1. Ken Wassum & Abigail Halperin Session 13: Behavioral Counseling and Pharmacotherapy 09/14/2011

2. Counseling & Pharmacotherapy

3. Who Calls the Quitline? Smoked / used tobacco >20 years Not well educated Lower income Motivated to quit Confidence lower than motivation Chronic illness High nicotine dependence

4. Theoretical Counseling Models Environment Personal Motivation/ Confidence Why? Behavior Social Cognitive Theory Transtheoretical Stages of Change Brief Solution Focused Therapy

5. Counseling Tools Cognitive Behavioral Motivational Interviewing Education Modeling Skill building Reinforcement

8. Counseling Focus Tobacco only Counselor backgrounds Counselor training

9. Facilitation Goals Develop rapport and trust Get clarity on outcome goal Provide encouragement Enhance motivation and confidence Demonstrate empathy and non-judgment Engage the caller in the quitting process Demonstrate subject matter expertise

10. Content Goals Provide basic information about the nature of tobacco use and dependence Educate caller about what to expect when quitting Help caller create a plan to quit Teach problem-solving and coping skills Provide medication decision support Address relapse prevention

11. Smoke-free policies Tobacco-tax Article 14 Healthcare referral

12. Integrating Pharmacotherapy into Quitlines

13. Pharmacotherapy Medications significantly improve success rates * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents. “Providers should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.”

14. Quit Rates for Cessation Medications Graph reprinted with permission, Rx for Change, The Regents of the University of California, University of Southern California, and Western University of Health Sciences. Percent quit 19.5 14.6 11.5 8.6 16.4 8.8 23.9 11.8 17.1 9.1 20.0 10.2 9.4 22.5

15. How does pharmacotherapy help people quit? Nicotine is physiologically addictive Medications help reduce cravings and withdrawal symptoms More medication => higher quit rates

16. Integrating Medication with Counseling in a Quitline Setting Great opportunity to combine counseling and medication to maximize quitting success Counselor training and support needs – Knowledge about medications – Protocols and algorithms – Informational tools and resources Access to medications – Options and challenges

17. Factors to consider in recommending pharmacotherapy All are safe, effective and well tolerated – Minor side-effects common/adverse events rare – Some use exclusions or contraindications Decision support assessment – Number of cigs per day and time to first cigarette – History of prior quit attempts/use of medication – Advantages/disadvantages of each medication – Personal preference

18. Pharmacotherapy Options Nicotine replacement products – Non-prescription: Patches, Gum or Lozenge – Prescription: Oral Inhaler or Nasal Spray Non-nicotine products (by prescription only) - Bupropion SR (Zyban) and Varenicline (Chantix)

19. Nicotine Gum (2 mg, 4 mg) Advantages May satisfy oral cravings and delay weight gain Titrate use to manage withdrawal symptoms Disadvantages Visible use Difficult with dentures or jaw problems/TMJ Must use proper technique to minimize side-effects and maximize effectiveness 2 mg for those smoking less than 25 cpd 4 mg for those smoking 25 or more cpd Patients should use ad lib but not exceed 24 pieces per day

20. Transdermal Nicotine Patch 21 mg for those smoking 11+ cigarettes per day 14 mg for those smoking 5-10 cigarettes per day 7 mg for those smoking 1-4 cigarettes per day Advantages Provides consistent nicotine levels Easy to use and conceal Fewer compliance issues Disadvantages Reactions to adhesive are common Cannot titrate the dose

21. Nicotine Lozenge (2 mg, 4 mg) 2 mg if smoke > 30 minutes after waking 4 mg if smoke within the first 30 minutes Should not exceed 20 lozenges per day Advantages May satisfy oral cravings Easy to use and conceal Titrate to manage withdrawal symptoms Disadvantages Gastrointestinal side effects (nausea, hiccups, heartburn)

22. Nicotine Nasal Spray Advantages Easily titrated with rapid control of withdrawal symptoms Disadvantages Nasal or throat irritation common Dependence can result Must wait 5 minutes before driving or operating heavy machinery Those with chronic nasal disorders or severe reactive airway disease should not use Rapid onset of action Doses per hour: 1-2 Maximum doses per day: 40 Maximum duration of treatment: 3 months

23. Nicotine Inhaler Advantages Easily titrated to rapidly manage withdrawal symptoms Mimics hand-to-mouth ritual Disadvantages Mouth and throat irritation common Absorbed through oral mucosa (not lung) 12 week course Initial dose of 6 to 16 cartridges per day Frequent continuous puffing for 20 minutes

24. Bupropion SR (Zyban) Start 1 week before quit date 150 mg 1x per day for 3 days 150 mg 2x per day for duration (7-12 weeks) Advantages Easy to use Can be taken with NRT May help with depression Disadvantages Seizure risk is increased Avoid or use with caution in those with history of seizures, head trauma, eating disorders or heavy alcohol use Use contraindicated with certain medications

25. Varenicline (Chantix or Champix) Advantages  Unique mechanism of action (partial nicotinic receptor agonist; lessens withdrawal symptoms and inhibits smoking “reward”)  Easy to use Disadvantages  Nausea common (up to 40% of users)  FDA “black box” warning  Use with caution in those with psychiatric diagnosis or history Start 1 week before quit date 0.5mg 1x per day for days 1-3 0.5mg 2x per day for days 4-7 1.0 mg 2x per day for 12 weeks

26. Panelist Questions Counseling & Pharmacotherapy Is the model your counselors use based on practice, theory or both? Please describe your model. How does your quitline address use of medications to quit? – Do you help callers choose medications? – Do you explain how to use the medications? – Are you able provide free or low-cost access to medications? Do you have advice to offer those who are developing or expanding new quitlines?

27. Thank you!