1. Best Practices for Tobacco Treatment with Behavioral Health Patients Dior Hildebrand, RN, PHN Los Angeles County, Department of Public Health Tobacco Control Prevention Program 1

2. 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

3. Common Benefits of Quitting TimeBenefits Within a few weeks Increase in pulmonary function & exercise tolerance Decrease in respiratory symptoms One yearRisk of coronary disease cut by half Within 2 yearsAll-cause death rate declines 10 yearsRisk of pulmonary & other cancers falls by 50% By age 654 additional years of life compared to those who dont quit by then Schroeder, 2005 Bottom line: Quality of life is increased by cessation.

4. Clinical Practice Guidelines

5. 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.)

6. Evidence-Based Model: The 5 As A sk : Systematically identify all tobacco users at every visit A dvise: Advise tobacco users to quit A ssess:Assess each tobacco users willingness to quit A ssist: Assist tobacco users with a quit plan A rrange: Arrange follow-up contact

7. 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…

8. Behavioral Health Professionals Often the clinician for whom contact is the most frequent and who knows the 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

9. A sk : 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 As and A, A, R A dvise: Advise smokers to quit A rrange: Arrange follow-up contact A ssist: Assist smokers with a quit plan A ssess : Assess each smokers willingness to quit R efer to the California Smokers Helpline and/or Peer-to-peer counselor

10. California Smokers Helpline 10

11. 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

12. Available Services Self-help materials Referral lists of local cessation programs Updated by each countys tobacco control program Individual telephone counseling Confidential One pre-quit call, multiple proactive follow- up calls Trained counseling staff

13. 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

14. 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

15. Self-Reported Behavioral Health Conditions Among Helpline Callers % Smoking Zhu,et al, 2009. Unpublished data

16. Treatment Fundamentals 16

17. 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

18. 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

19. 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

20. Determining Readiness to Proceed Motivation –Interested is sufficient –Dont rule out some type of intervention, even if motivation to quit now is low Motivational Interviewing

21. 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

22. Treatment Considerations (cont.) Psychiatric stability –How are the clients 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

23. 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.

24. 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 clients level of functioning, resources, skills, and needs. Treatment Considerations (cont.)

25. 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

26. Pharmacotherapy 26

27. Behavioral Health and Tobacco Cessation Online CME https://cmecalifornia.com/Activity/1023974/Detail.aspx 27

28. 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

29. 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

30. 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

31. Nicotine Gum Nicorette; 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

32. 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

33. Nicotine Gum: Dosing Dosage and schedule: –If 1 st cigarette is smoked 30 minutes after waking, use 2 mg gum –If 1 st 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

34. Nicotine Gum: Side Effects Jaw muscle ache Irritation of throat and mouth* Lightheadedness* Nausea and vomiting* Hiccups* Indigestion* * Especially when chewing gum too fast

35. 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.

36. 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

37. Nicotine Lozenge Nicorette 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

38. Nicotine Lozenge: Dosing Dosage and schedule: –If 1 st cigarette is smoked 30 minutes after waking, use 2 mg lozenge –If 1 st 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)

39. Nicotine Lozenge: Side Effects Nausea Hiccups Cough Heartburn Headache Flatulence Insomnia

40. 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

41. 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

42. Nicotine Patch NicoDerm 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

43. Nicotine Patch: Dosing ProductLight SmokerHeavy 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)

44. 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

45. 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

46. 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.

47. Nicotine Nasal Spray Nicotrol 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

48. 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

49. Nicotine Inhaler Nicotrol 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

50. 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

51. 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

52. 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

53. 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

54. Varenicline Chantix Non-nicotine, oral cessation aid Binds to 4 2 nicotinic acetylcholine receptors –Stimulates low-level agonist activity –Competitively inhibits binding of nicotine Clinical effects – symptoms of nicotine withdrawal –Decreases pleasure associated with smoking

55. 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

56. 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

57. Long-Term Quit Rate for First-Line Cessation Medications 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 Percent quit 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

58. 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

59. Comparative Daily Costs of Smoking Cessation Medications $/day Average $/pack of cigarettes, $5.95

60. 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)

61. 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

62. 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

63. Special Thanks and Acknowledgement Gary Tedeschi, PhD California Smokers Helpline, UCSD Cancer Center Robin L. Corelli, PharmD Department of Clinical Pharmacy, UCSF School of Pharmacy Kirsten Hansen, MPP Center for Tobacco Cessation, UCSD Cancer Center

64. Los Angeles County Resources Its Quitting Time L.A.! http://www.laquits.com LA County Tobacco Control and Prevention Program http://www.lapublichealth.org/tob/ County Listings http://www.nobutts.org/CountyListings.aspx http://www.nobutts.org/CountyListings.aspx To add resources to the list contact Donna Sze at dsze@ph.lacounty.govdsze@ph.lacounty.gov