Tony Klein, MPA, CASAC, NCACII

Tony Klein, MPA, CASAC, NCACII

Presentation Overview Tobacco Dependence in Individuals with Co-occurring Addictions Challenges and Barriers Organizational Change Strategies Program & System Changes to Support Tobacco Interventions

Tobacco Use Status Among Respondents National Co-Morbidity Survey (n=4,411) Report of Mental Illness in the Past Month Diagnosis in Past Month No Mental Illness Social Phobia Panic Disorder Major Depression Non-Affective Psychosis Bipolar Disorder PTSD ASPD Alcoholism Drug Addiction % in US Population 50.7 4.0 1.4 4.9 0.2 0.9 2.3 14.6 2.6 1.0 % Current Smokers 22.5 31.5 42.6 44.7 45.3 60.6 44.6 45.1 56.1 67.9 Lasser, K. et al. (2000). JAMA. 284: 2606-2610.

NYS OASAS 2006 Data Tobacco Use in the Seven Days Prior to Admission Using Males Using Females Using Intensive Residential 76% 74% 82% Community Residential 73% 71% 80% Supportive Living 81% 79% 84% Inpatient Rehabilitation 80% 79% 82% Outpatient Clinic 63% 63% 65% Outpatient Rehabilitation 77% 76% 79% Methadone Clinic 83% 82% 84%

More Than a Million Alcoholics, Drug Addicts, and Mentally ill Have Died From Tobacco since 9/11

Tobacco Industry Research Philip Morris Behavioral Research Lab Project 1620 to study the basic dimensions of the cigarette as they relate to cigarette acceptability [and] to record and interpret changes in smoke inhalation patterns [and nicotine retention] in response to changes in smoke composition, and to develop a better understanding of the actions of nicotine and other smoke compounds, especially those which reinforce the smoking act. Nicotine & Tobacco Research, Volume 6, Number 6, December 2004

An Illustration of Factors Determining the Effects of Cigarette Smoking SENSORIAL CHEMICAL PHYSICAL CIGARETTE PERCEPTUAL COGNITIVE PHYSIOLOGICAL Philip Morris Sensory Technology Operation Plans, 1991

Tobacco Use as a Chronic Disease Neurochemical Behavioral Psychological

Primary and Secondary Factors in Tobacco Dependence Acute Withdrawal Syndrome Negative Affect (Mood Modulation) Positive Effects (Satisfaction and Reinforcement) Primary Secondary DA, NA, 5-HT Stress DA, NA, GABA DA, NA, ACh, Glu Tobacco Use Maintenance and Relapse DA, EOP, NA, Glu DA, EOP, ECB Weight Control Antinociception EOP, ECB DA, ACh, 5-HT, Glu, GABA Conditioned Cues (Protracted Abstinence) DA, NA, ACh, Glu Cognitive Enhancement Figure 1. State, trait and environmental factors, and neurotransmitter systems that mediate smoking maintenance and relapse. The blue circles represent primary contributors to smoking maintenance and relapse, whereas the green circles represent secondary contributors to those processes. Abbreviations: ACh, acetylcholine (nicotinic ACh receptor); DA, dopamine; ECB, endocannabiniod (CB, receptor); EOP, endogenous opioid peptide; Glu, glutamate; 5-HT, 5-hydroxytrypamine; NA, noradrenaline. George T.P. and O Malley S.S. Trends Pharmacol. Sci. 2004;25:42-48.

Why Individuals With SUD & PD Have Higher Rates of Tobacco Dependence The pathophysiology of these disorders increases vulnerability to nicotine dependence. Individuals with are self-medicating affective and cognitive deficits associated with these disorders. Social factors (e.g., peer modeling, settings). Kalman, Morrissete and George, 2005. Am. J. Addict. 14: 106-123

Challenges & Barriers Tobacco Use is the Social Norm Tobacco Use Behavior is Modeled in Alcohol & Drug Recovery Tobacco Use Behavior is Strongly Associated with Other Drug Use Behavior Addict Beliefs of Chemical Coping: I Gotta Have Something Perceived Differences to Intoxication and Consequences of Use Nicotine Dependence Among Staff Tobacco Interventions are Inadequately Incorporated into Addiction Services Programming

UMDNJ Guidelines Ziedonis, D.M., Barriers and Solutions to Addressing Tobacco Dependence in Addiction Treatment Programs. Alcohol Research & Health 2006; Vol. 29, No. 3 228-235.

Two Fundamental Goals Incorporate Tobacco Interventions into Existing Programming to: 1. Denormalize Tobacco Use Within AOD Culture 2. Reduce Tobacco Use

Change Strategies Strategically Address the Resistance Use Language Consistent with AOD Culture Anchor the Topic of Tobacco to the Organization s Mission Match Training to Agency Stage-Readiness and Job Description Think Carrots, Not Sticks

Agency Stage Readiness

Reframing Language Consistent to AOD Culture and 12-Step Philosophy Common Terminology Smoking Quit date Cessation Language to Promote Norm Change Tobacco use, hit, fix Recovery start date Treatment, recovery

Setting The Stage Alcohol, Tobacco, & Drug-Free Policy We Need Your Help Evelyn Brandon Health Center Strives to maintain a healthy and safe environment On September 7, 2004 the sidewalk at our front entrance and the parking lot will become Alcohol, Tobacco, and Drug-Free By not using these substances within those areas, we can support one another in recovery and make a positive difference in our community Thank You For Your Support And Cooperation

Tobacco Interventions Nicotine Awareness motivational-based engagement strategy Nicotine Recovery pharmacotherapy & intensive behavioral counseling Alcohol, Tobacco & Drug-Free Environmental Policy

System Changes Assessment Intake/Orientation Tx Planning Tx Services Psychoeducation Case Review/QA Discharge Current System Change Related Tasks

Motivational Counseling Model Ambivalence Fear Nicotine Awareness Should I? Change Talk Desire, Ability, Reasons, Needs Contemplation Commitment Language Personal Change Plan Preparation Nicotine Recovery Can I? Behavior Change Recovery Process Action

Nicotine Awareness Engagement Strategy Client-Centered Tobacco-Specific Psychoeducation Utilizing a Narrative Therapy and Motivational Interviewing Approach Make it fun! - use a communication style to support autonomous motivation and promote an interest in the topic. Promote insight into tobacco use behavior. Identify correlation of tobacco use to regulation of mood, AOD use & the AOD recovery/relapse process. Introduce ambivalence toward tobacco use and elicit change talk.

Nicotine Awareness Topics Tobacco s Relationship to AOD Use and Recovery Decisional Balance Exercise Letting Go of Unhealthy Relationships Health Risks of ATOD CO testing Death related to ATOD Impact of Use on Relationships, Children- Secondhand Smoke Manipulation by the Tobacco Industry

Key Considerations Program & System Changes to Advance Change to Social Norms and Treat Tobacco Dependence Intervention Framework: Environmental policy to support clinical interventions (Alcohol, Tobacco, & Drug-Free) Pharmacotherapy tailored for addiction client populations Incorporate reference to tobacco in all existing components of care

Key Considerations Shifting Cultural Norms: Climate resistance vs. acceptance Language consistent to AOD treatment & recovery Timing match intervention to stage readiness of clients, staff, and the organization Enhancing Patient Motivation: Importance self-determination (Nicotine Awareness) Confidence self-efficacy (Nicotine Recovery)

Key Considerations Behavioral Counseling Method: Informative vs. Prescribing Communication Style Client-Centered vs. Program-Centered Cognitive-Behavioral Therapy Motivational Interviewing Narrative Therapy

Addressing Tobacco to Improve Quality of Care Addressing tobacco use among individuals with addiction disorders is important not only for health reasons but also because it may improve abstinence from other substances and result in further improvements in recovery. Stuyt et al., Psychiatric Annals, Vol.33, Number 7, P 447, July 2003

Tony Klein, MPA, CASAC, NCAC II Tobacco Counseling Services Evelyn Brandon Health Center 81 Lake Avenue Rochester, New York 14608 585-368-6900 x8898 tklein@unityhealth.org