1. Tobacco Use Disorder A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1 A Presentation for SOMC Medical Education A Presentation for SOMC Medical Education A Presentation for SOMC Medical Education Kendall L. Stewart, MD, MBA, DFAPA September 21, 2012 1 This presentation is designed as a problem-based learning module.

2. Why is this important? Scioto County has the highest smoking rate in the United States! (36%!)highest smoking rate Tobacco kills more people each year than anything else. Secondhand smoke causes 10% of the tobacco-related deaths. Nonsmokers live more than a dozen years longer than smokers. Nicotine is highly addictive. About 20% of us smoke. Many more are affected by that smoke. Our progress in decreasing smoking has stalled. 1 After listening to this presentation, you will be able to answer the following questions: –Why is this important? –What are the diagnostic criteria? –How many people does smoking kill each year? –What are some of the demographics of tobacco use disorder? –What counseling techniques are helpful? –What medications are helpful? –What excuses do we physicians make for not engaging these patients more? 1 Young people often start smoking because they still view smoking as cool.

3. What current diagnoses are included in this category? Nicotine Dependence Nicotine Withdrawal Nicotine-Related Disorder NOS In DSM-5, these will likely be replaced with Tobacco Use Disorder and included in the Substance Use Disorders category.

4. What are the diagnostic criteria? 1 Problematic pattern of tobacco use causing significant impairment or distress –Tobacco used longer than intended –Unsuccessful efforts to cut down usage –A great deal of time consumed by tobacco-related activities and complications –A tobacco-related failure to fulfill obligations at school, work or home –Continued tobacco use in spite of the problems it causes –Tobacco use negatively impacts social, occupational or recreational activities –Recurrent use when physically hazardous –Continued use in spite of tobacco-related complications –Tolerance –Withdrawal –Craving 1 These are the proposed DSM-5 criteria.

5. How many people does smoking kill each year? 1 1 Adapted from Rakel and Rakel, Textbook of Family Medicine and the CDC, Average Annual Number of Deaths, 2000-2004.

6. What are some of the key demographics of tobacco use? 1 Few people start smoking after age 18. About 4000 children smoke for the first time every day; 2/3 will become addicted. 70% of smokers would like to stop. 50% try to stop. Less than 5% will succeed. College graduates are more likely to succeed. Only about 6% of people with graduate degrees smoke. People with mental illness smoke 70% of the cigarettes in the United States. Smoking is a pestilence mostly embraced by the poor, uneducated and mentally ill. 1 1 Rakel and Rakel, Textbook of Family Medicine

7. What about filtered cigarettes? 1 These varieties, 97% of those sold here, are not safer. Those who smoke low nicotine, low tar cigarettes just smoke more of them to get the same nicotine hit. Likewise, natural and organic cigarettes are just marketing ploys. 1 Rakel and Rakel, Textbook of Family Medicine

8. What about cigars? 1 These carry the same risks as cigarettes. The risk varies with the number smoked and the degree on inhalation. More than 9% of men and 2% of women smoke cigars. The higher pH of cigar smoke permits nicotine absorption across the oral mucosa. Cigar smokers do tend to inhale less. The use of alcohol multiplies the risks. 1 Rakel and Rakel, Textbook of Family Medicine

9. What about electronic cigarettes? 1 These were developed in China in 2003. They contain a battery, atomizer and cartridge with liquid nicotine, and propylene glycol (used in antifreeze and cosmetics) propylene glycol Flavors such as chocolate and bubblegum are included to entice children. The FDA regulates them, but testing has not yet been completed. Internet sales are growing. The price is dropping. These may become harm reduction tools and play some helpful role. 1 Rakel and Rakel, Textbook of Family Medicine

10. What about smokeless tobacco? 1 Snuff greatly increases the odds of cancer of the gums and cheeks. About 9% of high school students use smokeless tobacco products; it is more popular with boys than girls Spitting tobacco is popular in organized sports. Carcinogens are more concentrated in smokeless tobacco than in cigarette smoke. Nitrosamine levels are 10,000 times greater than in bacon and beer. Tobacco companies are marketing snus as an alternative to spitting and smoking.snus Smokeless tobacco users are less successful at quitting. 1 Rakel and Rakel, Textbook of Family Medicine

11. What about secondhand smoke? 1 1/3 of lung cancers are caused by living with a smoker. Passive smoking is the third most common preventable cause of death–after smoking and drinking. Passive smoking increases SIDS, respiratory infections, ear infections, asthma and slows lung growth. There is no risk-free level of exposure. Only eliminating smoking indoors completely protects nonsmokers. Cleaning rooms after smokers pollute them is not entirely possible. 1 Rakel and Rakel, Textbook of Family Medicine

12. What about third hand smoke? 1 Tobacco smoke reacts with nitrous acid to produce tobacco-specific nitrosaminesa carcinogen that becomes more potent over time. It is concentrated in dust and carpeting and is thus more harmful to children. Worse still, this stuff is essentially impossible to remove. This danger is regularly overlooked by parents who mistakenly think not smoking indoors when kids are present is safe. 1 Rakel and Rakel, Textbook of Family Medicine

13. What counseling techniques are helpful? 1 Assess the patients readiness for change and respond accordingly: –Pre-contemplation (not interested) –Contemplation (thinking about quitting) –Preparation (planning to quit in next 30 days) –Action (in process of quitting) –Maintenance (tobacco free for 3 months or more) Use motivational interviewing to build patients self motivation.motivational interviewing Brief counseling (<3 minutes) = 13% quit rate. Intensive counseling = 22% quit rate Prenatal care, non fatal MIs and hospitalizations for tobacco-use complications are the best teachable moments. Seize them! Study Treating Tobacco Use and Dependence: 2008 Update, a critical clinical practice guideline.Treating Tobacco Use and Dependence: 2008 Update 1 Rakel and Rakel, Textbook of Family Medicine

14. What medications are helpful? 1 Nicotine Patch (Nicoderm, Habitrol, Nicotrol, ProStep)Nicotine Patch –Start 2 weeks before the patient plans to quit. –This first-line treatment is often combined with counseling and other medications. –Avoid insomnia by removing the patch before going to bed. –Adding gum, the lozenge or nasal spay for breakthrough symptoms increases the odds of success. Nicotine Gum (Nicorette)Nicotine Gum –Chew slowly, intermittently and park between the gum and cheek for a half hour. –Avoid eating or drinking anything but water for 5 minutes and during administration. –Use enough! –Use the 4 mg strength for those who smoke more than 1 pack per day. –Continue the trial for at least 6 weeks. 1 Rakel and Rakel, Textbook of Family Medicine

15. What medications are helpful? 1 Nicotine Lozenge (Commit)Nicotine Lozenge –The effect lasts 20-30 minutes –Do not eat or drink 15 minutes before or during use. –Use up to 20/day for up to 12 weeks. –The side effects are similar to those with nicotine gum (sore teeth, throat, gums, indigestion) Nicotine Inhaler (Nicotrol Inhaler)Nicotine Inhaler –Use up to 16 cartridges/day for 12 weeks, then taper and discontinue over the next 12 weeks. –Each cartridge is equivalent to 2 cigarettes. –Nicotine delivery declines in cold temperatures. 1 Rakel and Rakel, Textbook of Family Medicine

16. What medications are helpful? 1 Nicotine Nasal Spray (Nicotrol NS)Nicotine Nasal Spray –Do not use if you have severe restrictive airway disease. –Do not sniff, inhale or swallow when you spray. –Tilt your head slightly back when spraying. –Spray once in each nostril up to 40 times/day for 12 weeks. Bupropion SRBupropion –Start 2 weeks before quitting. –Take 150 mg every morning for 3 days, then BID for 12 weeks. –Do not use if you have a history of head trauma, seizures or if you have used a MAOI in the past 14 days. –Side effects include nausea, bad dreams, insomnia, headache and flatulence. 1 Rakel and Rakel, Textbook of Family Medicine

17. What medications are helpful? 1 Varenicline(Chantix)Varenicline –Start 1 week before you plan to quit. –Take 0.5 mg daily for 3 days, then BID for 4 days, then 1.0 mg daily for total of 12 weeks. –The side effects are similar to bupropion SR. Combination Therapy –This may be the best approach. –Think of bupropion SR or the patch as maintenance and short-acting NRT agents breakthrough drugs. –Triple therapy (patch, bupropion SR and the inhaler) for up to 6 months has produced the best documented results. 1 Rakel and Rakel, Textbook of Family Medicine

18. What public health interventions actually work? 1 Enforce tobacco advertising bans. Raise the price of tobacco products. Provide smokers who want to quit with the help they need. Prevent unwanted exposure to secondhand smoke. Publicize the health hazards of tobacco use. Decrease the impact of the marketers of death. Increase the influence of anti-smoking forces. Use attention-getting warning labels. Read more about this problem here.here 1 Rakel and Rakel, Textbook of Family Medicine

19. What excuses do physicians make? 1 My patients are not motivated. My patients dont have the necessary insurance coverage. I am not reimbursed enough for my time when treating these people. I dont have enough time to do this. There are not enough resources to refer my patients to. Nothing works anyway. Im not trained to do this; this is not my specialty. I dont like this kind of work. 1 Rakel and Rakel, Textbook of Family Medicine

20. What should you do? 1 You must be the change you want to see in the world. Mahatma Gandhi Become a wellness champion and continue that lifestyle as long as you live. If you smoke or use any tobacco product, stop now. Support prevention efforts for kids. Ask every new patient about tobacco use. If they use, ask them to please stop. Inquire whether patients who are using tobacco are ready to stopat every visit. 1 Rakel and Rakel, Textbook of Family Medicine

21. What else should you do? 1 Seize every teachable moment to urge quitting. Make sure your users know 1-800- QUITNOW (1-800-784-8669) Remember, the first two weeks are critical; arrange daily phone or text follow up contacts. View this as a chronic disease. Focus on what you can do instead of fretting about what you cant do. Never, never, ever give up. 1 Rakel and Rakel, Textbook of Family Medicine

22. The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process Introduce yourself using AIDET 1.AIDET Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

23. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, Dealing With Anxiety: A Practical Approach to Nervous Patients, 2000Dealing With Anxiety: A Practical Approach to Nervous Patients, Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.here

24. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.here Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. www.KendallLStewartMD.com Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.www.SOMC.org Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.here

25. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

26. Safety Quality Service Relationships Performance Safety Quality Service Relationships Performance Are there other questions? Thomas Carter, DO Justin Greenlee, DO