How to Address Tobacco Disparity and Reduce Dependence in Substance Abuse Treatment Facilities Jill M Williams, MD

Transcription

1 How to Address Tobacco Disparity and Reduce Dependence in Substance Abuse Treatment Facilities Jill M Williams, MD Director, Division of Addiction Psychiatry Robert Wood Johnson Medical School

2 Disclosure The faculty, Jill Williams, MD, has received grant funding from Pfizer, Inc. in the past two years. Pfizer, Inc manufactures chantix. Dr. Williams will be discussing chantix in her presentation. The following people have no relevant financial, professional or personal relationships to disclose: CME/CNE Program Planner(s): Robert Cohen, MD (CME Programs) Marsha Marecki, EdD, WHNP-BC (CNE Programs) Melanie Steilen, RN, BSN, ACRN (CNE Programs) CME/CNE Program Reviewer(s): Robert Cohen, MD (CME Programs) Melanie Steilen, RN, BSN, ACRN (CNE Programs) There are no commercial supporters of this activity. Accreditation status does not imply endorsement by NJSNA, CAI, or ANCC of any commercial products or services.

3 Housekeeping & Logistics Polls Live questions Typed questions/chat Raise hand Tech Difficulties

4 IMPORTANT NOTICE This GotoWebinar/GotoMeeting service includes a feature that allows audio and any documents and other materials exchanged or viewed during the session to be recorded. By joining this session, you automatically consent to such recordings. Please note that any such recordings may be subject to discovery in the event of litigation.

5 Introduction/Presenter Jill M. Williams, MD Professor of Psychiatry Director, Division of Addiction Psychiatry Rutgers- Robert Wood Johnson Medical School New Brunswick,

6 Learning Objectives Review the high prevalence and consequences of tobacco use in persons with other addictions. Discuss barriers that have prevented substance abuse staff from addressing tobacco dependence in their clients Explain key concepts in brief assessments of tobacco dependence including level of dependence and motivation to quit. Describe how treatment for tobacco dependence is an effective method for increasing the success of quit attempts and the role a nonprescriber can have in promoting treatment. Review evidence based treatments for tobacco dependence treatment and how to integrate tobacco dependence treatment into recovery plans.

7

8 Tobacco Use Rates in NJ Addictions Treatment Settings Tobacco Use Rates US NJ Addictions Residential Methadone Outpatient NJ ADADS

9 Smoking Prevalence in Addiction Treatment Review of 40 papers (over 20 years) Inpatient, outpatient, methadone programs Alcohol and drug treatment Median prevalence for a single year 76% (range 65% to 76%) Odds of smoking 2.25 times higher in methadone treatment as compared to other outpatient programs (Guydish, Passalacqua, Tajima, Chan, Chun & Bostrom, 2011)

10 Rationale Not to Treat Tobacco Dependence in SUD Patients Not a real drug Fewer consequences / Not as disruptive to patients life Disruptive to SUD treatment Patients don t want tobacco treatment Patients can t quit smoking successfully Jeopardizes recovery from other substances

11 Not a Real Drug

12 % of Basal Release % of Basal Release % of Basal Release Effects of Drugs on Dopamine Levels 400 Accumbens COCAINE 300 DA DOPAC HVA hr Time After Cocaine hr Time After Nicotine NICOTINE Accumbens Caudate Source: Di Chiara and Imperato Accumbens AMPHETAMINE DA DOPAC HVA hr Time After Amphetamine

13 Fewer Consequences; Not Immediate More alcoholics die from smoking related diseases than from alcohol related diseases Synergistic effects of alcohol and tobacco risk of developing pancreatitis and oral cancers Smoking reduces recovery from cognitive deficits during alcohol abstinence Hurt et al, 1996; USDHHS 1982 Durazzo et al, 2007

14 Disruptive to SUD Treatment No increase in irregular discharges when residential SUD settings went TF(NJ) Clients enrolled in treatment when facility went TF (Kotz et al, 1993) Longer LOS when patients enrolled in smoking cessation program (Burling et al., 1991). No increase in early discharges (Joseph, 1993). Williams et al, 2005

15 2001 NJ Integration of Tobacco Dependence Treatment into Residential Substance Abuse Treatment In 1999, NJ established NJAC 8:42A Required residential addictions programs To provide tobacco assessment and treatment Prohibited tobacco products on the grounds of facilities. Full implementation by Nov The state provided free nicotine patches and gum to clients in these settings UMDNJ training and consultation

16 Staff shall not use alcohol, tobacco or illegal drugs during working hours or when representing the treatment facility. 8:42A-3.5 (b) 1

17 Joseph et al., 1990; Irving et al., 1994; Sees and Clark, 1993; Saxon et al., 1997; Seidner et al., 1996; Foulds & Doverty, 2003: Joseph et al., 2002 Advantages of Addressing Tobacco During Early Substance Recovery Structured environment focused on recovery Staff and peer support readily available Patients may be more motivated, believing this is the best time to quit Smoking quit rates in early substance recovery are the same as when treatment is delayed 6 mos (Joseph et al.,2003). Financial advantages if clients lack insurance

18 Did the NJ 2001 implementation of the Tobacco Provisions of the Licensure Standards result in an increase in premature client discharges? NO There was no increase in irregular discharges. Rates were not statistically significant from discharge rates in previous years. The rates of irregular discharge were also not statistically significant between smokers and non-smokers. Williams et al, 2005

19 % reporting activity NJ Policy Resulted in Increased Tobacco Treatment Figure 1: Percent of New Jersey residential addictions treatment agencies reporting tobacco-related activities before (1999) and after (2002) statewide Tobacco Licensure S tandards (n=30) Tobacco Assessment Tobacco Counseling NRT Available Tob. in Discharge Plan Staff Trained on Tobacco Written Staff Tob. Policy Foulds et al., 2006

20 Aug Nov Feb May Aug Nov Feb May Aug Nov # Admissions No Reduction in Program Admissions Total For All Major Program Types OASAS NY Tobacco-Free Implementation - July ,000 31,500 28,000 24,500 21,000 17,500 14,000 10,500 7,000 3,500 0 Total For All Major Program Types August 2007 to December 2009 Time Period

21 Patients Resistant to Tobacco Treatment Two-thirds of smokers wanted to stop (41%) or cut down on tobacco use (24%) at time of admission to residential addictions treatment Williams et al, 2005 Patients highly interested in treatment and believe inpt treatment is best time Orleans & Hutchinson, 1993; Shoptaw et al., 2002; Richter et al, 2001; Nahvi, et al, 2006; Sees & Clark, 1993; Clemmey et al, 1997; Frosch et al, 1998; Clarke et al 2001; Joseph et al., 1990; Saxon et al., 1997; Joseph et al., 2002

22 Patients with SUD Can t Quit Smoking H/o ETOH Just as likely to succeed in quitting smoking as other smokers Usual treatments effective Smokers learned skills in recovering from alcohol that helped them quit smoking Hughes & Kalman, 2006

23 Lifetime Quitting Smokers with current alcohol problems, were less likely to have quit in their lifetime than smokers with no problems? Fewer quit attempts Hughes & Kalman, 2006

24 Jeopardizes Recovery from other Substances Several studies show no adverse effects on abstinence Bobo et al. 1996, 1998; Hurt et al., 1994; Cornelius et al. 1997, 1999; Prochaska et al. 2004; Lemon et al, 2003; McCarthy et al, 2002; Shoptaw et al., 2002 Quitting smoking may help with longterm abstinence from alcohol and other drugs

25 Smoking Cessation Treatment Does Not Jeopardize Recovery from other Substances META ANALYSIS OF 19 RANDOMIZED CONTROL TRIALS WITH INDIVIDUALS IN CURRENT ADDICTION TREATMENT OR RECOVERY SMOKING CESSATION INTERVENTIONS PROVIDED DURING ADDICTIONS TREATMENT WERE ASSOCIATED WITH A 25% INCREASED LIKELIHOOD OF LONG-TERM ABSTINENCE FROM ALCOHOL AND ILLICIT DRUGS SMOKING CESSATION WORKED WELL INITIALLY BUT WAS DIFFICULT TO SUSTAIN IN THE GROUPS IN THE LATER STUDIES WHICH USED NRT S, SUCCESS WAS INCREASED PROCHASKA ET AL JCCP 2004

26 Smoking cessation in outpatient SA treatment Part of CTN, included methadone sites N=225 smokers SC adjunct or treatment-as-usual (TAU) 9 weeks group counseling plus NP No difference in SC vs TAU on rates of retention in SA tx abstinence from primary substance craving for primary substance. Reid et al., 2008

27 Tobacco Treatment Availability National survey of 550 OSAT units ( ) 88% response rate 41% offer smoking cessation counseling or pharmacotherapy 38% offer individual/group counseling 17% provide quit-smoking medication More likely : medically oriented, more comprehensive services, recognize the health burden of smoking Friedmann et al., JSAT 2008

28 Twelve Steps to Addressing Tobacco within Addiction Treatment Programs 1. Acknowledge the Challenge to Address the Barriers and Integrate the Solutions 2. Establish a Leadership Group and Make a Commitment to Change 3. Create a Change Plan and Realistic Implementation Timeline 4. Start with easy program and system changes, including tobacco policies 5. Conduct Staff Training 6. Assess and Document in charts nicotine use, dependence, and prior treatments 7. Incorporate Tobacco Issues into all client education curriculum 8. Provide Medications for Nicotine Dependence Treatment 9. Provide treatment and recovery assistance for interested nicotine dependent staff 10. Integrate Motivation-Based Treatments throughout the program 11. Establish ongoing communication with 12-Step Recovery Groups, Professional Colleagues, and Referral Sources about system changes 12. Consider additional Addressing Tobacco Policies, including Smoke- Free Grounds

29 Assessment Level of Nicotine Dependence Motivation to Quit First age smoked Years smoked Current amount Tobacco types (pipes, cigars, smokeless) Smokers in household Consequences of use- health or other

30 Tobacco Use Disorder Most tobacco users are addicted (2 or more) withdrawal tolerance desire or efforts to cut down/ control use great time spent in obtaining/using reduced occupational, recreational activities use despite problems larger amounts consumed than intended Craving; strong urges to use DSM-5

31 Nicotine Pharmacology Pharmacology depends on delivery route Reaches brain in 10 sec Arterial levels 6-10x higher than venous Half-life 2 hours Metabolized to cotinine in liver

32 Russell et al., BMJ, 1983

33 Tobacco Withdrawal Depressed mood Insomnia Irritability, frustration or anger Anxiety Difficulty concentrating Restlessness Increased appetite or weight gain

34 Heaviness of Smoking Index= Measure of Dependence Number of cigarettes per day (cpd) AM Time to first cigarette (TTFC) 30 minutes = moderate 5 minutes = severe Heatherton 1991

35 Smokers in Addiction Treatment are Moderately to Severely Addicted to Nicotine 0-5 min 6-30 min > min 6-30 min >31 N=1882 smokers in NJ addictions treatment, ; Williams et al., 2005

36 MORE Nicotine Dependence and Withdrawal in SUD Current, past or lifetime alcohol problems were associated with nicotine dependence Smokers with SUD are more likely to report withdrawal symptoms Smokers with SUD have likelihood of withdrawal-related discomfort and smoking relapse Hughes & Kalman, 2006; Weinberger 2010

37 READINESS to QUIT in SPECIAL POPULATIONS Intend to quit in next 6 mo Intend to quit in next 30 days General Population General Psych Outpts Depressed Outpatients Psych. Inpatients 40% 43% 55% 41% 20% 28% 24% 24% Smokers with mental illness or addictive disorders are just as ready to quit smoking as the general population of smokers. Methadone Clients 48% 22% 0% 20% 40% 60% 80% 100% * No relationship between psychiatric symptom severity and readiness to quit Slide Courtesy J Prochaska; Acton 2001; Prochaska 2004; Prochaska 2006; Nahvi 2006

38 Hard to Quit Without Treatment 70% of smokers report wanting to quit someday Few people quit successfully without treatment Only 1/3 of quitters (without treatment) remain abstinent for 2 days < 5% ultimately successful on a given quit attempt

39 Pharmacological Treatment Rationale Reduce or eliminate withdrawal Block reinforcing effects of nicotine Manage negative mood states Unlearn smoking behaviors Cost-effective treatment Lessen/delay weight gain

40 First-line Treatments (FDA Approved) Nicotine Replacement Bupropion Zyban/ Wellbutrin Varenicline Chantix

41 Nicotine Medications Not a carcinogen Use high enough dose Scheduled better than PRN Use long enough time period Can be combined with bupropion Can be combined with each other Have almost no contraindications Have no drug-drug interactions

42 Nicotine Replacement Smokers misinformed about safety/efficacy Risk-benefit ratio nicotine > tobacco

43 NRT for Smokers with Addictions No reason not to use Not introducing a new drug Safer nicotine delivery vs. smoking More patient education Off-label?? Longer time?? Use when continuing to smoke small amounts

44 Pharmacological Treatment Nicotine Replacement Patch Gum Lozenge Inhaler Nasal Spray Bupropion Varenicline

45 Combination Therapies Improves abstinence rates Decreased withdrawal Well tolerated Kornitzer 1995

46 A randomized placebo-controlled clinical trial of five smoking cessation pharmacotherapies 1504 smokers 5 treatments and 5 placebo groups nicotine lozenge nicotine patch bupropion SR nicotine patch + nicotine lozenge bupropion + nicotine lozenge Piper et al., 2009

47 Odds Ratio for 6 months after Quit Date all monotherapies > placebo Loz NP Bup Bup + Loz NP + Loz 0 NP + Loz greatest time to relapse

48 Smoking with NRT Relatively safe Harm Reduction Less reinforcing effects Withdrawal of treatment=punishment for relapsing

49 Cut Down To Quit (CDTQ) NRT previously licensed in the UK for quitting have recently been granted a new licensed indication called cut down to quit (CDTQ). Aims at smokers unwilling or unable to stop smoking in the short term Gradually to cut down smoking over an extended period while taking NRT Gum and inhaler Wang et al., 2008

50 NRT Assisted Reduction 7 Smoking Reduction trials (four Nicotine gum, two inhaler, and one free choice NRT) 2767 smokers NRT for 6-18 months 6.75% of smokers receiving NRT had sustained abstinence for six months, 2X more those receiving placebo No statistically significant differences in adverse events and discontinuation because of adverse events except nausea more with NRT Whether smokers are motivated to reduce then quit or simply motivated to reduce may make little difference to the efficacy of NRT for smoking cessation Moore et al., BMJ, 2009

51 First-line Treatments (FDA Approved) Nicotine Replacement Bupropion Zyban/ Wellbutrin Varenicline Chantix

52 Bupropion SR Start 150mg/day to dose of 150mg bid Nonsedating, activating antidepressant with effects on NE and DA systems Start days prior to quit date Side effects- headache, insomnia Contraindicated in h/o seizures or bulemia Noncompetitive nicotinic receptor antagonist Slemmer 2000

53 Varenicline Summary Selective a4b2 nicotinic receptor partial agonist No drug-drug interactions Precaution in ESRD Dosed with food to reduce nausea

54 Varenicline: a selective a4b2 nicotinic receptor partial agonist Nucleus accumbens Dopamine Mesolimbic system Ventral tegmental area

55 Varenicline Partial Agonist Partially stimulates receptor Some DA release at NAcc Prevents withdrawal Antagonist Blocks nicotine binding a4b2 **Don t use as combination

56

57 Varenicline vs Nicotine Patch Open label (N=776) 12 Week varenicline vs 10 week NP Nausea: varenicline (37%) > NP (10%) Continuous Abstinence, Week 9-12 Week 52 Aubin et al., 2008

58 Varenicline and Alcohol No DB-PC studies Open-label, > 6 months sober 31% quit at 12 weeks (7dPP) No serious adverse events Short-term lab studies of heavy drinkers Smoked less on varenicline vs. placebo Had less alcohol craving and fewer heavy drinking days on varenicline vs. placebo Varenicline reduces alcohol intake in rats Hays 2011; McKee 2009; Fucito

59 Varenicline Labeling Updates Warning (Reported with Chantix) Observe patients for serious neuropsychiatric symptoms including changes in behavior, agitation, depressed mood, suicidal thoughts or behavior Worsening of preexisting psychiatric illness Causal relationship not established Clinical trials (N>5000; SI rate = placebo) Sleep disturbance/ vivid dream

60 Varenicline and Suicide 80,660 smokers prescribed NRT (~63k), varenicline (~11k), and bupropion (~6k); UK, primary care Compared with NRT, the hazard ratio for self harm among people prescribed varenicline was 1.12 (95% CI 0.67 to 1.88), and it was 1.17 (0.59 to 2.32) for people prescribed bupropion. No clear evidence that varenicline was associated with an increased risk of fatal (n=2) or non-fatal (n=166) self harm No evidence that varenicline was associated with an increased risk of depression or suicidal thoughts Gunnell et al., 2009; BMJ

61 Case Report Data Review of FDA's Adverse Event Reporting System (AERS) Case reports for varenicline, bupropion and NRT Suicidal/self-injurious behavior or depression highest in varenicline group Not controlled, randomized studies Re-report of same case report data Moore et al., 2011

62 Bupropion Adverse Effects French dataset: 700,000 patients 1682 cases of adverse reactions were reported ~ 1/3 of these involved SAR Allergic reactions (31.2%), including angioedema and serum sickness-like reactions. Serious neurological reactions were frequent (22.5%), mostly comprising seizures; almost half of these patients had history seizures or other risk factors. Serious neuropsychiatric adverse events reported (17.3%), suicide attempts/suicides were a cause for concern, although risk factors (history of depression, suicide attempts, etc.) were described for 66% of patients experiencing these events. Beyens et al., 2008

63 Medication Interactions with Tobacco Smoke Smoking P450 enzyme system Polynuclear aromatic hydrocarbons (tar) 1A2 isoenzyme activity Smoking metabolism of meds serum levels Smokers on higher medication

64 Drugs Reduced by Smoking Antipsychotics Olanzapine Clozapine Fluphenazine, Haloperidol, Chlorpromazine Antidepressants Amitriptyline, doxepin, clomipramine, imipramine, fluvoxemine desipramine, Others Caffeine, theophylline, warfarin, propranolol, acetominophen Desai et al., 2001; Zevin & Benowitz 1999

65 Quitting Smoking Risk for medication toxicity May levels acutely Consider dose adjustment Clozapine toxicity Seizures Reduce caffeine intake Nicotine (or NRT) Does Not Change Medication Levels Nicotine metabolized by CYP2A6

66 Conclusions Medications should be used for all smokers No contraindication to NRT for outpatient smokers with other addictions Bupropion advantage in depressed smokers- two indications Varenicline more effective than other medication treatments Combinations more effective

67 Questions?