Al Heuer, PhD, RRT, RPFT Professor & Program Dir. Rutgers School of Health Related Professions

Transcription

1 Al Heuer, PhD, RRT, RPFT Professor & Program Dir. Rutgers School of Health Related Professions

2 Learning Objectives Review the Epidemiology and statistics regarding tobacco dependence Identify new tobacco dependence tx quality measures for accreditation/reimbursement Assess the tobacco user s readiness for quit-attempt - Stage of Change Differentiate between type of tobacco user: physical dependence on nicotine vs. behavioral users Advise tobacco users on first-line medications for nicotine dependency Provide Add l Resources

3 Types of Tobacco Dependence Cigarettes Vaping, E-Cigarettes (electronic nicotine delivery systems) Heavy Cigar and Pipe Smokers Smokeless Tobacco (Chewing tobacco, snuff, etc)

4 A Word or Two About Vaping Heated liquid, thus creating fewer hazardous particles that can be inhaled. Mostly Propylene glycol and/or glycerin Nicotine, flavorings and preservatives. Exploding popularity over the past 5 years. Newness means longitudinal studies about health dangers are still in the distant future. Appear to be less harmful than smoking. Saying something is safer than smoking cigarettes isn t exactly setting a high bar. Smoking causes 1 in 5 U.S. deaths each year. Leading preventable cause of premature death

5 Epidemiology--Smoking/Tobacco Use 20.6% U.S. adults smoke, NJ=14.8% #1 Preventable cause of morbidity and mortality in U.S. 443,000 deaths/yr. - $96billion/yr. healthcare 1 Causality established for many cancers, cv & lung disease 1. DNA damage, inflammation, oxidative stress Primary etiology of COPD is exposure to tob. Smoke Only known method to prevent or slow COPD progression: stop smoking Disproportionate smoking prevalence in Medicaid insured 1.

6 Is it Ever Too Late to Consider Quitting??? After One Day without Smoking Blood Circulation Improves Carbon Monoxide Levels Drop Heart Rate and Blood Pressure Drop Heart Attack Risk Drops Within a Few Days of Quitting Smell & Taste Improve PFTs increase Breathing becomes easier

7 Long-term Benefits to Quitting Decrease risk of heart disease Risk drops by half after one-year of quitting! Decrease risks to lung cancer, eventually approaching that of a non-smoker. Decreased Risks of Other Cancers Mouth & esophagus Bladder Pancreas Decreased Risk of COPD Other Health Benefits: Lower risk of cataracts, hearing loss, erectile dysfunction and dementia

8 CDC Clinical Practice Guideline: Treating Tobacco Use and Dependence Evidence Based Guideline Tobacco Dependence is a chronic disease Often requires repeated intervention Multiple quit attempts Avg. 5 to 7 for success Effective treatments exist Treatment significantly increase rates of long-term abstinence Clinicians should offer brief interventions

9 Health Benefits, Even if You Already Suffer from Smoking-Related Illness Reduced risk of a second, third, etc., heart attack. Less risk of subsequent stroke. Reduced progression of COPD. Increased chance of recovery from: Heart Attack Lung Cancer

10 Oversee Hospital Tobacco Use Tx The Joint Commission/CMS Peer review org. of hospital quality care Partner in CMS quality initiatives JC accreditation based on compliance with set performance standards Standard: Smoking cessation advice or counseling is required to be given to admitted patients identified as smokers Smoker = smoked a cigarette in the past year

11 Smoking Cessation Performance Measure Diagnoses Effective July 2011: Any & All diagnoses All admitted patients >18 y/o Consequences of noncompliance: Risk losing accreditation Lose CMS $$ reimbursement for pt. hospital days

12 Inpatient Tobacco Use & Dependence Program Measures 1. Tobacco Use Screening 2. Tobacco Use Treatment Provided or Offered (during hospital stay) 3. Tobacco Use Treatment Provided or Offered at Discharge 4. Tobacco Use Follow-up After Discharge: Assessing Status After Discharge

13 More on Program Measures: 1. Tobacco Use Screening # of inpatients who receive an assessment of tobacco use status Assessment components: Ask about tobacco use Assess willingness to quit Includes all forms of tobacco use: Cigarettes, Cigar, Pipe,Smokeless

14 More on Program Measures 2. Tobacco Use Treatment Provided or Offered # inpatients who receive evidence based counseling to quit AND received or refused FDA approved medications. Includes: 1. Current tobacco user = use in past 30 days 2. Psych. Pts,.Excluded Inpatients: Hospice Comfort measures only documented

15 More on Program Measures 2. Tobacco Use Treatment Provided or Offered Excluded, for counseling only: Severe cognitive impairment Excluded, for medication only: Smokeless tobacco users Pregnant smokers Light smokers (< 10 cig./day) Adolescents <18 y/o Pt. s with contraindications to all FDA approved meds.

16 More on Program Measures:. 3. Tobacco Use Treatment Provided or Offered at Discharge # inpatients referred to or refused evidence based out-pt. counseling AND received or declined FDA approved prescribed medications upon discharge. Excluded for counseling & med. s: Same as measure #2 Post-discharge counseling defined as: Documentation of a fax, call to Quitline, ongoing counseling, referral to community resources

17 More on Program Measures: 4. Assessing Tobacco Use Status After Discharge Outcome Measure Follow-up phone call within 2 weeks after discharge. # inpatients who made a quit attempt or quit Quit attempt: No tobacco in a 24 hr. period Quit: No tobacco in the previous week

18 Hospital-Based Design: Tobacco Treatment Program (TTP) 6 Steps 1. Identify tobacco use on admission 2. Assess readiness to quit - stage of change 3. Assess level of dependency (Not specified in The new JC measures) 4. Practical counseling 5. Recommend/Acquire med. order 6. Post-discharge follow-up

19 Assess readiness to quit: Determine Stage of Change * 6 Stages of readiness for self-change Pre-contemplation no / not ready Contemplation thinking about it Preparation planning quit date Action not using tobacco Maintenance tobacco-free after quit Lapse/Relapse use tobacco again after abstinence period * Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51,

20 Tobacco Dependency Assessment 8 Elements 1. Previous/Present tobacco usage 2. Previous quit attempts 3. Previous withdrawal/abstinence symptoms 4. Fagerstrom Test for nicotine dependence 5. Kessler 6 - mental health screening 6. Medical History 7. Assess Triggers to smoke 8. Optional: CO level Proceed with practical counseling

21 Fagerstrom Test for Nicotine Dependence 6-item measure of physical dependency Validated with biochemical indices of smoking Important for choice of med., dosages Goal - Prevent withdrawal symptoms Score Range: 0-10 points 6-10 = highly dependent on nicotine 5 = moderately dependence < 5 = lower dependence (behavioral)

22 Fagerstrom Test for Nicotine Dependence

23 7 First-Line Medications Nicotine Patch (OTC) Gum (OTC) Lozenge (OTC) Inhaler Nasal Spray Non-Nicotine Bupropion Varenicline (Chantix) Med. Use doubles or triples success rates Counseling + meds. = evidence of most success Fiore, M.C. et al. (2008). Treating Tobacco Use and Dependence, Clinical Practice Guideline, 2008 Update, U.S. Dept. of Health and Human Services, Public Health Service

24 Varenicline (Chantix) Antagonist & Partial agonist Selective for Alpha4 Beta2 nicotinic acetylcholine receptor subtypes Antagonist Blocks nicotine receptors in brain Agonist Partially activates nicotine receptors to cause some release of dopamine

25 Dosage of Chantix Start med. 1 week before quit date Quit smoking on Day #8 (2 mg BID) First Month 0.5mg tablet once a day for 3 days 0.5mg tablet BID for 4 days 1mg tablet BID on day 8 (con. t 3 months) May continue up to 6 months

26 Precautions of Chantix Nausea (take with food) Headache Insomnia Abnormal dreams Depressed Mood* Agitation* Changes in behavior* Suicidal ideation* Suicide* Risk car accidents *FDA recommends: Ask pt. hx of psychiatric illness Monitor any/all pt. for behavior/mood changes *Feb FDA Warning

27 Bupropion (Zyban) SSRI (antidepressant) Inhibits reuptake of dopamine, some serotonin & norepinephrine Dopamine - a feel good neurotransmitter Lingers at brain receptor for pleasure/reward pathway For the Patient on Zyban: No need to use tobacco (nicotine) to activate receptor pathway to release dopamine

28 Bupropion (Zyban) Dosage Start 1-2 weeks before quit date 150 mg every A.M. for first 3 to 7 days Then, on 8 th day, 150mg BID or 300 mg once a day SR & XL formulations available Recommend use 7-12 weeks (up to 6 months) Most common SE: Insomnia, dry mouth

29 Nicotine Replacement Tx (NRT) General Guidelines for CVD 1 NRT use is Not an independent risk factor for acute myocardial events Not contraindicated for general cardiovascular disease patients Use with caution these groups: Within 2 weeks of post-mi Serious arrhythmias Unstable Angina Pectoris

30 Other Nicotine Replacement Tx (NRT) General Guidelines Common possible SE Insomnia Precautions for use in Pregnancy, Class D Patch Gum Oral Inhaler Nasal Spray Not evaluated for safety in Pregnancy: Lozenge Most common mistake is Underdosing!

31 Nicotine Gum/Lozenge: Dosage Decisions: 2 or 4 mg (per piece) Gum: #Cig./Day 2mg (< 25 cig/day) 4 mg (> 25 cig/day) Use 1 piece Q 2-3 hours Don t exceed 24/day Use up to 12 weeks Lozenge: minutes to first cig. after wake 2mg (> 30 min. after wake) 4mg (< 30 min. after wake) Use 1 piece Q 1-2 hrs for first 6 wks (Min. 9/day) Don t exceed 20 day Use up to 12 weeks

32 Nicotine Gum/Lozenge (Cont.) Prescribing instructions Gum: Chew-Park-Chew (oral mucosal absorption) In mouth for 30 minutes only Absorption (alkaline) No acidic beverages/food for 15 min. pre/post Side effects (mild) mouth soreness hiccups (heartburn-lozenge) Dyspepsia (stomach upset) jaw ache

33 Nicotine Oral Inhaler (prescription only) Dosage: 1 inhalation or puff One 4 mg cartridge = 80 inhalations Frequent puffing recommended Use 6-16 cartridges/day, for 6 months Begin to taper use after 3 months Absorption mechanism same as gum/lozenge Side Effects: Local mouth, throat irritation, coughing

34 Nicotine Nasal Spray (prescription only) Dosage: one 0.5mg/spray-each nostril 1-2 doses per hour; increase if needed Minimum (8 doses/day) Maximum (40 doses/day) 100 doses/bottle Use 3-6 months Prescribing Instructions Tilt head back. Do not sniff, swallow, or inhale through the nose (increases irritation).

35 Nicotine Patch (Cont.) Dosages (16 or 24 hour patches) < 10 cig/day = 14 mg (Step 2) for 6 wks 7 mg (Step 3) for 2 wks > 10 cig/day = 21 mg (Step 1) for 4 wks 14 mg (Step 2) for 2 wks 7 mg (Step 3) for 2 wks Minimum Tx Period is 8 Weeks!! Prescribing Instructions Place on skin between neck and waist May remove before sleep if insomnia

36 Combination NRT 1 More effective than single NRT Especially useful if single NRT insufficient to control cravings 1. May be seen with high pack-year history 1. Nicotine patch long-term (> 14 weeks) + gum, or nasal spray (37% ) 2. Nicotine patch + inhaler (26%) Fiore, M.C. et al. (2008). Treating Tobacco Use and Dependence, Clinical Practice Guideline, 2008 Update, U.S. Dept. of Health and Human Services, Public Health Service

37 Symptoms of Nicotine Overdose Severe headaches Dizziness Upset stomach/pain Salivation Vomiting Diarrhea Cold sweat Blurred vision Hearing difficulties Mental confusion Weakness Fainting

38 Other Combination Therapy NRT and Bupropion 1 (29%) Triple Combination 6 (Bupropion + patch + nicotine inhaler) 6 (35%) One study only NRT and Chantix (first week only) 1 Higher rates of side effects (nausea, headaches) *Fiore, M.C. et al. (2008). Treating Tobacco Use and Dependence, Clinical Practice Guideline, 2008 Update, U.S. Dept. of Health and Human Services, Public Health Service. Steinberg MB, Greenhaus S, Schmelzer AC, Bover MT, Foulds J, Hoover DR, Carson JL. Triple Combination Pharmacotherapy for Medically Ill Smokers. A Randomized Trial. Annals of Internal Medicine. 2009; 150(7):

39 RCP Brief Tobacco Intervention: 2A s + R Ask your patients if they smoke Advise them to quit Refer them to in-patient program, community resources 3 minute healthcare worker intervention is effective

40 If all Else Fails Go to the Mad Russian - Yefim Shubentsov

41 Prepare for the Future Online AARC Tobacco Free-Lifestyle Roundtable (AARC Connect) Training Program for Tobacco Dependence Treatment Specialist Rutgers SPH Implement a Tobacco Dependence Treatment Program.

42 Community Resources National Hotline QuitNow Smokfree.gov New Jersey Quit line NJ-STOPS New Jersey QuitNet New Jersey Quit Centers THANK YOU!

43 Selected References 1. Fiore, M.C. et al. (2008). Treating Tobacco Use and Dependence, 2008 Update: Clinical Practice Guideline, Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality, [Acessed March 2011] 2. Colbert, B.J., Kennedy, B.J. (2008) Integrated Cardiopulmonary Pharmacology. Pearson/Prentice Hall, Upper Saddle River, NJ, p Centers for Disease Control and Prevention. Vital Signs: Current Cigarette Smoking Among Adults Aged 18 Years United States, Morbidity and Mortality Weekly Report 2010;59(35): [accessed March 2011].

44 Selected References 4. Steinberg MB, Greenhaus S, Schmelzer AC, Bover MT, Foulds J, Hoover DR, Carson JL. Triple Combination Pharmacotherapy for Medically Ill Smokers. A Randomized Trial. Annals of Internal Medicine. 2009; 150(7): Kessler RC et al (2002). Psychol Med.;32: Kessler et al (2003). Arch of Gen Psych, 60(2) 7. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking- Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.