State of Behavioral Health. The Arizona Initiative for Tobacco Free Living in Individuals with Behavioral Health Disorders

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1 Helping People with Mental Health Issues Live Longer Lives without Tobacco The Arizona Initiative for Tobacco Free Living in Individuals with Behavioral Health Disorders Stephen S. Michael, MS Director, Arizona Smokers Helpline, University of Arizona College of Public Health, Tucson, AZ State of Behavioral Health Freedom Report 2003:.for too many Americans with mental illnesses, the mental health services and supports they need remain fragmented, disconnected and often inadequate, frustrating the opportunity for recovery. -Dr. Michael F. Hogan, PhD

2 Arizonans with Mental Illness Those with mental health diagnoses die 31 years younger Tobacco-related disease is the biggest killer 75% of people with a mental illness (approx. 100,000) use tobacco (5 x the Arizona rate) SAMSHA reports that nearly half of tobacco is purchased by people with a mental illness The Arizona Initiative Marketing/ Media County/ Community Advocacy and Education Social Networks (work, etc) Smokers Service Providers Relapse ASHLine Quit The Arizona Behavioral Health Initiative Stage One focuses on people in the public mental health system with a diagnosis of a chronic mental health diagnosis. Develop an integrated model that provides access to tobacco cessation in treatment/support/case management facilities through on-site service or quitline referral

3 Recognize Differing Levels of Intervention Inpatient/Residential (onsite cessation interventions) Intensive Treatment Settings (onsite cessation interventions with quitline support) Outpatient Treatment Settings (quitline cessation) Case Management/Medication Management (quitline cessation) A New Twist To relieve the fears of providers when a client has multiple medications Additional support is provided by trained pharmacist to complete a medication assessment and provide suggestions to the psychiatrist regarding possible interactions or concerns with quitting tobacco and/or using medications. Things to Consider Quitting can affect other medications Involve Case Management Team in quitting Coordination with the Psychiatrist Quitting tobacco IS a treatment issue Medications might need to be adjusted

4 Why Include a Quitline? Feds Require every State to have one: QUITNOW Because they WORK! Just What is a Quitline? All Quitlines are not created equal. Three types: Reactive Proactive Comprehensive Example: ASHLine (Comprehensive) Inbound telephone calls answered by tobacco coaches Self-help (mail & web) Proactive, multi-call program Medication assistance

5 What is the ASHLine? Funding by the CDC and state tobacco tax through ADHS BTCD Housed at University of Arizona Mel and Enid Zuckerman College of Public Health Providing quitline services since 1995 What is the ASHLine? Free help to quit tobacco Coaching over the phone Self-paced quit program online Medication assistance Partner to healthcare systems and professionals Referral program Technical assistance and training resources ASHLine Protocol Individualized Use standard types of treatment methods Primary goal: stay with us until you are quit for 90 days:

6 The Role of a Pharmacist Often have more information about medications than physicians. Recognize when someone is filling a smoking cessation medication prescription. Build in protocols to refer them to a quitline. Messages to Clients Coordinate your quitting with those who you already work with: psychiatrist, case manager, etc. Get involved with the quitline they know what works. Identify some motivated partners. Ask to have tobacco cessation included in your ISP (individual service plan) Keep checking in, even if things are not going so well Messages to Providers (Recovery Agents) Tobacco Cessation is a treatment issue, not a lifestyle choice. You don t allow people to drink or use illicit drugs on campus, why tobacco? People with mental health challenges REALLY DO want to quit tobacco.

7 How Pharmacists Can Help with Assessment and Referral for Tobacco Cessation Treatment Shannon Vaffis, MPH Assistant Director, Community and Referrals Arizona Smokers Helpline University of Arizona College of Public Health, Tucson, AZ You can help. Ask. Advise. Refer. US Public Health Service Key Recommendations 1) Clinicians should strongly recommend the use of effective tobacco dependence counseling AND discuss medications with their patients who use tobacco 2) Health care systems, insurers, and purchasers should assist clinicians in making such effective treatments available Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2008.

8 You CAN Help You DOhave a positive effect when you provide brief tobacco cessation interventions! Tobacco Use is a Chronic Disease If tobacco is so dangerous, why don t users just quit? The reasons are: Biological Psychological Sociocultural Biological Tobacco use results in true drug dependence Comparable to dependence on heroin, speed, and cocaine Nicotine affects essential brain structures associated with reward Changes in the brain structure and function persist long after tobacco use ends The addictive power of nicotine may strengthen the learned behaviors that form tobacco-use patterns and make users more resistant to change

9 Psychological Reinforced, conditioned drug-taking behavior, not only physical dependence, is now thought to be centralto the concept of addiction Tobacco use is a coping mechanism Nicotine may also be used to self-medicate underlying problems such as schizophrenia, depression, anxiety, attention deficit disorder, or stress Sociocultural Tobacco may be used as a way to identify with a group or be a regular part of social activities or cultural practices Social forces, such as peer pressure, may influence tobacco use or experimentation, especially among adolescents Social media, including advertising, often portray tobacco use as attractive, while minimizing the health effects Quitting Tobacco: What Works Research shows that two treatment modalities are effective: 1) Coaching, counseling, groups 2) Quit tobacco medications *Highest success rates are seen when multiple treatment modalities are used Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health andhuman Services. Public Health Service. June 2008.

10 The Role YOU Play in Quitting Tobacco Tobacco use is cited as the chief avoidable cause of death in the US Smokers cite physician advice to quit as an important motivator Healthcare systems should craft policy that makes tobacco use treatment an integral part of healthcare Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June Components of a Clinical Intervention Components include: Ask, Advise, Assess, Assist, and Arrange Intervention components can be shared among health professionals or even among health organizations An intervention should take less than 10 minutes of a clinician s time! ASHLine s Recommended Model Ask, Advise, Refer Complete 3 of the 5 A s Let ASHLine do the rest!

11 Ask Ask about tobacco use at every visit Keep it simple. Use the following questions Do you use tobacco? Have you ever used tobacco? Does anyone in your house use tobacco? Advise In a clear, strong, personalized manner, urge all tobacco users to quit Talk about how quitting will help patients with their Motivational specific health interviewing concerns skills can be useful in helping tobacco users see the advantages of quitting Refer Assist individuals interested in quit tobacco information by referring to Arizona Smokers Helpline A proactive referral (via fax or online at ashline.org/webquit) ensures ASHLine will call your client within 24 hours ASHLine completes the remaining components of a clinical intervention for you!

12 Client Services Client-directed, Outcome-informed approach (CDOI) Motivational Interviewing Self-paced online treatment program Medication assistance Client-directed, Outcome-informed Values the client-coach relationship Client determines focus, length, frequency of phone calls No script or curriculum Coaching can last anywhere from 3 to 6 months after the client quits The client can continue to work with the coach, even if they relapse Motivational Interviewing Resolve ambivalence toward quitting Help develop problem solving skills Create a quit plan Withstand cravings Work to develop social support network to maintain tobacco free lifestyle

13 Additional Quit Tobacco Resources Combining treatments increases success! Quitline coaching can complement tobacco cessation classes and/or individual counseling Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June Medication Assistance Enrolled ASHLine clients are eligible to receive 2 weeks of nicotine patch, gum, or lozenge Mailed directly to residence EXCEPT Title XIX AHCCCS beneficiaries who can receive 12 weeks of any FDA-approved quit tobacco medication with a prescription from their primary care provider ASHLine Referral Program 3 Ways to Refer: QuitFax referral form WebQuit online referral Electronic Health Records

14 QuitFax Referral Form WebQuit Online Referral Electronic Health Records

15 ASHLine Referral Reports Confirmation Within 24 hours Status report Within 10 days First call within 24 hours Up to 5 attempts to contact over 10 days Monthly newsletter Can be received by fax, , or both! ASHLine Mission Improve the health of Arizonans by providing client-centered tobacco cessation services through technology based interventions. Thank You Stephen S. Michael, MS (520) smichael@ .arizona.edu Shannon Vaffis, MPH (520) vaffis@ .arizona.edu Arizona Smokers Helpline (ASHLine) Zuckerman College of Public Health University of Arizona

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