1 Delivery of Tobacco Dependence Treatment for Tobacco Users with Mental Illness and Substance Use Disorders (MISUD)
2 Learning Objectives Upon completion of this module, you should be able to: Describe how tobacco use poses an especially high burden for people with MI/SUD Identify special treatment issues and challenges that must be considered when providing cessation services for this population group Provide recommendations for patient/client assessment and treatment planning Name at least three tobacco dependence treatment strategies for clients with MI/SUD for which there is good evidence of effectiveness Locate additional training resources specific to tobacco use dependence in MI/SUD populations
3 Although only 20% of Americans have MI/SUD Persons with mental illness smoke half of all cigarettes produced, and are only half as likely to quit as other smokers More than 44 percent of adults with serious mental illness are smokers, compared with about 20 percent for society at large Half of [smoking] related deaths (200,000) are among people with mental illnesses Studies shows that people with serious mental illness die 25 years before the general population Concurrently, this population experiences higher rates of disease and premature death and a reduced quality of life. Most will die from smoking caused diseases. Source: Smoking Cessation Leadership Center, A National Program Office of the Robert Wood Johnson foundation website:
4 In Hawaii Smoking prevalence of adults with Serious Psychological Distress (SPD) is more than twice the rate of adults who do not have a mental illness (33.3% vs. 15.7%) Those with Frequent Mental Distress (FMD) smoke at nearly twice the rate of those who do not have a mental illness (26.6% vs. 15.7%) Hawaii BRFSS Mental Health and Stigma Report, Hawaii Department of Health, March, 2009
5 Among alcoholics who smoke: 10x greater risk of pancreatitis than in those who do not smoke 3x greater risk of cirrhosis 38x greater risk of developing mouth and throat cancer than nonsmoking nondrinkers Chronic cigarette smoking increases the severity of brain damage associated with alcohol dependence (Durazzo, 2004) Source: Institute for Health and Recovery
6 Impact on Co morbidity Negative impact on co occurring diseases: HIV/AIDS, HCV Negative impact on metabolism and efficacy of medications, including antidepressants, antipsychotics, asthma meds, ritonavir, insulin Adds to health effects from illicit drug use Source: Institute for Health and Recovery
7 Tobacco Users with MI/SUD Often need more intensive services to help them quit using tobacco Health Care Settings Community Cessation Programs Require good coordination of care, and follow-up, which can be best provided by an extensive and multidisciplinary referral network Mental Health Facilities Tobacco User Substance Abuse Facilities Quitlines
8 Benefits From Treating Tobacco Dependence in Clients with MI/SUD Growing body of evidence that morbidity is reduced May enhance abstinence from other substances Reduces financial burden (for clients and health care system) Reduces medication burden Increased client s self confidence
9 Tobacco Users with MI/SUD find it Harder to Quit Difficulty quitting for all tobacco users Tobacco users with mental illness/ substance use disorders Less difficulty Some difficulty More difficulty Most difficulty From: Bringing Everyone Along: Resource Guide for Health Professionals Providing Tobacco Cessation Services for People with Mental Illness and Substance Use Disorders
10 Patients/Clients with MISUD desire to quit, but Often struggle to find assistance to quit that is tailored to their needs Often encounter barriers/challenges to accessing effective cessation services.
11 Why do clients with MI/SUD smoke more? Research indicates that a combination of biological, psychological and social factors contribute to increased tobacco use among persons with mental illnesses
12 Biological Pre disposition Persons with mental illnesses have unique neurobiological features that may increase their tendency to use nicotine, make it more difficult to quit and complicate withdrawal symptoms Nicotine affects the actions of neurotransmitters Nicotine enhances concentration, information processing and learning. And this is especially important for persons with psychotic disorders for whom cognitive dysfunction may be a part of their illness or a side effect of antipsychotic medications. Other biological factors include nicotine s positive effects on mood, feelings of pleasure and enjoyment From: Smoking Cessation for Persons with Mental Illness: A Toolkit for Mental Health Providers
13 Neurobiological factors reinforce use of nicotine May increase tendency to use nicotine Make it more difficult to quit, and complicate withdrawal Self medication with nicotine Greater vulnerability for dependence
14 Challenges in meeting needs of clients with MI/SUD Staff of mainstream tobacco cessation programs typically do not have specific training and may feel uncomfortable working with these individuals Programs may not be able to address coexisting behavioral health disorders Written materials may be too complicated for clients with cognitive deficits.
15 Challenges cont. Lower rate of quit attempts Clients with MI/SUD have often not been advised to quit or provided opportunities to quit In some cases, they may have even been told that smoking would help them Higher tobacco relapse rates than in general population
16 Challenges in treating SUD Clients Compared to smokers without substance use disorders, smokers with co occurring disorders: Tend to be more nicotine addicted Smoke higher nicotine cigarettes Smoke more per day Score higher on CO assessments / nicotine dependence measures Smoking is used to cope with urges to drink/use drugs Alcoholics who smoke (and the systems and counselors who work with them) may have stronger views about the benefits of continued use than other smokers (Gulliver et al, 2006)
17 Challenges in treating SUD Clients cont. Reinforcement of tobacco use in many Health Systems Smoking norms, such as using cigarettes as rewards for behavior modification, integration of smoke breaks into treatment plans, etc. Knowledge, attitudes or beliefs perpetuated by staff and patients: Tobacco isn t a real drug It is too hard to quit all substances Stopping tobacco use will worsen or delay treatment and recovery Clients don t want to quit
18 Challenging the Idea that Smoking is Normal and Needed in Clients with MI/SUD Beach Two Posters from the Cigarettes Are My Greatest Enemy campaign.
19 Reasons to try and meet these challenges There is demonstrated interest in quitting across MI/SUD populations 75% of clients believe tobacco treatment should be offered while in addictions treatment. (Williams et al., 2005) 50% 77% of clients in substance abuse treatment expressed interest in quitting. (Joseph et al., 2004) 79% of depressed smokers reported an intention to quit; 24% within 30 days. (Prochaska et al., 2004) 75% of clients in a substance abuse facility accepted an offer for smoking cessation treatment. (Seidner et al., 1996)
20 Reasons to try and meet these challenges, cont. Participation in smoking cessation efforts while engaged in other substance abuse treatment has been associated with a 25% greater likelihood of long term abstinence from alcohol and other drugs (Prochaska, J.L. et al 2004) Treatment for heroin, cocaine, or alcohol addiction might be more effective if it included concurrent treatment of tobacco addiction (Taylor et al, 2000) There are compelling reasons for implementing smoking cessation programs for patients in methadone treatment, as the benefits of smoking cessation may extend to opiate addiction as well (Frosch et all, 2000) Source: Institute for Health and Recovery
21 Research is showing that treating tobacco use does not jeopardize stability of primary disorder or recovery Does not negatively affect abstinence from other substances (Bobo et al., 1995; Burling et al., 2001; Hughes, 1996; Hughes et al., 2003; Hurt et al., 1993; Pletcher, 1993; Rustin, 1998; Taylor et al., 2000) Combining smoking cessation with other substance abuse treatment has been associated with a 25% greater likelihood of long term abstinence from alcohol and other drugs Mental health symptoms do not worsen and may actually improve as individuals attempt to quit. (Sharp, JR et al 2008, Gallagher, SM, et al, 2007; Morris, unpublished Source: Institute for Health and Recovery Reasons to try and meet these challenges, cont.
22 Evidence of Effectiveness for Treating Tobacco Use Dependence in Clients with MI/SUD
23 Client Assessment Clients are more likely to be successful and need less program tailoring if they are: Currently functioning adequately Able to participate in treatment Have a history of adequate functioning during previous quit attempts Motivated Ready to quit Stable on any medications.
24 Client Assessment cont. Assessment needs to take into account co morbidities and concurrent treatments/providers Categories for Assessment questions should include: Demographic characteristics Tobacco use history Current quit attempts Social support Current life situation Current health history Screening for mental health or substance use disorders Sample Cient Assessment forms are available in the Bringing Everyone Along Resource Guide
25 Working with the Client in Recovery Identify through assessment that the client is in recovery Ask questions to allow discussion of other major lifestyle changes that the client has made, including recovery Tobacco Treatment Specialist should develop familiarity with supports 12 step programs, AA and NA Alcoholics Anonymous ( ) Nicotine Anonymous ( anonymous.org ) SMART Recovery, Women for Sobriety, SOS, Religious support, family support, psychotherapy
26 Behavioral Interventions for Smoking Cessation According to the American Psychological Association, while the use of brief psychosocial interventions, self help and supportive therapy have been shown to be effective with general medical patients, these methods may not be sufficient for consumers with psychiatric problems (APA, 1996) Clients with MI/SUD often have fewer social supports and coping skills, and therefore, intensive behavioral therapy should be considered for these people even in the early quit attempts
27 Smoking Cessation Models for Persons with MI/SUD Models generally combine nicotine replacement therapy (NRT) with Cognitive Behavioral Therapy (CBT) CBT programs that produce the most successful quit rates for the mental health population generally have groups of approximately 8 10 individuals that meet once a week for 7 10 weeks.
28 Behavioral Interventions for Smoking Cessation Typically 7 10 sessions which include: Introduction to tobacco history and prevalence of use Education about the properties of nicotine, health effects of nicotine and addictive nature of nicotine A review of the reasons why people smoke Education about ways one can quit smoking, use of medication and development of a quit plan
29 Advantages for Treating MI/SUD Clients in Groups Group setting shown to be the most cost and time effective method to help clients quit Advantages for clients; group members can learn from each other make new friends who are dealing with similar problems or issues They can provide support to each other From: Learning About Healthy Living: Tobacco and You
30 Special Concerns in Treating Clients with MI/SUD Compared to other tobacco users, clients with MI/SUD Need more intensive behavioral therapy More person to person contact yields better outcomes May need more assistance with motivation and encouragement to try and quit Need to have psychosocial issues addressed that can undermine cessation Have unique medication and pharmacokinetic issues Need individualized treatment plans based on diagnoses and assessment of stability and functionality May need a longer preparation time before quitting From: Bringing Everyone Along Resource Guide
31 Recommendation for Clinical Monitoring of Clients with MI/SUD Client should be seen 1 3 days after initiating smoking cessation Should be monitored weekly for the first four weeks for signs of psychotic relapse, onset of depression or depressive symptoms, and the need to change medication levels After the first months, patients should be reviewed monthly for six months. The primary care provider and the mental health provider should communicate at the beginning of tobacco dependence treatment and then during the cessation period if any psychiatric complications occur From: Bringing Everyone Along Resource Guide
32 Pharmacotherapy Clients with MI/SUD May need higher doses of NRT May benefit from combination of medications (e.g., nicotine patch + fast acting NRT such as nicotine gum or inhaler, NRT + bupropion) May need medications for longer duration
33 Depression Pharmacotherapy based on MI Diagnosis Demonstrated effectiveness of Bupropion SR May have adverse effects on patients with bipolar disorder and/or a history of eating disorders Some research shows effectiveness of using nicotine transdermal patch Schizophrenia Smoking cessation programs that use the nicotine transdermal patch (NTP) demonstrate the highest quit rates for patients with schizophrenia (Williams &Hughes, 2003)
34 Specific mental disorders: Depression cont. Among patients seeking smoking cessation treatment, percent have a history of major depression, and many have a condition known as minor dysthymic disorder (defined as a chronically depressed mood accompanied by one or more other symptoms of depression) Depression has been shown to predict poorer smoking cessation rates CBT in combination with antidepressants has been found to improve smoking cessation rates in those with a history of depression or symptoms of depression. For those smokers with a history of depression and who are currently taking antidepressant medication, it is important to note that some antidepressant levels will increase with smoking cessation.
35 Keys to Good Treatment Planning Tailor plan to stage of readiness Use Wellness approaches for consumers/clients less stable or not ready to try quitting (example: Learning About Healthy Living program) Use Preparation techniques for consumers/clients who are interested in quitting Reduced smoking/flexible quit dates for consumers/clients who are ready to try quitting Tailor plan to level of impairment Quitline referral + pharmacotherapy for consumers/clients with little functional impairment Cognitive behavioral therapy (CBT) + pharmacotherapy for consumers/clients with greater functional impairment From: Bringing Everyone Along: Module Two: Clinical Solutions, Clinical Systems, and Policies Needed to Support Treatment
36 In Summary Use Stages of Change framework Acknowledge and work with ambivalence Tie in with addictions treatment: integration; language: ATOD; similarity of approaches Build buy in of leadership and line staff Take the long view: change is a process; changing norms and culture Promote systems based approach
37 Resources Available from Tobacco Cessation Leadership Network (TCLN) Available online at
38 TCLN Bringing Everyone Along Online Training Modules Meeting the Challenge of Tobacco Cessation for Persons with Mental Illness and Substance Use Disorders (CE credits available) Module One: Problem, Barriers, Challenges, and Evidence of Success Module Two: Clinical Solutions, Clinical Systems, and Policies Needed to Support Treatment Module Three: Treating Persons with MI/SUD on Quitlines Module Four: Addressing Smoking Policy Changes for MI/SUD