Overview of the Treatment Program Mayo Clinic s Nicotine Dependence Center

Transcription

1 Overview of the Treatment Program Mayo Clinic s Nicotine Dependence Center Thomas Gauvin, M.A, CTTS Timothy Milbrandt, M.S. CTTS gauvin.thomas@mayo.edu Milbrandt.timothy@mayo.edu

2 Overview of Mayo Model Tobacco Epidemic Consequences, Prevalence 4 Components of Mayo Model History, Interventions Counseling Intervention Motivational Interviewing

3 he Cigarette Death Epidemic Perspective No. (000s) Annual smoking deaths Environ- All Annual Vietnam AIDS Annual Annual mental World auto War murders heroin, tobacco War II accidents 1990 morphine smoke & cocaine deaths deaths CP

4 Smoking-Attributable Mortality, Number of average annual deaths Smoking-attributable (18.2%) All Deaths Other Total Neoplasms Cardiovascular diseases CDC, 2005 Respiratory disease Perinatal conditions Burn deaths Total Lung cancer Ischemic heart disease Environmental Tobacco Smoke

5 Past Month Tobacco Use among Persons Aged 12 or Older Results from the 2009 National Survey on Drug Use and Health

6 Gray Matter Maturation Source Gogtay, Niten et. Al. (Proc. Natl. Acad Sci. 101, by the National Academy of Sciences

7 Maturation starts at the back of the brain... and moves to the front Physical coordination, sensory processing Motivation Amygdala Cerebellum Nucleus Accumbens Emotion Notice: Judgment and executive control Are last to develop Judgment Executive function Prefrontal Cortex

8 A pediatric addictive illness Nicotine dependence usually begins in childhood or adolescence No one plans to become addicted Person feels in control until control has already been lost

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10 Mayo Clinic Nicotine Dependence Center Treatment Program Outpatient Inpatient Residential Treatment

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12 For the patients of today and the patients of tomorrow

13 Hospitals at Mayo Clinic Rochester Rochester Methodist Saint Mary s Generose

14 Inpatient Treatment Nurse Initiated Tobacco Use Protocol Bedside Nurse can order A. Nicotine Replacement Patch to treat withdrawal B. Consultation with a Tobacco Treatment Specialist (TTS) TTS will provide Motivational enhancement Behavioral counseling Medication recommendations Post discharge follow-up

15 Differences Between Hospital Patients and Outpatients Out Patient Hospital Patient Comes prepared Just had a cigarette Show or no-show Shut office door Usually mentally stable May not have glasses May be in withdrawal X-rays, procedures, transfer to different unit Multiple interruptions Psychiatric admission

16 Fundamental Treatment Components Addiction Concepts Pharmacotherapy Cognitive/Behavioral Relapse prevention MOTIVATIONAL INTERVIEWING

17 Mayo Component: Addiction It Is A Disease

18 Withdrawal Symptoms Insomnia Restlessness Anxiety, Irritability, Frustration, Anger Difficulty concentrating Sad, depressed mood Increased appetite

19 Withdrawal Symptoms Headache Mouth ulcers Nausea Constipation Diarrhea

20 Mayo Component: Pharmacotherapy Rationale for Medication(s) Goal is to stop tobacco use Can t match dose delivery or concentration of nicotine Double the success rate Takes the edge off while incorporating behavioral change

21 Pharmacotherapy Give patient a menu of options Varenicline

22 Nicotine Delivered by Inhalation

23 Mayo Component: Cognitive-Behavioral Thoughts Smoking isn t an option I happily see myself as a nonsmoker I can do this. Behaviors Alter routines Behavioral substitutes Problem-solving skills

24 Mayo Component: Cognitive-Behavioral Look at thoughts as well as behaviors Awareness is first step Reframing Positive Self-Affirmations

25 Anatomy of Attentional Networks James (1890) Attention is the taking possession of the mind in clear and vivid form of one out of what seem several simultaneous objects or trains of thought

26 The memory of nicotine stays alive in the brain Front of Brain Amygdala not lit up Amygdala activated Back of Brain Nature Video Smoking video

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29 Mayo Component: Relapse Prevention Individualized Plan - Red flags Medication Monitor and make changes as necessary Stress Management Follow-up

30 Predictors of Cessation (Smith, 1999) High level of confidence that they will quit smoking Age > 45 years No evidence of depression Low nicotine dependence No alcohol use Hospitalized--Smoking related disease Nonsmokers for major support system

31 Relapse Prevention Relapse is common, but not required. How to anticipate and cope with the problems which pull one toward relapse. Requires both behavioral and cognitive components. Relapse Prevention begins at the beginning at the initial assessment, not after they ve relapsed.

32 Relapse Prevention Realistic Hope and Confidence I can do this! I want to do this! Increase Motivation It s worth doing! Practical Problem Solving I m going to

33 FEV1 Scale COPD Risk and Smoking Cessation

34 USPHS Clinical Practice Guideline AHRQ Publ

35 Effective treatment Includes both Medication and Counseling

36 Assessment Dependence level Tobacco type and amount Stressors Barriers Previous quit attempt(s) Previous relapse(s) Coping skills Support

37 What are the 2 key issues to assess in tobacco dependence treatment?

38 Assess Level of dependence How? Level of motivation How?

39 Fagerstrom Test of Nicotine Dependence (FTND) Measures physical dependence to nicotine Correlated with biochemical measures of nicotine dependence (cotinine( levels) Predicts smoking abstinence Score: > 4 = Nicotine Dependence > 6 = Severe Nicotine Dependence

40 Measures of Dependence (General) Amount: > 20 cigarettes/day; > 3 tins/week Smokes/dips within 30 minutes of waking Strong withdrawal symptoms in first few days of previous quit attempts History of psychiatric disorder History of chemical dependency

41 Carbon Monoxide Detector Measures CO in expired air Does not measure lung functioning Objective feedback Personalized teaching tool

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43 The Spirit of Motivational Interviewing (MI) The Dance COLLABORATION Not Confrontation EVOCATION Not Education/Advice AUTONOMY Not Authority Careful eliciting of the values, assumptions, fears, expectations and hopes of the patient

44 Principles of MI Express Empathy Support Self-Efficacy Develop Discrepancy Roll with Resistance

45 Misconception of Patient Motivation: You either have it or you don t

46 What Gets People to Change?

47 Behavior Change Change is a process

48 Patient s Motivation Importance of change Confidence in one s ability to change Readiness to change

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50 Ambivalence Smoking helps me relax I m afraid I m going to die young I really enjoy it I hate the way I smell

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52 Ambivalence is common Resistance is normal Roll with it Stay with your patient Hear both sides Help point out discrepancy Resolve ambivalence in favor of change

53 Early Traps to Avoid Question-answer trap Trap of taking sides Expert trap Labeling trap Premature-focus trap Blaming trap

54 Opening Strategies Open-ended questions Reflective Listening

55 Open-Ended Questions Patient Benefits Allows patient to express himself Patient verbalizes what is important to him at the moment Practitioner Benefits Learn more about the patient Sets a positive tone for the session How do you feel about quitting smoking? What do you see as your biggest challenge? Tell me more about that.

56 Resistance is an interpersonal phenomenon How we respond matters

57 Reflective Listening Making a statement to clarify meaning and to encourage continued exploration of content Patient: It is stressful to think that my daughter might someday take up smoking because she sees me doing it. Practitioner: You re worried about the impact your smoking has on your child.

58 Reflective Listening By utilizing the skill of reflective listening, the counselor is conveying: I am listening. This is important to you. I would like to hear more. I am not judging you. I can understand why you might feel this way.

59 Yeah, but syndrome I can t afford the medication I m afraid I ll gain weight if I quit. I don t smoke nearly as much as some other people that I know.

60 Resistance vs. Change Talk Change Talk Resistance

61 Preparatory Change Talk Moving Towards Change Counsel in a way that invites the patient to make arguments for change Desire Ability Reason Need

62 Change Talk What to look for: Desire - I really want to Ability - I ve done it before. Reason - I would have whiter teeth if I quit. Need - I can t go through life like this. I have to

63 Relapse is a Process Triggers Lapse Relapse Lapse vs. Relapse?

64 Abstinence-Violation Effect Lapse leads to Loss of control I might as well give up

65 Key Treatment Components Cognitive-Behavioral Thoughts Smoking isn t an option I happily see myself as a nonsmoker I can do this. Behaviors Alter routines Behavioral substitutes Problem-solving skills

66 Using the 5 R s Relevance Why is quitting important to you? Risks Rewards What do you see happening if you continue smoking? How will quitting smoking help you? Roadblocks What makes it difficult to quit? Repetition Ask questions each visit

67 Predicted Causal Chain Motivational Interviewing (Express Empathy, Roll with resistance, Develop discrepancy, Support self-efficacy) Listen for Change Talk Strengthen Commitment and Build a Plan Behavior Change

68 Individualized Plan Motivational Interviewing next steps Addiction Concepts Pharmacotherapy Cognitive/Behavioral Relapse prevention

69 References/Resources Dunn, C. & Rollnick, S. (2003). Lifestyle change. London: Elsevier Limited. Miller, W. R. & Rollnick, S. (2002). Motivational interviewing (2nd ed.). New York: The Guilford Press. Rollnick, S., Mason, P., & Butler, C. (1999). Health behavior change. New York: Churchill Livingstone. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 update. Clinical Practice Guideline. USDHHS Web site: