Best Practices for Tobacco Treatment with Behavioral Health Patients Dior Hildebrand, RN, PHN Los Angeles County, Department of Public Health Tobacco Control.

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Best Practices for Tobacco Treatment with Behavioral Health Patients

Dior Hildebrand, RN, PHN

Los Angeles County, Department of Public Health

Tobacco Control Prevention Program

Smoking is arguably the most modifiable risk factor for decreasing

excess mortality & morbidity.

National Association of State Mental Health Program Directors, 2006; U.S. Department of Health and Human Services, 2004

Common Benefits of Quitting

Time BenefitsWithin a few weeks

Increase in pulmonary function & exercise toleranceDecrease in respiratory symptoms

One year Risk of coronary disease cut by half

Within 2 years All-cause death rate declines

10 years Risk of pulmonary & other cancers falls by 50%

By age 65 4 additional years of life compared to those who don’t quit by then

Schroeder, 2005

Bottom line: Quality of life is increased by cessation.

Clinical Practice Guidelines

• All patients/clients should be screened for tobacco use, advised to quit and be offered intervention

• There is a dose response relationship with the amount of contact provided

Clinical Practice Guidelines (cont.)

Evidence-Based Model: The 5 A’s

Ask: Systematically identify all tobacco users at every visit

Advise: Advise tobacco users to quit

Assess: Assess each tobacco user’s willingness to quit

Assist: Assist tobacco users with a quit plan

Arrange: Arrange follow-up contact

The Team Approach

• The Team– Mental health and alcohol and drug

professionals, primary care physician, pharmacist, dentist, behavioral health, quitlines, cessation programs, peer counselors, family, public health…

Behavioral Health Professionals

• Often the clinician for whom contact is the most frequent and who knowsthe client/consumer best

• Able to coordinate pharma& behavioral/counseling treatment

• Trained in mental health and/or substance abuse treatment

• Able to identify and address any changes in psychiatric symptoms during the quit attempt.

Adapted from Prochaska, 2009

Ask: Systematically identify all tobacco users at every visit

The Helpline provides behavior modification counseling (quit plan and quit date)

The Helpline provides 5 follow-up calls – timing is based on the probability of relapse.

The 5 A’s and A, A, R

Advise: Advise smokers to quit

Arrange: Arrange follow-up contact

Assist: Assist smokers with a quit plan

Assess: Assess each smoker’s willingness to quitRefer to the California

Smokers’ Helpline and/or Peer-to-peer counselor

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California Smokers’ Helpline

• Free statewide tobacco cessation program• In operation since 1992• Funded by tobacco taxes - Propositions 99 & 10• Scientifically proven to be effective• All services available by telephone• Hours of operation: M-F 7:00am – 9:00pm &

Sa 9:00am – 1:00pm• Adults, teens, pregnant women & proxy callers• Multiple languages

Available Services

• Self-help materials• Referral lists of local cessation programs

‒ Updated by each county’s tobacco control program

• Individual telephone counseling‒ Confidential‒ One pre-quit call, multiple proactive follow-

up calls‒ Trained counseling staff

First Session• Treatment overview &

rationale• Motivation• Self-efficacy• Health considerations• Smoking & quitting

history• Quitting methods

• Environmental considerations

• Self-image• Planning• Call summary• Setting a quit date• Addressing follow-up

calls

Zhu S-H, Tedeschi GJ, Anderson CM, Pierce JP, 1996

Proactive Follow-up Sessions

• Quit status• Withdrawal review• Pharmacotherapy

review• Challenges &

smoking events

• Motivation & self-efficacy

• Support• Planning for future• Self-image

Zhu S-H, Tedeschi GJ, Anderson CM, Pierce JP, 1996

Self-Reported Behavioral Health Conditions Among Helpline Callers

% S

mok

ing

Zhu,et al, 2009. Unpublished data

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Treatment Fundamentals

Treatment: MI/SUD Fundamentals

• Demonstrated interest in quitting across populations

• Smoking cessation rarely jeopardizes stability of primary disorder or recovery

• Similar treatment/relapse prevention approaches‒ Motivational Interviewing ‒ Cognitive-behavioral strategies‒ Making quit attempts

Treatment Approaches

• Motivational Interviewing‒ Help resolve ambivalence‒ Empower clients to choose change

• Cognitive-Behavioral strategies‒ Create an individualized plan to quit‒ Identify relapse prevention strategies

• Encouraging Quit Attempts‒ Moves clients into action‒ Increase experience in quitting

Assessment Considerations

• Past/current history of MI treatment and SUD recovery

• Current health history including medications• Current life situation• Social support• Tobacco use history

– Determine current interest in quitting– If interested, determine readiness to quit

Determining Readiness to Proceed• Motivation

– “Interested” is sufficient– Don’t rule out some type of intervention, even

if motivation to quit now is low

• Motivational Interviewing

Treatment Considerations• Determine need for involvement from primary

care/other health care providers• Determine need for more intensive behavioral

therapy• Address psychotropic medication issues• Tailor treatment plan based on

– Current stability of symptoms/recovery– Functional status– Previous quit history

Treatment Considerations (cont.)

• Psychiatric stability– How are the client’s symptoms?– Is the client in treatment?– How consistent is the client with treatment & how

is it working?

• No major life changes• No major medication changes• No active intoxication/withdrawal from other

substances

Treatment Considerations (cont.)

• Quitting history & symptoms– Past quit attempts are helpful indicators of what to

expect.– What changes in symptoms were noticed?

• Biochemical factors– Nicotine acts much like a psychotropic medication

on brain chemistry.– The blood levels of some medications can increase

dramatically when quitting.– Medications may need to be adjusted.

• Content, length, & number of sessions– Based on level of functioning and support

(professional & personal)

• Counselor style – How much direction vs. facilitation should a

counselor provide?– Provide direction and support based on client’s

level of functioning, resources, skills, and needs.

Treatment Considerations (cont.)

Treatment Considerations (cont.)

• Client contact with prescribing MD– Refer back to the primary care provider

• Professional support & referral– May need to help clients identify support in

their local area

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Pharmacotherapy

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Behavioral Health and Tobacco Cessation

Online CME

https://cmecalifornia.com/Activity/1023974/Detail.aspx

Pharmacotherapy Guidance for Behavioral Health

• Smokers with behavioral health diagnoses who are trying to quit should receive pharmacotherapy (PHS Clinical Practice Guideline, 2008)

• Dose level and duration of drug treatment individualized.

• Many will need – Higher doses– Combination treatments (long acting & short

acting agents)– Longer duration of treatment

Pharmacotherapy Guidance• Smoking induces CYP1A2 isoenzyme• Approximately doubles clearance of

–Antipsychotics: Prolixin (fluphenazine), Haldol (haloperidol), Zyprexa (olanzapine), Clozaril (clozapine), Thorazine (chlorpromazine)

–Antidepressants: Elavil (amitriptyline), Aventyl (nortriptyline), Jaminine (imipramine), Anafranil (clomipramine), Sinequan (doxepin), Fluvox (fluvoxamine)

• Cessation may produce rapid, significant increase in blood levels

• Need to monitor for increased side effects

Nicotine Replacement Therapy

• Used to help smokers taper off nicotine slowly. Nicotine is released into the bloodstream (via the type of NRT) in order to help reduce physical withdrawal symptoms

• NRT works by replacing some of the nicotine from smoking at the receptor sites with nicotine from less harmful sources

• Allows individual to focus on behavioral and psychological aspects of quitting

Precautions: pregnancy or nursing, recent (<2 weeks) myocardial infarction, serious arrhythmias, severe or worsening angina

Nicotine GumNicorette; generics

• Resin complex– Nicotine

– Sugar-free chewing gum base• Contains buffering agents to increase

absorption of nicotine across the lining of the mouth

• Available: 2 mg, 4 mg; original, cinnamon, fruit, mint (various), and orange flavors

Nicotine Gum: Chewing Technique

Park between cheek & gum

Stop chewing at first sign of peppery taste or tingling sensation

Chew slowly

Chew again when peppery taste or tingle fades

Nicotine Gum: Dosing

Dosage and schedule:– If 1st cigarette is smoked ≥30 minutes after

waking, use 2 mg gum– If 1st cigarette is smoked <30 minutes after

waking, use 4 mg gum

Weeks 1-6: 1 piece every 1-2 hours

Weeks 7-9: 1 piece every 2-4 hours

Weeks 10-12: 1 piece every 4-8 hours

Nicotine Gum: Side Effects

•Jaw muscle ache•Irritation of throat and mouth*•Lightheadedness*•Nausea and vomiting*•Hiccups*•Indigestion*

* Especially when chewing gum too fast

Nicotine Gum: Key Information

• Consult MD first if precautions for use are of concern• To improve chances of quitting, use at least nine

pieces of gum daily (maximum 24 pieces/day)• The effectiveness of nicotine gum may be reduced by

some foods and beverages:

Coffee Juices

Wine Soft drinks

Do NOT eat or drink for 15 minutes BEFORE or while using nicotine gum.

Nicotine Gum: Summary

DISADVANTAGES Need for frequent dosing

Might be problematic for patients with significant dental work

Patients must use proper chewing technique to minimize adverse effects

Gum chewing might not be socially acceptable

ADVANTAGES Might satisfy oral cravings Might delay weight gain (4-mg

strength) Can use as needed to manage

withdrawal symptoms A variety of flavors are available

Nicotine LozengeNicorette Standard, Nicorette Mini; generics

• Oral formulation– Delivers ~25% more nicotine

than equivalent gum dose• Sugar-free mint (various),

cherry flavor • Contains buffering agents to

increase absorption of nicotine across the lining of mouth

• Available: 2 mg, 4 mg

Nicotine Lozenge: Dosing• Dosage and schedule:

– If 1st cigarette is smoked ≥30 minutes after waking, use 2 mg lozenge

– If 1st cigarette is smoked <30 minutes after waking, use 4 mg lozenge

Weeks 1-6: 1 lozenge every 1-2 hours

Weeks 7-9: 1 lozenge every 2-4 hours

Weeks 10-12: 1 lozenge every 4-8 hours

• Allow lozenge to slowly dissolve slowly in mouth (20-30 minutes for standard; 10 minutes for mini)

Nicotine Lozenge: Side Effects

• Nausea• Hiccups• Cough• Heartburn

• Headache• Flatulence• Insomnia

Nicotine Lozenge: Key Information

• Consult MD first if precautions for use are of concern• Use at least nine lozenges daily (maximum 20/day)• The effectiveness of nicotine lozenge may be reduced

by some foods and beverages:

Coffee Juices

Wine Soft drinks

Do NOT eat or drink for 15 minutes BEFORE or while using nicotine lozenge

Nicotine Lozenge: Summary

DISADVANTAGES Need for frequent dosing

Gastrointestinal side effects (nausea, hiccups, and heartburn) may be bothersome.

ADVANTAGES Might satisfy oral cravings Might delay weight gain (4-mg

strength) Easy to use and conceal Can use as needed to manage

withdrawal symptoms Several flavors are available

Nicotine PatchNicoDerm CQ; generics

• Nicotine is well absorbed across the skin

• Patch delivers nicotine continuously over 24 hours

• Blood nicotine levels are lower and fluctuate less than with smoking

Nicotine Patch: Dosing

Product Light Smoker Heavy Smoker

NicoDerm CQ

10 cigarettes/day

Step 2 (14 mg x 6 weeks)

Step 3 (7 mg x 2 weeks)

>10 cigarettes/day

Step 1 (21 mg x 6 weeks)

Step 2 (14 mg x 2 weeks)

Step 3 (7 mg x 2 weeks)

Generic

10 cigarettes/day

Step 2 (14 mg x 6 weeks)

Step 3 (7 mg x 2 weeks)

>10 cigarettes/day

Step 1 (21 mg x 4 weeks)

Step 2 (14 mg x 2 weeks)

Step 3 (7 mg x 2 weeks)

Nicotine Patch: Side Effects

• Side effects to expect in first hour:–Mild itching–Burning–Tingling

• Additional possible side effects:–Skin redness/burning/itching after patch removal–Vivid dreams or sleep disturbances–Headache

Nicotine Patch: Key Information

• Consult MD first if precautions for use are of concern

• Apply new patch daily to a different, clean, dry hairless part of body (upper arm recommended)

• Do not cut patches to adjust dose– Nicotine may evaporate from cut edges– Patch may be less effective

• Water will not harm the nicotine patch if it is applied correctly; patients may bathe, swim, shower, or exercise while wearing the patch

Nicotine Patch: Summary

DISADVANTAGES Patients cannot titrate the

dose to acutely manage withdrawal symptoms.

Allergic reactions to the adhesive may occur.

Patients with dermatologic conditions should not use the patch.

ADVANTAGES Provides consistent

nicotine levels.

Easy to use and conceal.

Once daily dosing associated with fewer compliance problems.

Nicotine Nasal SprayNicotrol NS

• Solution of nicotine in a 10-ml spray bottle

• Each metered dose actuation delivers–50 mcL spray–0.5 mg nicotine

• ~100 doses/bottle

• Rapid absorption across lining of nose

Nicotine Nasal Spray: Summary

DISADVANTAGES Need for frequent dosing

Nose and throat irritation may be bothersome

Higher dependence potential

People with chronic nasal disorders or certain lung disease should not use the spray

ADVANTAGES Can use as needed to

rapidly manage withdrawal symptoms

Nicotine InhalerNicotrol Inhaler

• Nicotine inhalation system consists of:–Mouthpiece–Cartridge with porous plug

containing 10 mg nicotine and 1 mg menthol

• Delivers 4 mg nicotine vapor, absorbed across lining of mouth and throat

Nicotine Inhaler: Summary

DISADVANTAGES Need for frequent dosing

Initial throat or mouth irritation can be bothersome

People with certain lung diseases should use the inhaler with caution

ADVANTAGES Can use as needed to manage

withdrawal symptoms The inhaler mimics the hand-to-mouth

ritual of smoking

Bupropion SR Zyban; generics

• Nonnicotine, cessation pill

• Sustained-release atypical antidepressant

• Affects levels of dopamine and norepinephrine in the brain – craving for cigarettes– symptoms of nicotine

withdrawal

• Neuropsychiatric symptoms and suicide risk–Changes in mood (depression and mania)–Psychosis/hallucinations/paranoia/delusions–Homicidal ideation/hostility–Agitation/anxiety–Suicidal ideation or attempts–Completed suicide

Bupropion: Warnings and Precautions

Patients should stop bupropion and contact a health care provider immediately if agitation, hostility, depressed mood or changes in

thinking or behavior (including suicidal ideation) are observed

Bupropion: Summary

DISADVANTAGES The seizure risk is increased

Several contraindications and precautions preclude use in some patients

Patients should be monitored for potential neuropsychiatric symptoms

ADVANTAGES Easy to use oral formulation Might delay weight gain

Might be beneficial in some people with depression

VareniclineChantix

• Non-nicotine, oral cessation aid• Binds to 42 nicotinic

acetylcholine receptors–Stimulates low-level agonist activity–Competitively inhibits binding of

nicotine• Clinical effects

– symptoms of nicotine withdrawal–Decreases pleasure associated with

smoking

• Neuropsychiatric Symptoms and Suicidality–Changes in mood (depression and mania)–Psychosis/hallucinations/paranoia/delusions–Homicidal ideation/hostility–Agitation/anxiety/panic–Suicidal ideation or attempts–Completed suicide

Varenicline: Warnings and Precautions

Patients should stop varenicline and contact a health care provider immediately if agitation, hostility, depressed mood or changes in

thinking or behavior (including suicidal ideation) are observed

Varenicline: Summary

DISADVANTAGES May induce nausea in up to

one third of patients.

Patients should be monitored for potential neuropsychiatric symptoms

ADVANTAGES Easy to use oral formulation Offers a new mechanism of action for

people who have failed other agents

Long-Term Quit Rate for First-Line Cessation Medications

0

5

10

15

20

25

30

Nicotine gum Nicotinepatch

Nicotinelozenge

Nicotinenasal spray

Nicotineinhaler

Bupropion Varenicline

Active drugPlacebo

Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev

Per

cen

t q

uit 18.0

15.8

11.3

9.9

16.1

8.1

23.9

11.8

17.1

9.1

19.0

10.3 11.2

20.2

Combination Therapy

• Combination NRT–Long-acting formulation (patch)

• Produces relatively constant levels of nicotine

PLUS–Short-acting formulation (gum, inhaler, nasal spray)

• Allows for additional nicotine as needed for withdrawal symptoms

• Bupropion SR + Nicotine Patch

Regimens with enough evidence to be ‘recommended’ as first-line

Gum Lozenge Patch Inhaler Nasal sprayBupropion

SR Varenicline

Trade $5.49 $4.50 $3.40 $6.39 $3.58 $6.20 $5.96

Generic $1.90 $1.89 $1.60 $2.71

$0

$1

$2

$3

$4

$5

$6

$7

Comparative Daily Costs ofSmoking Cessation Medications

$/d

ay

Average $/pack of cigarettes, $5.95

Coverage for Tobacco Dependence Treatments

• Health insurance coverage & requirements vary by plan

• Medi-Cal provides FREE pharmacotherapy• Medicare

– Prescription drug benefits – Part D– Reimburses for cessation counseling

CPT Codes: 99406 (3-10 minute intervention) 99407 (>10 minute intervention)

Pharmacotherapy Guidance• Smoking induces CYP1A2 isoenzyme• Approximately doubles clearance of

–Antipsychotics: Prolixin (fluphenazine), Haldol (haloperidol), Zyprexa (olanzapine), Clozaril (clozapine), Thorazine (chlorpromazine)

–Antidepressants: Elavil (amitriptyline), Aventyl (nortriptyline), Jaminine (imipramine), Anafranil (clomipramine), Sinequan (doxepin), Fluvox (fluvoxamine)

• Cessation may produce rapid, significant increase in blood levels

• Need to monitor for increased side effects

Clinical Monitoring Recommendations

• Patients should be seen 1-3 days after initiating smoking cessation

• Monitor weekly for the 1st 4 weeks for MI/SUD relapse and the need to adjust medication levels

• After 1st month, monthly review for 6 months• Communication between the primary care

provider and MI/SUD provider(s) should occur– During the initiation of the cessation attempt– During the cessation period if any psychiatric

complications occur

Special Thanks and Acknowledgement

Gary Tedeschi, PhDCalifornia Smokers’ Helpline,

UCSD Cancer Center

Robin L. Corelli, PharmDDepartment of Clinical Pharmacy,

UCSF School of Pharmacy

Kirsten Hansen, MPPCenter for Tobacco Cessation,

UCSD Cancer Center

Los Angeles County Resources• It’s Quitting Time L.A.!

http://www.laquits.com

• LA County Tobacco Control and Prevention Programhttp://www.lapublichealth.org/tob/

• County Listings http://www.nobutts.org/CountyListings.aspx

• To add resources to the list contact Donna Sze at dsze@ph.lacounty.gov