Clinical Education Initiative SMOKING CESSATION AND HIV. Speaker: Emily Senay, MD

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Bartholomew Long
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1 Clinical Education Initiative SMOKING CESSATION AND HIV Speaker: Emily Senay, MD 6/7/2017

2 Smoking Cessation and HIV [video transcript] 00:00:08 - [Dr. Senay] I'm going to leave this slide set for you guys. 00:00:09 I'm going to try to keep this really short, 00:00:12 but basically, patients with HIV have two to three times higher smoking rates than the HIV negative population. And the best person to begin, and if possible, to follow through, on helping them to quit smoking, is the provider in front of them. So, that is you guys. You're the ideal counselor. And so, we can go to the next slide. 00:00:39 We'll talk briefly about (laughter) vulnerability, severity, and keeping in mind throughout, that cigarette smoking is a chronic relapsing illness. Okay, let's go to the next slide. 00:00:52 I mentioned this. Because of their higher rate of smoking, they are also at risk for respiratory and nonrespiratory problems like lung cancer, COPD, coronary artery disease, bronchitis, pneumonia, hairy leukoplakia, and thrush. 00:01:11 Next slide. Yep. So, this is where there's very specific HIV information is that there are independent risk factors for non-hiv related mortality, even in patients who are receiving HAART. HIV positive patients lose more life years from smoking than HIV negative patients, and there are very high rates of depression, which is a risk factor in and of itself for smoking and for relapse. And there are lower scores for quality of life, physical functioning, bodily pain, energy, and cognitive functioning in HIV patients who smoke compared to non-hiv patients. 00:01:53 So even when you control for, after you control for increased smoking rates, HIV positive patients have a higher risk of lung cancer. Let's see here. They develop it at an earlier age. And obviously they have a higher rate of COPD. You guys probably know all this, so you can skip through this. Next slide. 00:02:16 And, as you well know, there's an increased risk of cardiovascular disease due to the interaction between smoking, hyperlipidemia, chronic inflammation, so on, so forth. So they have a 50% increased risk of acute MI beyond that explained by recognized risk factors. 1

3 00:02:32 You know this too. I'm not sure if you're familiar with the latest and greatest in the genetics of vulnerability to nicotine addiction, but there is a very heritable quality to how addicted you become to nicotine, and how quickly that happens. So, genetics account for 50% of risk initiation and 70% of the variance for continuing to smoke. What's important to note about this is this is something you can convey to your patients, and this is a very important point that smoking is a genetically driven, most of smoking is genetically driven, and that it's not something that's a weakness of will or a character flaw, and that you are there to help them address this as you would any other genetic condition. It lets the patient off the hook from a counseling standpoint. It also lets them know, it primes them, for the fact that the medication is very helpful, something that many patients are resistant to when it comes to smoking cessation. So, the risk of smoking increases, obviously, the earlier a person starts, and brain changes in rats exposed as adolescents are greater, so if people have started smoking earlier, they're gonna be, probably, more addicted. And as you can see from this little fact, 7th grade girls can become addicted within just two weeks. By that, I mean the brain changes that facilitate and sort of support craving for smoking. Okay, and another important point, I'm not going to get into all the molecular pathways. I do have a slide that I can send to you guys if you want to understand how that works. But basically, psychiatric illness and drug addiction share very many similar pathways, metabolic and physiologic in the brain. So, next slide. 00:04:26 Two questions you wanna ask your patients: How soon after you wake up do you need that first cigarette? And how many cigarettes do you smoke? 00:04:35 The first question is all about how addicted you are. And that's going to determine which medications you use and what sort of follow-up they're gonna need. Here's the bottom line: when people smoke, they're smoking not only to get the pleasure from the nicotine, but they're also smoking to prevent withdrawal, and that's the sum of this slide. Nicotine makes withdrawal go away, always, every time within ten seconds. So, when you think about preventing withdrawal, that's another reason why, for the right patient, you're really going to want to push them towards nicotine replacement and explain this to them. That you're smoking not just for the pleasure, but to prevent bad things, too, and we can help you substitute that with something that's not going to cause lung cancer. Okay, next slide. 00:05:32 This is all about brain circuitry, don't think we have time for this now, let's skip. 00:05:39 So, the important thing, at least, in terms of my experience with smoking cessation, for many of my patients, is to plan. The more you have a plan, the better you're off coping with the bad things that come your way that you think you don't have control over. So, getting people to analyze, sit down, think, what are your triggers? What is the first thing you do in the morning? What primes you to need that cigarette? Or that extra cigarette? And really get them to sit down, write it all down, and create a plan 2

4 for how they're going to go around that. Very very helpful. When we counsel them, we take them through all their triggers, we make sure they have an alternative. What are you going to do when the boss calls and says, "Blah, blah, blah, blah?" How are you going to manage that without that cigarette? What are the roads you're going to take and the avenues that you're going to go around to avoid those triggers, or to cope with them better when those stresses come? Because they will come, that's life. So, that's an important part of the initial counseling, and then you wanna always refresh that. That's a key part of relapse prevention, as well. Okay, next slide. 00:06:46 Okay, so, I think this is the important point, is really, using the medications that we have as effectively as possible. We all know about nicotine replacement patch, gum, inhaler, lozenge, nasal spray, Wellbutrin or Zyban, Varenicline or Chantax. I'm not sure if this is appropriate for you guys, but Medicare doesn't cover OTC meds. Medicaid does though. Okay, next. 00:07:12 Okay, I'm not sure what your experience is, but a lot of patients are very resistant to nicotine replacement. I've tried it, it doesn't work. If they tried it, and it didn't work, it's probably because they were not dosed correctly. If they tried it, and they didn't, they got sick from it, it's probably because they were getting too much. So, making sure that you are giving the correct dose, matching the dose to exactly what the patient is saying they are smoking is very important, and making them understand that if they're still having cravings, they're not getting enough nicotine, and if they get a headache or they feel nauseous, they're getting too much and to back off. So, you're gonna have to get around this, this block, this barrier for, a lot of patients, nicotine replacement. Here are some language and some motivational interviewing that you can use, if you want to read this on your own, when they throw this stuff at you like, "I don't need it." You always want to say, "Listen, you can't control this part of your brain. There's no thinking you can do that can block the nicotine receptors in your brain. Let me help block the nicotine receptors with this medication, so you only have to cope with your triggers and planning your day around those stressful situations or those automatic moments where you're going to be needing or wanting that cigarette." And I find that it does help convince them. Unload the burden of that from them and say, "Let me help you. I have something that can help. Everybody says that, but I know this works." Okay, let's go to the next. 00:08:43 Okay, this slide is basically a long way to say that the best way to get nicotine into the bloodstream is through a cigarette. It happens very quickly, within seconds. (laughter) - [Dr. Urbina] Right. - [Dr. Senay] So, what are we going to do to help people who are, need to get that nicotine, not only as a steady stream, but also, as bursts over the day? We're gonna combine, so we can skip this slide. 00:09:08 3

5 We're gonna combine the various routes of nicotine replacement that we have. So, this is very pro forma. It's in all the package inserts. If they're smoking a pack a day, you're gonna use the 21 milligrams. They put it on first thing in the morning when they wake up. There's plenty of great patient information out there about how to use it correctly so they don't get a rash, you know, whether or not they can shower with it. All that information is there. You step it down, 14 milligrams for half a pack a day, 7 milligrams for people who are smoking a third of a pack per day. And you're going to adjust the dose for symptoms. Again, if they feel nauseous, dizzy, headache, step back on it. The key to nicotine replacement is to make sure they're not getting just one form. So, you're gonna start with the patch, but it takes an hour for the patch to work. Most people are going to need that first burst of nicotine in the morning. Especially those who are reporting that they smoke a cigarette within thirty minutes of waking up. So, you're gonna use either the gum, the lozenge, you can also use the nasal spray. I don't love the nasal spray, some people find it irritating. Or you can use the Nicotrol inhaler. Don't love the inhaler either because, for a lot of patients, that reminds them of smoking, and that sort of feeds the automaticity of their smoking. Some people find it very useful and they use an inhaler for the rest of their life. These things are out there, you can use them. I try to convince them the best thing to do is to pop that piece of gum in their mouth, and you don't chew the gum. Unfortunately, they call it gum, that was a mistake. You crack the gum twice between your teeth, and you put it between your cheek and your teeth, and you let it sit there until it stops buzzing. You move it to the other side, crack it twice on the other side, let it sit there 'til it stops buzzing. Do not chew the gum. If you chew the gum, you will swallow the nicotine, and it won't help you at all. Lozenge the same, you just put it on your tongue and let it dissolve. So, patch first thing in the morning, for those who are smoking within thirty minutes of waking up, you gotta add something on top of it. I tend to choose the gum or the lozenge. Some people don't like the taste of the lozenge, but they do like the gum. Okay, so, all right, we can, 00:11:16 oh, you remove the patch at bedtime. Nobody is smoking at night, usually, so, and the patch can cause some bad dreams, so just tell them to take it off at night time, put it on first thing in the morning. All right. So, dosing is not an exact science. You really want to hit that sweet spot of minimal craving, but no nausea, headache, or dizziness. We can go to the next slide. 00:11:39 I know I'm kind of running out of time here. Okay, next slide. Okay, Bupropion blocks the reuptake of dopamine and norepinephrine. I have a great slide, again, that I'll send you guys, so you can see how all this stuff works. Very similar to nicotine replacement therapy. It's less effective than Varenicline. I rarely use Bupropion. So we can go to the next slide. 00:12:06 This is on the dosing. This is all on the package insert. A lot of people are now using Bupropion for one year for relapse prevention. We can go to the next slide. 00:12:17 4

6 Now, for those people, increasingly, it's looking like Varenicline is really the way to go, for the right patient. And, if you don't have a lot of time to work with people and go through all the counseling, for the right person, and, by the way, the package insert, I'm sorry, the black box warning on the package has come off. Not sure if you guys are aware of that, but they took it off in terms of suicidality, and a lot of the other issues, which has helped a lot, convince people to take it. This is under-used. There are a lot of different schools of thought about how you go about getting people to quit smoking. Some people say everybody who walks in your office is smoking should walk out with some form of treatment rather, as opposed to a referral. So, that's one school of thought. The other school of thought is the more you counsel the patient, the more face-to-face contact with them that you have, the more you use the medicine, the higher the quit rates are. I don't know if you guys are tracking quit rates in any of your clinics, probably not, I'm guessing. - [Dr. Urbina] They're attempting to do that. - [Dr. Senay] Right. - [Dr. Urbina] Through Epic. It's a little difficult, but yeah. - [Dr. Senay] Epic is totally un-user friendly for that. So, I track it in a Excel spreadsheet. (laughter) - [Dr. Urbina] Old school. - [Dr. Senay] Yeah. Old school. So, having said that, I think getting comfortable with Varenicline, for all people who are seeing patients, is a really good idea. So, we can go to the next slide. 00:13:52 So, for moderate to severe addiction, and I think that's right, greater than ten cigarettes per day or early smoking, there are polymorphisms, which I took out of this because we didn't have time to get into that. As I said, there are genetic predispositions to vulnerability and to level of addiction. And this is personalized medicine, this is where we're going. We're getting closer and closer to this, to understanding. Right now, obviously, we're not testing people to see where they fall on this, maybe in time. People who take Varenicline and for whom it works, all I can say is they basically seem to forget that they smoke. It's really interesting. I have patients say, "I just didn't want to smoke anymore. I forgot about it." It's really interesting. Doesn't work that way for everybody. Some people use it and say it doesn't help at all. Then fall back on the nicotine replacement, if you can, but I believe them when they say, "It's not helping me." You know, after a good two months, three months, I bag it and go to something else. Okay, so, next slide. 00:15:01 There are side effects: nausea, yes, people do report bizarre dreams, some people do report psychiatric disturbances. It says it makes them feel a little bit on edge. Okay, we are definitely running out of time. We'll go to the next. 00:15:19 They took the black box warning off, I mentioned that. We can skip this. 5

7 00:15:25 Relapse prevention is increasingly important. Understanding that this is a chronic illness, and that rebooting people every now and again, and I tell my patients in World Trade, I say, "You know what, let's meet again in three months." There's nothing medically, other than I'm having them come in and talk about relapse prevention. I can do that in World Trade. I can also tell you how to bill it, if you guys want to do it. I try to give them as many outlets, in terms of other resources, like QUIT-NOW, social media, the New York state quit line, so that they have other resources should they feel that they are slipping. Or they can just call and come in to see me. Next slide. 00:16:14 Okay. I think we can end here. I'll just say that if you guys stand in the room and tell them you would like them to quit, that is incredibly powerful. You speak to them directly. I would like you to quit. I'd like to help you quit. And then you talk to them about medication use. I would just say that if everyone could get comfortable with it, even some of the preliminary counseling. And if you work with someone doing counseling in your clinic, it's a very powerful thing to be able to call them, follow up on them, and meet with them routinely. [end] 6

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