1. Addressing Nicotine Dependence in Drug Treatment Kimber Paschall Richter, PhD, MPH Robert M. McCool, MS University of Kansas School of Medicine, Kansas City

2. Thanks to: KC Area Methadone Clinics KC Area Methadone Clinics KU Methadone Clinic KU Methadone Clinic Paseo Clinic Paseo Clinic KCTC KCTC DRD-KC DRD-KC Bridgeway Recovery Bridgeway Recovery Rodgers South Rodgers South NIDA NIDA Robert Wood Johnson Foundation Robert Wood Johnson Foundation CSAT OPAT CSAT OPAT

3. Active Drug Users CAN Quit Smoking 16,661 participants, NHSDA 16,661 participants, NHSDA 1,465 used and illicit drug past month 1,465 used and illicit drug past month Most were occasional marijuana users Most were occasional marijuana users Most (71%) current users smoke Most (71%) current users smoke 1 IN 5 (21%) current users were FORMER smokers 1 IN 5 (21%) current users were FORMER smokers Quit rate of 23% (% of “ever” smokers that have quit) Quit rate of 23% (% of “ever” smokers that have quit) Compared to about 50% quit rate in general population Compared to about 50% quit rate in general population

4. People in Treatment CAN Quit, Too 550 participants, KC Metro Methadone Survey 550 participants, KC Metro Methadone Survey 84% patients participated 84% patients participated Most (77%) smoke cigarettes Most (77%) smoke cigarettes 11% were FORMER smokers, 11% NEVER smokers 11% were FORMER smokers, 11% NEVER smokers Quit rate of 12% Quit rate of 12%

5. Why Quit? I see my grandparents, my relatives that have all got emphysema. …They can’t go to the mall. They can’t go to dinner. … And I think why should I keep doing this shit to me. [Noah] I don’t want to get hurt and I don’t want to hurt anyone else. … I have three babies. …I am falling asleep with cigarettes in my hand and that is the reality that I need to stop smoking. [KCTC, unidentified]

6. Patients That Smoke Pay the Price Addictions patients that continue to smoke die from tobacco related illnesses 11-year longitudinal study of 845 addictions patients: 51% of deaths were related to tobacco 11-year longitudinal study of 845 addictions patients: 51% of deaths were related to tobacco 24-year follow-up of 405 patients from ‘60s: death rate of smokers 4X that of non-smokers 24-year follow-up of 405 patients from ‘60s: death rate of smokers 4X that of non-smokers

7. Can We Help MORE Quit? (Sussman 2002) 24 studies 24 studies 9 inpatient, 5 newly “sober”, 5 sober several years, 3 teen inpatients, 2 opioid/cocaine outpatient 9 inpatient, 5 newly “sober”, 5 sober several years, 3 teen inpatients, 2 opioid/cocaine outpatient Generally small sample sizes, descriptive Generally small sample sizes, descriptive Outcomes Outcomes Inpatient no higher than 12% abstinent, 6 months Inpatient no higher than 12% abstinent, 6 months Outpatient as high as 25%, 1 year Outpatient as high as 25%, 1 year Sober several years – up to 46% abstinent, 1 year Sober several years – up to 46% abstinent, 1 year 2003 study: Past alcohol problems do not predict worse smoking cessation outcomes (Hughes et al.) 2003 study: Past alcohol problems do not predict worse smoking cessation outcomes (Hughes et al.)

8. Helping Methadone Patients Quit Shoptaw et al., 2002 Shoptaw et al., 2002 2X2 design, 175 patients 2X2 design, 175 patients 12 weeks of treatment 12 weeks of treatment all got patches, were assigned to a mix of relapse prevention and contingency management all got patches, were assigned to a mix of relapse prevention and contingency management up to 36% quit during treatment, most relapsed afterwards up to 36% quit during treatment, most relapsed afterwards tobacco free=drug free tobacco free=drug free Ongoing studies Ongoing studies Clinical Trials Network patch study (Malcolm Reid, PI) Clinical Trials Network patch study (Malcolm Reid, PI) Rhode Island Patch Study (Michael Stein, PI) Rhode Island Patch Study (Michael Stein, PI)

9. Breathe Easy (Ongoing pilot study, Richter et al.) 28 patients from 5 local clinics 28 patients from 5 local clinics Dual pharmacotherapy, counseling Dual pharmacotherapy, counseling Bupropion – 7 weeks Bupropion – 7 weeks Nicotine gum – 12 weeks Nicotine gum – 12 weeks 20% were quit at 6 months 20% were quit at 6 months Excellent attendance – 85% of all appointments were made, 2 lost to follow up Excellent attendance – 85% of all appointments were made, 2 lost to follow up

10. Who Treats Patients, Why & Why Not? Which clinics provide services, what services do they provide? Which clinics provide services, what services do they provide? What clinics do/don’t provide services What clinics do/don’t provide services Understand barriers, benefits for clinics Understand barriers, benefits for clinics Understand covert/overt pro-smoking forces Understand covert/overt pro-smoking forces How well clinics adhere to guidelines for treating nicotine dependence (5 A’s) How well clinics adhere to guidelines for treating nicotine dependence (5 A’s) Help policymakers support clinics Help policymakers support clinics

11. Services Provided, Past 30 Days % Providing service to at least 1 patient Brief Advice Counseling Groups NRT Zyban Referral Brochure Acupunct.

12. Most Important Barrier to Providing Smoking Cessation Services Staff not trained Staff not trained Patients not interested Patients not interested Other drug treatment more important Other drug treatment more important Not enough staff Not enough staff Clinic does not receive reimbursement Clinic does not receive reimbursement Staff are too busy Staff smoke cigarettes Smoking treatment is ineffective Other

13. Name 3 Clinic Benefits From Providing Smoking Cessation Services Improve health of all Improve health of all Permit more comprehensive services Permit more comprehensive services Improve drug treatment Improve drug treatment Monetary/financial benefits for clinic/patient Monetary/financial benefits for clinic/patient Cleanliness, Aesthetics Cleanliness, Aesthetics Improved education for clinic or patient Improved education for clinic or patient No benefit or unclear benefit No benefit or unclear benefit Total comments = 593 Total comments = 593

14. Lessons Learned People in recovery CAN quit smoking People in recovery CAN quit smoking Methadone clinics DO help with quitting Methadone clinics DO help with quitting But not routinely But not routinely There ARE barriers to offering services There ARE barriers to offering services There are also BENEFITS to offering services There are also BENEFITS to offering services

15. Recommendations Need culture change to create more support & encouragement for quitting Need culture change to create more support & encouragement for quitting Regulatory agencies could require/encourage clinics to >in some way in some way< address nicotine addiction among stable patients Methadone clinics need CEUs – offer Nicotine Dependence Treatment Training! Methadone clinics need CEUs – offer Nicotine Dependence Treatment Training! Could find clinics that are already doing it, empower them to disseminate programs Could find clinics that are already doing it, empower them to disseminate programs