Integrating Nicotine Addiction Treatment in Substance Abuse Treatment Systems: Massachusetts Comprehensive Approach

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1 Integrating Nicotine Addiction Treatment in Substance Abuse Treatment Systems: Massachusetts Comprehensive Approach Keywords: Tobacco use, nicotine addiction, substance abuse treatment, substance abuse treatment systems. Authors: Janet Smeltz, M.Ed., Norma Finkelstein, Ph.D., Jane Moore, M.S.W., Institute for Health and Recovery, 349 Broadway, Cambridge, MA 02139; Sarah Ruiz, M.S.W., Bureau of Substance Abuse Services, Massachusetts Department of Public Health, 250 Washington Street, Boston, MA Title Page

2 Authors: Janet Smeltz, M.Ed., Director of TAPE Project, Norma Finkelstein, Ph.D., Executive Director, Jane Moore, M.S.W., Consultant, Institute for Health and Recovery, 349 Broadway, Cambridge, MA 02139, (phone), (fax), Sarah Ruiz, M.S.W., Bureau of Substance Abuse Services, Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, (phone), (fax), Title Page

3 Integrating Nicotine Addiction Treatment in Substance Abuse Treatment Systems: Massachusetts Comprehensive Approach Title Page

4 Abstract: The prevalence of tobacco use and nicotine addiction among persons with substance use disorders, and associated morbidity and lethality, are well documented, and substance use disorder treatment systems have developed various strategies to integrate treatment of nicotine addiction. Barriers to integration include staff and client misperceptions about effects of tobacco use; provider concerns about resources and capacities; and development of clinical expertise in addressing this behavioral health issue. Massachusetts has undertaken a successful state- and system-wide effort using state-level policy changes combined with comprehensive capacity building to address tobacco use and integrate nicotine addiction treatment. The article describes this effort, which includes provider, staff and client involvement, clinical training programs, and pharmacological resources. Over fourteen years, Massachusetts has achieved substantial gains, increasing integration of nicotine addiction treatment to between 70% and 90% of treatment programs. Outcomes documented in surveys, focus groups and other reports are described. Abstract

5 Integrating Nicotine Addiction Treatment in Substance Abuse Treatment Systems: Massachusetts Comprehensive Approach In the mid 1990s, the Massachusetts Department of Public Health, Bureau of Substance Abuse Services (BSAS) initiated a broad strategy to address tobacco use and nicotine addiction in the substance abuse treatment system. The strategy applied stages of change 1 and motivational interventions to the statewide system of treatment by readiness assessment, comprehensive collaboration, and building commitment at all levels. State agency, treatment providers, staff and clients participated in this strategy since all have a stake in re-shaping the system to support individual, agency and system efforts to integrate nicotine addiction into substance use disorder treatment. Since 1994, the proportion of treatment programs screening for nicotine addiction rose from 37% to 91%, and by 2007, 70% of long term treatment programs were treating nicotine addiction at the same level as other addictions. This paper describes the context, approach and outcomes of the Massachusetts experience. I. Context: By the early 1990s, a growing body of research documented the large number of individuals treated for alcohol and drug dependence who were dying prematurely of tobacco-use related diseases. Among recorded deaths of alcoholics during a 20-year period after receiving inpatient treatment, 51% were tobacco related, while 34% were alcohol related; the observed mortality was 48.1% vs. an expected 18.5% for the group. 2 Among treated narcotic addicts, the death rate of smokers was four times that of nonsmokers. 3 While smoking kills more Americans than all other drugs and alcohol combined, 4-6 the morbidity and lethality among those with substance use disorders is 1

6 even greater, contributing to higher rates of death, pancreatitis, mouth and throat cancers, among other effects. 7-9 Following closely on these findings were inquiries into the readiness of the substance abuse treatment system to address smoking and tobacco use. Indeed, the past fifteen years have been a period of great change in the clinical understanding of the role of tobacco treatment in the overall treatment of substance use disorders. In the past, clients receiving treatment for alcohol and other drug (AOD) use may have been discouraged from attempting to stop smoking until completing treatment for their other addictions. 1 Some were even encouraged to continue smoking by clinical staff who believed that continued tobacco use would ease the process of withdrawal from other chemicals. 10 The Massachusetts approach has taken advantage of research and experience which dispels beliefs and practices that have kept tobacco use on the sidelines of substance use disorder treatment and which underscores the importance of involving clients and staff in change efforts, thus addressing discrepancies and fostering change. In fact, many clients are interested in quitting smoking. Sees and Clark 11 found that an overwhelming majority of clients admitted for treatment of alcohol, cocaine and/or heroin use expressed some interest in smoking cessation, and that nearly half of these were interested in receiving concurrent treatment for nicotine addiction. Orleans and Hutchinson 12 found similar results: nearly two-thirds of smokers in treatment (63.5%) reported one or more serious quit attempts, and a similar percentage (63%) reported at least moderate interest in including tobacco treatment in their overall chemical dependency treatment. Joseph 13 found that clients interest in quitting smoking 2

7 increased when new policy limited smoking. Richter and colleagues found that clients displayed considerable interest and fortitude in trying to quit or control their smoking in spite of limited institutional support. 14 More recent clinical studies have confirmed clients repeated attempts to quit smoking, reporting that between 50% 15 and 80% 16 of clients in substance use disorder treatment expressed interest in quitting smoking. Others have found that between 50% 14 and 68% 17 of clients have attempted to quit on their own. These findings highlight both the readiness of clients to contemplate addressing nicotine addiction and the importance of exploring attitudes or beliefs of clinical staff which present barriers to the integration of tobacco treatment and the creation of smoke-free and tobacco-free treatment facilities. These attitudes and beliefs cover a wide area of disparate concerns, from confusion over the medical effects of nicotine withdrawal on patients overall health to the timing of tobacco cessation treatment relative to AOD treatment. Staff beliefs about treatment priorities indicate a relatively low knowledge of the negative impacts that smoking has on patients health. For instance, Sussman 18 found that one of the five principle arguments against integrated tobacco treatment was the lack of immediate health consequences of tobacco use when compared to use of other illicit substances, despite evidence of the lethality of smoking. Other studies have noted this minimization or denial of health consequences of smoking and tobacco use. 10,19 This belief has led to an incorrect assumption that delayed tobacco cessation treatment may be ideal for clients in AOD treatment 14,19,20 while supporting the myth that tobacco cessation may undermine or jeopardize the effectiveness of AOD and mental health treatment. 10,19 3

8 Lack of training for clinical staff has contributed to their reluctance to address nicotine addiction. Ziedonis et al 10 found that clinical staff received no or little training about tobacco treatment in the AOD setting. Williams et al 21 confirm that few clinical staff members have been trained in integrating tobacco treatment with AOD and mental health treatment. Providers have also reported reluctance to establish limits on tobacco use and to address nicotine addiction based on practical concerns. These include anticipated loss of market share and reductions in patient completion rates, expenses of nicotine replacement therapies (NRT) and other medications, increased staff turnover, and lack of resources and insurance coverage. 13,22,23 Nevertheless, research consistently highlights the effectiveness and necessity of including tobacco dependence in substance abuse treatment. The pharmacological and behavioral processes that determine tobacco addiction are similar to those that determine addiction to other drugs such as heroin and cocaine. 24 Cigarette smoking exacerbates alcohol-induced brain damage. 25 brain to recover from chronic alcohol abuse. 26 Smoking interferes with the ability of the Smoking status (nonsmoker, chipper, heavy smoker) proved a more powerful predictor of cocaine and opiate use than daily methadone use. 27 Alcoholics who quit smoking are more likely to succeed in alcoholism treatment. 28 Non-tobacco users maintain longer periods of sobriety after inpatient treatment for alcohol/drug dependence than tobacco users. 29 Controlling for multiple factors, smoking cessation was associated with greater abstinence from drug use after completion of treatment. Since 2001, the National Association of Alcohol and Drug Abuse Counselors has advocated and officially supported development of policies 4

9 and programs that promote the prevention and treatment of nicotine dependence on a par with alcoholism and drug dependence. 30 Workplace smoking bans have stepped up pressure on the treatment system. However, these should be understood as only the first step. Increasingly, substance abuse treatment systems have acknowledged that treatment for tobacco and nicotine dependence must be fully integrated into treatment approaches. Williams et al 21 isolated three necessary components for successful integration of tobacco dependence treatment into residential substance abuse treatment: policy regulation, training of staff, and provision of nicotine replacement therapy for both clients and staff. Foulds et al 31 report that implementation of these policies resulted in increased quantity and quality of tobacco dependence treatment in residential substance use disorder treatment settings. Moreover, staff trainings, assessments for tobacco dependence, treatment planning, and pharmacological treatment all increased throughout the policy-implementation period ( ). 31 II. The Massachusetts Approach: An early adopter state, Massachusetts has moved apace with these efforts, developing capacity within the system through: broad system engagement in policy and program development; needs assessments supporting capacity building; focus on staff and client needs; and provision of resources. A. Broad System Engagement: In May 1994 the Massachusetts Department of Public Health, Bureau of Substance Abuse Services (BSAS) established the Tobacco Advisory Committee and funded two positions dedicated to capacity building (these positions became the 5

10 Tobacco, Addictions, Policy and Education [TAPE] Project at the Institute for Health and Recovery). Engaging the substance abuse treatment system from the outset, the Committee was made up of provider representatives including program directors and senior clinical staff and was supported by staff of the TAPE Project. The Committee s first task was to work with BSAS and TAPE in developing and implementing policies promoting smoke-free environments throughout the BSAS treatment system. The Committee undertook a needs assessment, including a survey and focus groups, and sought consultation from the New Jersey program, Addressing Tobacco in the Treatment and Prevention of Other Addictions. The survey and focus groups revealed a system which was in early stages of change some agencies had written policies governing smoking, some were smoke-free, and a number were contemplating change. The consultation and needs assessment helped focus efforts on staff training and development, understanding that, even with policy changes, staff are key to success. In 1995, the Committee, which had changed its name to the Council to End Nicotine Addiction in Recovery (CENAR), agreed on draft policies, which were distributed throughout the system for review and comment. The policy was issued in January 1996, with an effective date of July It required that all BSAS-funded substance abuse treatment and prevention programs must have written policies requiring all indoor environments to be free of tobacco use, including smokeless tobacco as well as smoking, eight years before Massachusetts laws restricting workplace smoking were enacted. 6

11 CENAR provided a critical element in the Massachusetts strategy. As an advisory group of providers, CENAR was able to give feedback to BSAS and help shape realistic and effective approaches, as well as provide outreach and advocacy within the treatment system. CENAR and BSAS saw policy as one component of the multi-leveled strategy. B. Ongoing Needs Assessment and Capacity Building In anticipation of the 1996 new state tobacco policy, a self-assessment survey tool was developed by Health and Addictions Research, Inc., with BSAS and TAPE. The survey, designed to capture a snapshot of the system in relation to the new policy, was sent to all executive and treatment program directors in March Directors were asked to assess their programs tobacco policies in a number of areas: tobacco use by staff, clients, and visitors; consequences of violations of tobacco use policy; resources for cessation (staff and clients); integration of nicotine addiction treatment into substance abuse treatment; and various components of institutional support of a comprehensive tobacco use policy. 32 The survey found that more than four-fifths of respondents had written policies restricting tobacco use and more than half provided some assistance, education, or services to staff and clients. At the same time, more than one-third (37%) did not address clients nicotine dependence at all (see Table 1). In 1996, only 16% of programs in Massachusetts had integrated nicotine addiction treatment. Telephone and in-person interviews indicated that on average two-thirds of clients and one-fourth of staff smoked; residential programs reported that more than 75% of clients smoked. 7

12 The 1996 survey report concluded that the substance use disorder services system was well-positioned to move into the next phase of tobacco policy development, based on the finding that the majority of programs responding had written tobacco policies consistent with the BSAS policy guideline. This was also based on the number of programs indicating interest in receiving technical assistance to facilitate their transition to a new level of policy. Most of this interest took the form of requests for staff education and training. 32 C. Focus on Staff and Clients While work was proceeding on policy development, the TAPE Project instituted a comprehensive program of training, education and consultation at treatment programs for staff and clients, based on identification of the program and clinical environments as persistent barriers to integration of tobacco treatment. Environmental change must emerge both from clinical interventions and from systems or program changes, and it must discourage on-site tobacco use among staff. 33 Research has demonstrated that encouraging and assisting in staff tobacco cessation can help create a treatment environment more amenable to limiting tobacco use. 10,19,21,34 TAPE staff developed targeted strategies for training. Sessions were individually tailored to programs through planning meetings with management and assessing data about smoking among staff and clients. Training was based on the Stages of Change model 35 and focused both on individual needs and the culture of the agency. Initial goals aimed at moving programs from resistance to addressing tobacco addiction to ambivalence and from ambivalence to contemplation while increasing staff buy-in regarding the rationale for and benefits of change. 8

13 Designers specifically applied the language of addictions to tobacco use and treatment We do not cessate narcotics use, we treat it acknowledging that tobacco dependence is a chronic, relapsing condition. 36 This framework facilitates application of skills for recovery from alcoholism and drug dependence to recovery from nicotine dependence and emphasizes the bio-psycho-social model of addiction. Many factors combine in developing addictions, and many approaches to treatment are required. Finally, the model used repeat exposures, usually three 90-minute workshops, rather than one or two longer programs. Content aimed to help staff explore personal barriers to and strategies for stopping smoking. Statewide training and conferences reinforced these efforts. Focus groups held with staff and clients in 1998 confirmed the benefits of these efforts. Staff identified TAPE trainings, as well as support from program leadership, influence of staff who quit smoking, and impact of public service announcements, all as facilitating efforts to incorporate interventions for nicotine dependence. Clients echoed the importance of staff role models and encouragement. Nevertheless, both staff and clients reported persistent beliefs that individuals should take one addiction at a time and that quitting smoking might jeopardize their recovery, 37 a finding which highlighted the need for additional investment in the system. Building commitment to change and clinical capacity requires a continual focus. In recent fiscal years, TAPE has provided an average of five capacity building sessions per month, providing training at treatment programs, and sponsoring regional and statewide forums. 9

14 D. Additional Resources: Building on the new policy and increasing the readiness of the system, Massachusetts began in 1997 to purchase and provide nicotine replacement therapies (NRT) for distribution among BSAS-funded programs. Research has confirmed that pharmacotherapy combined with behavioral therapy can improve nicotine-dependence treatment. 20,38,39 Foulds and colleagues 39 suggest that combined or integrated pharmacological and cognitive-behavioral interventions can increase patients quit rates by %, and that more intensive behavioral therapies double quit rates compared to treatments with minimal behavioral components. In their review of twenty-four empirical studies of outcomes for patients in mental health treatment who attempt smoking cessation, el-guebaly and colleagues 41 found that most smoking cessation interventions employed a combination of medication with educational and cognitivebehavioral approaches. Ziedonis and Williams 33 found that in addition to requiring multiple treatment attempts, chronic tobacco addiction also requires combinations of medications, patient/family education, and stage-based psychosocial treatment interventions. For patients dealing with comorbid depression and alcohol and tobacco dependence, Ait-Daoud and colleagues 42 recommend tailoring specific pharmacotherapies to specific mood disorders and combining medication with cognitive behavioral therapy (CBT), especially CBT that emphasizes group cohesion and social support. In their analyses of a smoking cessation intervention for mental health patients with posttraumatic stress disorder, McFall et al 38,43 endorse a model of integrated care that includes psychotropic medications and psychotherapy for PTSD and behavioral counseling and pharmacological interventions for smoking cessation. Hall and 10

15 colleagues 44 found similar positive results for combined pharmacotherapy and CBT among depressed mental health outpatients. With the bulk purchase of NRT resources, BSAS instituted a structured program. Treatment providers who wished to distribute NRT to staff and clients were required to apply for this resource, as well as to make a commitment to participate in training to build clinical skills. In addition, participation in CENAR and other forums to support integration of nicotine addiction treatment was required. By the state fiscal year 2007, 25 programs were participating in this effort, and 33 programs applied for 10 new slots. Massachusetts found that distributing free NRT provided a tremendous incentive to substance use disorder treatment programs to address nicotine addiction. Capacity was increased through the structured program and required commitments. Free NRT patches increased staff and client motivation to attempt to quit smoking, but implementation revealed that preparation for quitting and ongoing technical assistance and counseling are essential. Many were eager to try NRT because it was free and perceived to be a magic pill. Ongoing training, follow-up and support provided the means to educate staff and clients and support clinical interventions in conjunction with NRT. III. Outcomes: BSAS and TAPE have continued to monitor change in the system through surveys, focus groups and provider feedback. In 2000, TAPE repeated its 1996 survey to capture another snapshot and assess the degree of change in the system. A comparison with 1996 responses indicated a system moving well into action. Nearly 90% of respondents had written policies prohibiting indoor tobacco use, and more than 11

16 half were now screening and assessing for nicotine dependence. More than two-thirds provided some resources and support for staff efforts to quit, and nearly three-fourths provided similar resources for clients (Table 1). 45 While improvements are shown for each factor, the greatest changes are in education and cessation services and in including nicotine addiction in treatment planning, with 72.9% of programs providing education, services or incentives. Focus groups and surveys confirm progress while highlighting continued barriers arising from beliefs about the effects of nicotine dependence and the effects of nicotine treatment. Clients and staff alike reported they had a substantial amount of information about the serious adverse health effects of tobacco use and that interest in quitting was high. While supporting provision of nicotine dependence services, clients and staff continued to question the benefits of quitting smoking in relation to long-term sobriety and continued to endorse the concept of addressing one addiction at a time. 46 Seventyeight percent of client focus group participants reported they currently smoked. Nevertheless, comments of survey respondents highlight changes in attitudes and beliefs. In 1998, staff focus group participants believed: When people inquire about our program requirements, I say people with substance abuse problems and when I say that I don t include cigarettes. I strongly believe that if someone is going to quit smoking, they re going to have to do it on their own. Sobriety comes first. I ll quit smoking... but it s not as lifethreatening to me as drinking or drugging is. 12

17 In 2000, survey respondents reported: I m in favor of addressing nicotine dependence in treatment, both on the client level as well as with staff. I applaud the state s efforts to address this addiction. House is clean, smells good! Lots of folks have stopped coughing more and more clients want help to stop. It is really helpful to treat it in the overall context of addiction needs to be integrated into substance abuse program. In 2003, a staff focus group participant stated: I see tobacco use as just as dangerous as other illicit drugs. The effect of this addiction is the same as other drugs. That is, death. Four-fifths of clients in 2003 focus groups thought treatment programs should commit to assessing tobacco use and addressing nicotine addiction as quickly as possible. 46 During this period, Massachusetts stepped up efforts to increase clinical capacity, providing a tobacco treatment specialist certification program developed through the Center for Tobacco Prevention and Control, University of Massachusetts Medical School. The Massachusetts Tobacco Control Program engaged BSAS providers in trainings and the certification process. BSAS providers have received training in tobacco education and treatment strategies, including stages of change theory, motivational interviewing, cognitive behavioral counseling skills, and accessing tobacco treatment resources. In BSAS, TAPE, and CENAR developed new guidelines governing tobacco use and treatment. Draft guidelines were reviewed widely by treatment 13

18 providers. The guidelines took a more comprehensive approach, including specific requirements and recommendations: 1. All buildings and vehicles must be smoke-free; restricted smoking areas must be away from main entrances; client and staff smoking areas or smoking times must be separate. 2. The number of smoking breaks permitted should be reduced, and stress management activities should be introduced as replacements for breaks. 3. Staff should be prohibited from smoking with clients or providing tobacco to clients. 4. Staff and clients are prohibited from displaying visible tobacco products. 5. Pamphlets, posters and resources are available and visible. In addition, guidelines, expanded in 2008, promoted integration of tobacco assessment, education and treatment in clinical programming by: Promoting screening during pre-admission and intake by using the 5A s. 47 Informing clients of program tobacco policies. Assessing nicotine dependence similarly to other drug dependence using the Fagerstrom Test for Nicotine Dependence 48 and/or the Hooked on Nicotine Checklist. 49 Assessing readiness to quit at regular intervals. Developing a plan, as a component of the substance abuse treatment plan, to address tobacco use based on assessment. Addressing tobacco dependence through psycho-education groups, individual or group counseling, and coordination with other service providers. 14

19 Educating staff on NRT, buproprion, and management of withdrawal, and when possible, make NRT available. Providing tobacco assessment, education, and treatment training for all staff. Ensuring clinical and supervisory staff complete an online Tobacco Treatment Basic Skills course. Incorporating guidelines into agency policy. Designating a staff person as Tobacco Education Coordinator. A third survey was undertaken in This survey sought detailed information about integration of tobacco use and nicotine dependence into treatment, as well as agency policies about smoking and tobacco use. More than 200 programs (out of 372) responded to the survey (a return rate of 55.4%). Survey responses indicated substantial progress in capacity building in the treatment system and documented not only widespread prohibition of tobacco use, but substantial integration of nicotine addiction into clinical programming: 97.6% of respondents prohibit all tobacco use inside agency buildings. More than one third of those (36%) also prohibit tobacco use on all agency property indoors and outdoors. 91% screen for tobacco use during initial interviews (compared to 55% in 2000). Nearly three-quarters (70%) of long-term programs address tobacco use at the same level as alcohol and drug use in initial assessments; a similar number re-evaluate readiness to quit when service plans are reviewed. Of these, nearly two-thirds (63%) address tobacco use when identified; and nearly three-quarters (71.5%) re-evaluate readiness to quit as part of treatment plan review. 15

20 Programs are supporting staff who wish to stop using tobacco: 82% provide referrals for tobacco treatment. 81% of programs have designated a Tobacco Education Coordinator, providing onsite resources for staff and clients in supporting treatment integration. Regulations governing licensing of substance use disorder treatment programs, issued in 2008, require identified Tobacco Education Coordinators, staff training on tobacco use and nicotine addiction, and tobacco education and counseling services for clients. IV. Implications for Behavioral Health: The Massachusetts effort has demonstrated both the importance and effectiveness of broad and simultaneous engagement of every level of the system in promoting change. State level policy change moved apace with staff training, as well as direct support of staff and clients to address tobacco use and nicotine addiction. This effort echoed the United States Department of Health and Human Services, Public Health Service s clinical practice guidelines for tobacco dependence treatment. Aimed at health care systems, insurers, and practitioners, including substance use disorder treatment settings, the guidelines describe effective treatments as well as systemic approaches for institutionalizing intervention and treatment of tobacco dependence in clinical settings, including: Tobacco dependence is a chronic, relapsing condition that often requires repeated intervention. Effective treatments exist, such as pharmacotherapy in conjunction with cognitive behavioral counseling. 16

21 Clinicians and health care delivery systems must institutionalize the consistent identification, documentation, and treatment of every tobacco user. Brief tobacco dependence treatment is effective: interventions as brief as 3 minutes can increase cessation rates significantly. Massachusetts has also found that continued improvement and maintenance of achievements requires ongoing attention and support. Through TAPE and BSAS, training and resources have enhanced the system s capacity to address and treat tobacco and nicotine dependence. TAPE continues to provide more than 100 workshops, trainings and staff development meetings each year, to host annual conferences, and to support quarterly meetings of CENAR. In addition, collaboration among public entities has made other essential resources available: Advanced training is available through the University of Massachusetts Medical School Center for Tobacco Treatment, Research, and Training via online and intensive in-person training for tobacco treatment specialist certification. Scholarships are given to substance abuse treatment program staff every year. The Hazelden Quit and Stay Quit curriculum was purchased and distributed broadly. Nicotine patches and gum are purchased and distributed through structured programs, to promote and aid treatment. Posters and pamphlets are distributed at no cost. Resource lists have been widely distributed which list websites from which to order free and low-cost materials. Providers are linked to quality products which have been shown by experience to be helpful. 17

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