How to implement evidence-based addiction treatment in your practice Dr Liezl Kramer Addiction Symposium

What is EBT / EBP? specifies way professionals /decision- makers should make decisions identifying evidence for a practice rating it (how scientifically sound?) goal = eliminate unsound or excessively risky practices Encourages use of best evidence possible

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

To deepen our understanding of the principles of effective treatment we will need to look at some important concepts in addictions...

Principles of Effective Treatment Principles of Effective Treatment (NIDA) 1.Addiction is a complex, but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Summary of the Neurobiology of Addiction: PFC OFC Regulating impulses DL-PFC Analyzing Regulating Rationalizing Flexibility VM-PFC Regulating emotions Mesolimbic DA pathway VTA N. Accumbens (DA release) Amygdala / Hippocampus (Memories) “Top-down system” “Reflective reward system” “Willpower” Influenced by: Neurodevelopment Genetics Experience Peer pressure Social rules Delayed gratification Set Setting “Bottom-up system” “Reactive reward system” “Tempation”

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5.Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Spectrum of Use: Once-off use Experimental use Harmful use / Abuse Dependence Different strategies needed

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Barriers to AOD treatment (Myers et al) 1. Previously disadvantaged communities 2. Women 3. Lack of awareness of AOD treatment services 4. Lack of social networks or significant others 5. Financial barriers, competing priorities and limited income 6. Transport costs, longer travel times and loss of income due to work absenteeism 7. Stigma 8. Perceptions and satisfaction with AOD treatment services!

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Case management: A collaborative effort to: 1.Assess 2.Plan 3.Implement 4.Link and co-ordinate 5.Monitor ongoing needs, options and services 6.Advocate To meet the patient’s health needs!

Case Managers: One person is to take primary responsibility for service provision in order: 1.To assess needs 2.To identify barriers to treatment 3.To plan services used 4.To refer to appropriate services 5.To ensure attendance 6.To monitor compliance 7.To co-ordinate and link patients to services 8.To monitor progress

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5.Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Adherence to recovery plan: Responsibility Non-adherence leads to relapse Variety of interventions and professionals Frequent abstinence-based contacts Biopsychosocial and spiritual aspects Recovery prioritized for success Involve supportive network

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5.Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Behavioural Therapies help: Behavioural Therapies engage people in drug abuse treatment, provide incentives for them to remain abstinent, modify their attitudes and behaviours related to drug abuse, increase their life skills to handle stressful circumstances and environmental cues (triggers /cravings)

EBT Behavioural Therapies: (NIDA) CBT (Cognitive Behavioural Therapy) Contingency Management Interventions/Motivational Incentives CRA (Community Reinforcement Approach Plus Vouchers ) MET/MI (Motivational Enhancement Therapy) The Matrix Model 12-Step Facilitation Therapy Family Behaviour Therapy Also HR and BI

Examples of addictions treatments which are not evidence-based: Befriending Hypnosis Psychoanalysis ……. Not included in international guidelines currently

This list is not exhaustive (new treatments are continually under development)

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5.Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

EBT Pharmacotherapies: (NIDA) Opioid Addiction – Methadone – Buprenorphine – Naltrexone – (combined with behavioural therapies) Tobacco Addiction – NRT – Varenicline – Buproprion – (combined with behavioural therapies) Alcohol Addiction – Benzos and Thiamine – Acamprosate – Disulfiram – Naltrexone – Topiramate – (combined with behavioural therapies)

Examples of addictions treatments which are not evidence-based: Ibugaine Ultra-rapid opioid detox Buprenorphine for non-opioids ……. Not included in international guidelines currently

This list is not exhaustive (new treatments are continually under development)

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Cycle of Change: DiClemente and Prochaska 1992

Implications of Stages of Change: Not simply motivated or not motivated Different stages = different needs More successful if help matches needs Nudging to next phase, not trying to do too much May go around circle several times

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Comprehensive Assessment: History Experimental use vs abuse vs dependence Polysubstance use Comorbidity (physical and mental) Collateral Information (see with family) Confirm with urine toxicology Physical examination Bloods, ECG, etc.

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long- term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Phases of Treatment: 1.Assessment & Emergency treatment 2.Preparation for change 3.Detox (as in- or outpatient) 4.Rehab (in- or outpatient) learn a new lifestyle 5.Abstinence and aftercare live a new lifestyle

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Committal process:  Family to do affidavit: SAPD/Social worker  Appointment with Social Worker  Affidavit to state prosecutor/request court date  Social Worker to do investigation and report  Social Worker to arrange admission at treatment centre: date to be available at court date  Appearance in court: in magistrate chambers  Court hearing: all to be present/ opportunity for representation. Social work report to be presented.  Admission/detainment

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Cycle of Change:

Relapse as a learning experience!

Gold standard: – Random – Supervised Urine toxicology

Principles of Effective Treatment (NIDA) Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behaviour. 2.No single treatment is appropriate for everyone. 3.Treatment needs to be readily available. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6.Behavioural therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioural therapies. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9.Many drug-addicted individuals also have other mental disorders. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11.Treatment does not need to be voluntary to be effective. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

Phases of Treatment: 1.Assessment & Emergency treatment 2.Preparation for change 3.Detox (as in- or outpatient) 4.Rehab (in- or outpatient) learn a new lifestyle 5.Abstinence and aftercare live a new lifestyle

Comprehensive Assessment: History Experimental use vs abuse vs dependence Polysubstance use Comorbidity (physical and mental) Collateral Information (see with family) Confirm with urine toxicology Physical examination Bloods, ECG, etc.

References: Cornish, J.W.; Metzger, D.; Woody, G.E.; Wilson, D.; McClellan, A.T.; and Vandergrift, B. Naltrexone pharmacotherapy for opioid dependent federal probationers. Journal of Substance Abuse Treatment 14(6):529– 534, Gastfriend, D.R. Intramuscular extended-release naltrexone: current evidence. Annals of the New York Academy of Sciences 1216:144–166, Krupitsky, E.; Illerperuma, A.; Gastfriend, D.R.; and Silverman, B.L. Efficacy and safety of extended-release injectable naltrexone (XR-NTX) for the treatment of opioid dependence. Paper presented at the 2010 annual meeting of the American Psychiatric Association, New Orleans, LA. Fiellin, D.A.; Pantalon, M.V.; Chawarski, M.C.; Moore, B.A.; Sullivan, L.E.; O’Connor, P.G.; and Schottenfeld, R.S. Counseling plus buprenorphine/naloxone maintenance therapy for opioid dependence. The New England Journal of Medicine 355(4):365–374, Fudala P.J.; Bridge, T.P.; Herbert, S.; Williford, W.O.; Chiang, C.N.; Jones, K.; Collins, J.; Raisch, D.; Casadonte, P.; Goldsmith, R.J.; Ling, W.; Malkerneker, U.; McNicholas, L.; Renner, J.; Stine, S.; and Tusel, D. for the Buprenorphine/Naloxone Collaborative Study Group. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. The New England Journal of Medicine 349(10):949– 958, Kosten, T.R.; and Fiellin, D.A. U.S. National Buprenorphine Implementation Program: Buprenorphine for office- based practice. Consensus conference overview. The American Journal on Addictions 13(Suppl. 1):S1–S7, McCance-Katz, E.F. Office-based buprenorphine treatment for opioid-dependent patients. Harvard Review of Psychiatry 12(6):321–338, Anton, R.F.; O’Malley, S.S.; Ciraulo, D.A.; Cisler, R.A.; Couper, D.; Donovan, D.M.; Gastfriend, D.R.; Hosking, J.D.; Johnson, B.A.; LoCastro, J.S.; Longabaugh, R.; Mason, B.J.; Mattson, M.E.; Miller, W.R.; Pettinati, H.M.; Randall, C.L.; Swift, R.; Weiss, R.D.; Williams, L.D.; and Zweben, A., for the COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. The Journal of the American Medical Association 295(17):2003–2017, National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide, Updated 2005 Edition. Bethesda, MD: NIAAA, updated Available at pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htmpubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm

References cont: Dole, V.P.; Nyswander, M.; and Kreek, M.J. Narcotic blockade. Archives of Internal Medicine 118:304–309, McLellan, A.T.; Arndt, I.O.; Metzger, D.; Woody, G.E.; and O’Brien, C.P. The effects of psychosocial services in substance abuse treatment. The Journal of the American Medical Association 269(15):1953–1959, The Rockerfeller University. The first pharmacological treatment for narcotic addiction: Methadone maintenance. The Rockefeller University Hospital Centennial, Available at centennial.rucares.org/index.php?page=Methadone_MaintenanceExternal link, please review our disclaimer..centennial.rucares.org/index.php?page=Methadone_Maintenancedisclaimer Woody, G.E.; Luborsky, L.; McClellan, A.T.; O’Brien, C.P.; Beck, A.T.; Blaine, J.; Herman, I.; and Hole, A. Psychotherapy for opiate addicts: Does it help? Archives of General Psychiatry 40:639–645, Alterman, A.I.; Gariti, P.; and Mulvaney, F. Short- and long-term smoking cessation for three levels of intensity of behavioral treatment. Psychology of Addictive Behaviors 15: , Hall, S.M.; Humfleet, G.L.; Muñoz, R.F.; V.I; Prochaska, J.J.; and Robbins, J.A. Using extended cognitive behavioral treatment and medication to treat dependent smokers. American Journal of Public Health 101:2349– 2356, Jorenby, D.E.; Hays, J.T.; Rigotti, N.A.; Azoulay, S.; Watsky, E.J.; Williams, K.E.; Billing, C.B.; Gong, J.; and Reeves, K.R. Varenicline Phase 3 Study Group. Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist vs. placebo or sustained-release bupropion for smoking cessation: A randomized controlled trial. The Journal of the American Medical Association 296(1):56–63, King, D.P.; Paciqa, S.; Pickering, E.; Benowitz, N.L.; Bierut, L.J.; Conti, D.V.; Kaprio, J.; Lerman, C.; and Park, P.W. Smoking cessation pharmacogenetics: Analysis of varenicline and bupropion in placebo-controlled clinical trials. Neuropsychopharmacology 37:641–650, Raupach, T.; and van Schayck, C.P. Pharmacotherapy for smoking cessation: Current advances and research topics. CNS Drugs 25:371– 382, Shah, S.D.; Wilken, L.A.; Winkler, S.R.; and Lin, S.J. Systematic review and meta-analysis of combination therapy for smoking cessation. Journal of the American Pharmaceutical Association 48(5):659–665, Smith, S.S; McCarthy, D.E.; Japuntich S.J.; Christiansen, B.; Piper, M.E.; Jorenby, D.E.; Fraser, D.L.; Fiore, M.C.; Baker, T.B.; and Jackson, T.C. Comparative effectiveness of 5 smoking cessation pharmacotherapies in primary care clinics. Archives of Internal Medicine 169:2148–2155, Stitzer, M. Combined behavioral and pharmacological treatments for smoking cessation. Nicotine & Tobacco Research 1:S181–S187, 1999.

…Questions / Discussion…

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