isoenzyme activity Smoking can increase metabolism of meds (decreased serum levels) Those who smoke tend to be on higher medication doses 49

50 Drugs potentially affected by smoking Watch for signs of toxicity Caffeine Theophylline Fluvoxamine Olanzapine Clozapine Not a problem with NRT! 50

51 On the Horizon Rimonibant (a cannabinoid or CB-1 receptor antagonist) Nicotine Vaccines Monoamine oxidase inhibitors (MAO-A & MAO-B) Dopamine D 3 partial agonists or antagonists Inhibitors of CYP2A6 activity Selective nicotinic cholinergic receptor agonists and antagonists in addition to Varenicline 51

52 Medicare Tobacco Dependence Coverage Counseling: document time spent with patient 3 10 min, 10 min. or more per session Two cessation attempts/yr. Each attempt = 4 sessions Medicaid (NYS) Medications: NRT, bupropion SR, & varenicline Two courses/yr. Course = 90 day supply 52

53 Medications are not magic! Clients do best with properly dosed pharmacotherapy AND intensive tobacco dependence counseling 53

54 Practical Counseling: Skills building/problem solving and mobilizing social support Developing Quit Plans Problem-solving Skills building Identifying sources of social support Intratreatment (treatment team) Extratreatment (family/friends; not included in 2008 PHS Guidelines) 54

55 Process of counseling Studies have shown that the way in which you counsel your clients makes a difference in how successful they are in changing health behaviors The PROCESS of counseling is as important as the CONTENT of the intervention 55

56 Mobilizing Motivation: Autonomy Support/Motivational Interviewing Stay mindful of importance of psychological need satisfaction: Autonomy Competence Relatedness Counselor-client relationship is a partnership (not expert/recipient) Elicit and acknowledge the client s perspective Listen well and reflect 56

57 Mobilizing Motivation: Autonomy Support/Motivational Interviewing Advise client about the importance of stopping smoking to health in a clear but non-controlling manner Do not use information as a weapon/threatening manner Provide health risks/benefits information; pharmacotherapy & quit plan options when invited/client signals readiness Ask permission Check in with clients about how they are hearing the information Provide rationale for suggestions you offer Avoid willfulness and maintain neutrality Support client initiatives for change 57

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59 Preventing Relapse 4 Relapse prevention interventions should be provided with every smoker who has recently quit 4 Crucial to address relapse the first 3 months after quitting (6 months in SMI population) 4 Strategies to use with recent quitters: 0 Encourage continued abstinence 0 Invite discussion of benefits, success milestones, problems encountered or anticipated 0 Use or refer to an intensive intervention as appropriate 59

60 Case Study #1: Tobacco free X 3 weeks History: 44 y/o male with schizoaffective disorder; generalized anxiety disorder CPD X 31 years Meds: Risperidone Abilify Depakote Ativan Lipitor Successfully quit for 3 months using: 21mg. patch + 7 mg. patch doses of nasal spray Relapsed Unsuccessful trial of Varenicline Current NRT: 21 mg. Patch 7 mg. Patch 4 mg. gum (5-6 pieces) Nasal spray (6-7 doses) 60

61 Case Study #2: Smokes 2-4 cigarettes over the weekend only Hx: 48 y/o female with paranoid schizophrenia; 2 PPD X 34 years Received tobacco dependence counseling in group home Varenicline: 1 mg. BID (prescribed by PCP) Is tobacco free during week; smokes 2-4 cigarettes on weekends with mother; has had a few 2-4 week periods of abstinence Used 2 mg. gum over the weekends after feeling deprived Discontinued gum and continues on Varenicline X 9 months No adverse effects reported although client eager to discontinue ASAP: PCP advised her that she needed to be abstinent 3 months prior to d/cing Varenicline 61

62 Case Study #3: Tobacco free X 10 weeks Hx: 24 y/o male with schizoaffective disorder; seizure disorder and learning disability; alcohol dependence; 1 PPD X 4 years Meds: Depakote Lamictal Geodon Effexor Stopped smoking 6.5 weeks: January 08 using Nicotrol inhaler (5-6 cartridges a day) + 21 mg patch Called AA sponsor when tempted to use ETOH; advised to take a cigarette instead Bought chewing tobacco as did not want to smoke but then relapsed 8 weeks tobacco free using Nicotrol inhaler (3-4 cartridges) + Commit lozenge (4 mg.): up to 10 daily Psychiatrist then prescribed Varenicline/client used lozenges while building level in Week I Not currently smoking 62

63 Summary Tobacco dependence is an addictive disorder Long term & chronic Characterized by periods of relapse & remission Requires ongoing vs. acute care Calls for ongoing support, counseling, education & pharmacotherapy 63

64 Summary Few mental health professionals effectively address tobacco dependence currently Interventions delivered in primary care or other public health settings usually lack intensity needed for SMI population Effective treatment: Promoting a tobacco free culture in treatment settings No smoking policies Staff consistently addressing tobacco use and supporting clients efforts to quit Providing a specialized tobacco dependence service Easy access to medications Unlimited treatment sessions 64

65 Nursing s responsibility & challenge It is unethical to provide health care and at the same time remain silent (or inactive) about a major health risk The time to act is NOW! Failure to act = HARM Action = HOPE 65

66 References References available via separate document in conference booklet 66

67 Acknowledgements Smoking Cessation Leadership Center: Misty Gonzalez, PharmD Buffalo Psychiatric Center 67