NEXT STEPS: TREATING TOBACCO AND CREATING HEALTHY MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT FACILITY ENVIRONMENTS PART I

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1 NEXT STEPS: TREATING TOBACCO AND CREATING HEALTHY MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT FACILITY ENVIRONMENTS PART I Stan Martin, MM Program Director CAI, TCTP Dr John R. Hughes February 19, 2014

2 Housekeeping & Logistics True/False polling & typed chat answers Typed questions Tech Difficulties

3 IMPORTANT NOTICE This GotoWebinar/GotoMeeting service includes a feature that allows audio and any documents and other materials exchanged or viewed during the session to be recorded. By joining this session, you automatically consent to such recordings. Please note that any such recordings may be subject to discovery in the event of litigation.

4 Introductions/Presenters Stan Martin, Project Director of CAI, Tobacco Control Training Project. Over 20 years of experience in public health, including tobacco control initiatives both domestic and international. John R. Hughes, M.D. is Professor of Psychiatry, Psychology and Family Practice at the University of Vermont. He has over 380 publications on nicotine and other drug dependencies and is one of the world s most cited tobacco scientist.

5 Treatment of Smoking Among Smokers With Current or Past Alcohol/Drug Problems John Hughes Professor, Dept of Psychiatry University of Vermont

6 Disclosure In the last 3 yrs, I have received research grants from the National Institute on Health and Pfizer; the later develops and sells smoking cessation medications. I have received consulting fees or honorarium from many nonprofit and for-profit companies that develop or market smoking cessation products and services.

7 Prevalence of Smoking by Psychiatric Illness (Lasser, 00) % Current %Smokers Smokers Who Quit No mental illness Alcohol abuse/dependence Drug abuse/dependence Major depression 23% 43% 44% 34% 49% 32% 37% 38%

8 True or False: Smoking as a Marker for Alcoholism Current smokers have 3 times the risk for current alcoholism than neversmokers Past smokers have 3 times the risk for current alcoholism than neversmokers False, True

9 Alcoholism in Smokers vs Nonsmokers (Hughes, 01) Current Alcoholism Lifetime Alcoholism Never Smokers 5% 10% Ex smokers 5% 12% Smokers 14% 28%

10 Illicit Drug Use and Smoking Very high prevalence of smoking in those with heroin (80%), cocaine (70%) and marijuana (65%) dependence. Methadone and buprenorphine appear to increase smoking: whether they impair cessation is unclear

11 Responses Nicotine Increases Reinforcing Effects of Alcohol (Barrett 06) Alcohol Water Non-nicotine Cigs Nicotine Cigs

12 True or False: Genetics of Smoking Tobacco use is more or less inherited than alcoholism Most of genetic disposition is non-specific False, True

13 Heritability of Substance Use (Kendler, 07) 100% 80% 60% 40% Drug Specific Illegal Drugs Legal Drugs 20% 0% Nicotine Alcohol Marijuana Cocaine

14 True or False Poll: Harm of Smoking in Alcoholics Smoking causes more deaths among alcoholics than alcohol does

15 Attributable Deaths Cause of Death in Recovering Alcoholics Alcohol Tobacco Other Hurt et al, 1995

16 True or False: Smoking and Alcohol Dependence Alcoholic smokers are more dependent on nicotine than non-alcoholic smokers Alcoholic smokers are less likely to eventually quit smoking than non-alcoholic smokers False, True

17 Smoking Cessation in Smokers with a Past History (PH) of Alcoholism (Hughes, 06) PH smokers are more nicotine dependent (8/11 studies) PH smokers are less likely to eventually quit (4/5 studies)

18 True or False: Smoking and Alcohol Dependence On a given attempt, alcoholic smokers have more difficulty quitting than non-alcoholic smokers Alcoholic smokers are less likely to try to quit smoking than non-alcoholic smokers False, True

19 Smoking Cessation in Smokers with a Past History (PH) of Alcoholism (Hughes, 06) PH smokers do not have more trouble stopping (8/10 studies) PH smokers are less likely to try to quit (2/3 studies)

20 True or False Poll: Timing of Quitting Smoking Very few alcoholics want to stop smoking and alcohol at the same time

21 Interest in Quitting Smoking Among Those with Alcohol Problems (Hall, 09) 44% - 80% want to quit in near future 25% want to stop concurrent with stopping alcohol

22 True or False Poll: Timing of Smoking Cessation in Alcoholics Best to first treat alcohol problem and then smoking problem

23 Timing of Quitting Alcohol and Smoking Active alcoholic smokers rarely achieve tobacco abstinence (< 5%) In recovering alcoholic smokers, quit rates of smoking are similar for quitting during vs. after alcohol treatment

24 True or False Poll: Smoking Cessation and Sobriety Stopping smoking during alcohol treatment undermine sobriety

25 Timing of Quitting Smoking and Alcoholism Many case-control studies have found that alcoholic smokers who quit smoking do not have worse alcohol outcomes Two studies of alcoholics who wanted to quit smoking, found no difference in quit outcomes or alcohol outcomes when treatment was during or after alcohol treatment

26 Evidence That Cessation Interferes with Alcohol/Drug Abstinence % Abstinent Untreated Treated Joseph 93 Alcohol 63% 61% Cocaine 71% 40% Marijuana 47% 17% Joseph 04 Alcohol 42% 33%

27 Smoking Cessation and Sobriety Probable interpretation is that stopping smoking can prompt alcohol craving in small subset of alcoholic smokers Thus, need to either pre-treat or monitor for this and suggest more AA classes, antabuse, etc

28 Barriers to Treatment in Smokers with Alcohol/Drug Problems (Hall, 09) No behavioral problems due to smoking More urgent problems Use is not thought to impede abstinence Abstinence thought to threaten abstinence Not in mandate High prevalence in treatment personnel

29 True or False Poll: Treatment of Smoking In Alcoholics Tailoring the treatment to the problems of alcoholics increases quit rates

30 Studies of Treatments for Smoking Cessation in Smokers with History of Alcohol Problems Treatments that work for smokers without alcohol problems also work for smokers with past alcohol problems No tailored program has been found to be more effective

31 Prompting Quit Attempts Motivational Interviewing Set up as natural progression from conquering one dependence to taking on another one Emphasize learnings from prior recovery will help Role models important Combat myths about sobriety being threatened

32 True or False: Routes to Recovery Most quitting of tobacco is not due to treatment Most quitting of alcohol is due to self-help treatment Most quitting of heroin is due to methadone and drug free treatment False, True

33 Similarities in Recoveries Due to Self-Change (Sobell, 04, Klingemann, 01, Hughes, 09) Tobacco 78% Alcohol 76% Illicit Drugs 84%

34 Treating Smoking Among Those With Alcohol/Drug Problems Motivating smokers to try to quit (90% of time) Helping smokers who want to quit (10% of time)

35 Proven Psychosocial Treatments for Smoking (USPHS, 2008) Behavior therapy Social support Quit lines Groups Individual counseling Internet-based

36 Recommended Medications for Smoking Cessation (USPHS, 08) Nicotine patch plus lozenge or gum or inhaler Varenicline Nicotine patch Nicotine inhaler Nicotine gum Nicotine lozenge Nicotine nasal spray Bupropion

37 Tips for Treating Smoking in Recovering Alcoholics Keep smoking cessation on problem list Motivate every few months using personal risks and discussing barriers Let smoker decide timing

38 Tips for Treating Smoking in Recovering Alcoholics Recommend proven therapies Monitor weekly to prevent remission of alcohol / drug problem

39 Tips for Treating Smoking in Recovering Alcoholics Utilize past success strategies Associate with nonsmoking friends Buddy systems with exsmokers

40 True or False Poll: Smoke Free Facilities A major purpose of smoke-free facilities is to encourage smokers to stop smoking

41 Hints for Smoke-Free Facilities Explain rationale to decrease second hand smoke to decrease initiation and relapse among nonsmokers on ward not to pressure you to quit Treat withdrawal with NRT

42 Nicotine Withdrawal (DSM-IV) Anxiety Restlessness Irritability Difficulty concentrating Hunger/weight gain Insomnia Depressed mood Decreased heart rate

43 Nicotine Withdrawal (Hughes, 2008) 2-3 days Lasts 2-3 weeks Hunger, craving last longer

44 Overlap in Nicotine and Alcohol Withdrawal HR Weight loss Tremor Nausea Hallucinations Seizures Insomnia Irritability Difficulty concentrating Restlessness Impatience Anxiety Depression HtRate Weight gain

45 Summary Many alcohol/drug users die from tobacco-caused illnesses Quitting when actively alcoholic is rare Smokers in recovery want to quit and can do so Quitting may threaten sobriety but this is probably uncommon and can be controlled

46 Summary Multiple prompts to quit often needed Multiple proven treatments for smoking exist Monitor for rare worsening of alcohol/drug problem

47 Selected Databases of Information on Smoking Cessation Treatment and Stop Smoking Booklets U.S. Public Health Service Guidelines American Cancer Society Centers for Disease Control American Lung Association National Cancer Institute Society for Research on Nicotine and Tobacco Association for Treatment of Tobacco Use & Dependence

48 Articles Hall, S. & Prochaska, J. (2009). Treatment of smokers with cooccurring disorders: Emphasis on integration in mental health and addiction treatment settings. Annual Review of Clinical Psychology, 5, Hughes, J. (2009). Nicotine-related disorders. In B.Sadock, V. Sadock, & P. Ruiz (Eds.), Comprehensive textbook of psychiatry (9th ed., pp ). NY: Lippincott, Williams & Williams. Kleber, H. D., Weiss, R. D., Anton Jr, R. F., George, T. P., Greenfield, S. F., Kosten, T. R. et al. (2006). Practice Guideline for the Treatment of Patients with Substance Use Disorders. Second Edition. Washington, DC: American Psychiatric Press.

49 Mission Statement ATTUD is an organization of providers dedicated to the promotion of and increased access to evidence-based tobacco treatment for the tobacco user.

50 Follow-up & Evaluations

51 Q&A Please type in your questions about: Mental Health Alcohol/Drug Use Have any additional questions?

52 Thank You!

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