Module 5 - Co-Occurring Disorders: Integrating Tobacco Use Interventions into Chemical Dependence Services

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Module 5 - Co-Occurring DisordersIntegrating
Tobacco Use Interventions into Chemical
Dependence Services
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Welcome

• Add Trainer Name(s)

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This training was developed by the Professional
Development Program, under a contract with the
NYS Department of Health, Tobacco Control
Program. PDP developed five classroom-based
curricula and seven online modules, which are
available at www.tobaccorecovery.org

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Housekeeping

• Hours of Training
• Breaks
• Restrooms
• Tobacco Use Policy
• Cell Phones
• Active Participation
• Complete Training Evaluation Form

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Introductions
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Training Modules

• Module 1 - Foundations
• Module 2 - Assessment, Diagnosis, and
  Pharmacotherapy
• Module 3 - Behavioral Interventions
• Module 4 - Treatment Planning
• Module 5 - Co-occurring Disorders
• E-Learning - All Modules

PM 9
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Module 5 Agenda

• Review of prior modules
• Personal attitudes and beliefs
• Prevalence and co-morbidity
• Basic neurobiology of tobacco dependence
• Review of tobacco treatment strategies
• Case Studies

PM 10
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Module 5 Objectives

• Please review page 10 in your manual

PM 10
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Unit 1Attitudes and Beliefs, Challenges and
Barriers
PM 11
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Review

• Learning points from prior modules
• New knowledge or skills integrated into practice

PM 12
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Defining Co-occurring Disorders

• How do you define co-occurring disorders?
• Co-occurring disorders - when a person has a
  substance use disorder and mental health disorder
  at the same time.

PM 13
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Defining Co-morbidity

• How do you define co-morbidity?
• Co-morbidity - two or more disorders are present
  at the same time and they interact in ways that
  affect the course and/or prognosis of each
  disorder.

PM 13
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Setting the Context

• Currently very little research on co-occurring
  disorders (COD)and tobacco dependence.
• Tobacco treatment is effective for wide range of
  people, including those with mental health
  (MHD) and substance use disorders (SUD).
• What is known about tobacco users with a MHD or
  SUD, may be applicable for COD

PM 14
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Activity 1 Confidence, Attitudes, and Beliefs

• Assess your current confidence, attitudes, and
  beliefs about tobacco use among people with
  MHD and SUD

PM 15
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Debriefing Activity 1

• Examining how attitudes and beliefs about
  tobacco, affect staff and patient behavior to
  examine and address tobacco use.

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Activity 2 Video - Smoke Alarm

• Produced by Clubhouse of Suffolk Ronkonkoma, NY
• www.clubhouseofsuffolk.com

PM 16
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Video - Vignettes 1 to 3

• What is the relationship of tobacco to
  peoples mental health disorder?
• What are common fears about stopping tobacco
  use?

PM 16
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Vignette 1
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Vignette 2
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Vignette 3
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Video - Vignettes 4 and 5

• What are the barriers and challenges
• mentioned about stopping tobacco use?
• How might treatment for people with COD need to
  be modified or enhanced?

PM 16
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Vignette 4
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Vignette 5
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Summary
Definition of co-occurring disorders and
co- morbidity Confidence, attitudes, and beliefs
Patient perspectives on tobacco
use/dependence Challenges and barriers to
addressing tobacco use by people with SUDs and
MHDs
PM 17
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Unit 2 Prevalence and Co-morbidity Factors
PM 19
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Discussion

• What is the frequency of patients having a
  co-occurring mental health disorder and substance
  use disorder?

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National and NYS Data

• National Data
• 50 - 75 of SUD patients have MHD
• 25 - 50 of MHD patients have SUD (Center for
  Substance Abuse Treatment, 2005)
• NYS Chemical Dependence Programs
• 23 - 46 of SUD patients have MHD, rates varies
  by modality
• (Office of Alcoholism and Substance Abuse
  Services, 2008)

PM 20
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Activity 3

• Tobacco and Co-occurring Disorders
• Knowledge Activity

PM 21 - 23
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1. Average Rate of Tobacco Smoking
About 70 of people with a mental health disorder
(MHD) and/or a substance use disorder (SUD), also
smoke tobacco.
70

• Studies vary as to each disorder and people with
  some disorders have smoking rates up to 80 - 90.

PM 24
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2. Percentage of Cigarettes Consumed

• About half of all
• cigarettes consumed
• in the US are by
• people with MHD
• and/or SUD.

44-46
Results in significant illness, death, and health
disparity for two vulnerable populations.
PM 24
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3. Average Reduced Life Span
25 years! The average lifespan in US is 77.8
years. For smokers with MHD or SUD, this life
span is reduced by 32.
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• Primary cause of death is cardiovascular disease
  (CVD) and diabetes. 1 cause of CVD is tobacco
  smoke and tobacco is a key factor in onset of
  diabetes.

PM 24
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4. Average percent of monthly income spent on
tobacco

• Average percentage of monthly income spent on
  tobacco

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Averages about 142 per month based upon 2000 -
2002 costs.
PM 25
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5. Daily smoking can predict suicidal thinking
and attempts

• Facts !
• Increased suicide thinking and attempts even
  considering a prior history of depression,
  substance use disorder, and prior suicide
  attempts.
• Increased risk of suicide for people with
  bipolar illness and schizophrenia.

PM 25
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6. Heavy smoking can be a predictor of suicide
risk and completion

• Facts !
• Increased suicide completion rates for tobacco
  using adolescents and greater number of
  attempts, especially for females
• Heavy tobacco smoking is highly associated with
  increased suicide completion

PM 26
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7. Nicotine causes cancer and CVD

• Facts !
• Nicotine is not a carcinogen and is not a major
  risk factor of cardiovascular disease (CVD).
• Tobacco smoke is the disease-causing agent.

PM 26
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8. Nicotine can affect metabolism of psychiatric
medications

• Facts !
• Nicotine does not affect the metabolism of
  medications.
• Tobacco smoke induces the liver to increase the
  metabolism rate of some psychiatric and some
  non-psychiatric medications.

PM 26
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9. Stopping smoking requires an increase in
psychiatric medications

• Facts !
• Many people can stop without changes in
  medication levels.
• Some may require lower doses to avoid medication
  toxicity (i.e., clozapine, olanzepine) or to
  avoid increased side effects (i.e.,
  amitriptyline, nortriptyline, and imipramine).
• See Table 1 - Common Drugs Affected by Tobacco
  Smoke

PM 27
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10. Use of tobacco increases anxiety

• Facts!
• Increased feelings of general anxiety from using
  tobacco.
• Patients often confuse nicotine withdrawal
  symptoms with primary anxiety symptoms of MHD or
  SUD.
• Many mistakenly assume using tobacco causes
  their general anxiety symptoms to stop.

PM 28
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11. Stopping tobacco leads to panic attacks, and
smoking reduces panic attacks and panic disorder

• Facts !
• Tobacco use is a significant risk factor for
  panic disorder, agoraphobia, and generalized
  anxiety disorder (GAD).
• Also refer back to answer in Statement 10.

PM 28
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12. Most people with MHD or SUD are not
interested in stopping tobacco use

• Facts !
• 70 expressed an interest in stopping in the past
  year.
• People with MHDs and/or SUDs express an interest
  in stopping tobacco use as often as smokers in
  the general population.

PM 28
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13. Most people with MHD or SUD cannot stop
using tobacco

• Facts !
• Many can stop and need more frequent treatment,
  more intense treatment, and more engagement.
• No increased problems after stopping and recent
  research shows MH symptoms decrease after tobacco
  abstinence.

PM 29
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14. Chantix reduces the effects of some
psychiatric medications

• Facts !
• About 92 of Chantix is eliminated unchanged from
  body by kidneys.
• Chantix has no drug-to-drug interactions.

PM 29
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15. Smoking increases MHD/SUD risk

• Facts!
• Tobacco is a common gateway drug for AOD use
• Smoking increases risk for mental illness and
  doubles the risk for major depression when used
  in adolescence.
• Adolescent tobacco use associated with increased
  adult risk for panic disorder, anxiety disorder,
  agoraphobia, depression, suicidal behavior, SUD,
  and schizophrenia.

PM 30
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15. Smoking increases MHD/SUD risk, contd

• Facts !
• Active psychiatric disorders are associated with
  daily smoking and progression to dependence.
• Risk of major depression in women who smoke is
  increased 93.

PM 30
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Knowledge Summary

• How many of these answers did you already know?
• Were there any surprises from what you just
  learned?

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Biopsychosocial Approach to Substance Dependence
Tobacco dependence is a biopsychosocial disease
PM 31
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Neurobiological Factors and Neuro-chemical
Effects of Tobacco/Nicotine

• Various genes are involved for first tobacco
  use, risk of dependence, withdrawal severity,
  and inability to stop using.
• Different neurotransmitters are affected by
  nicotine and likely by other chemicals in
  tobacco smoke.
• Nicotine provides some short-term benefits, but
  tobacco use aggravates MHDs and SUDs.

PM 32 - 33
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Other Factors Affecting Tobacco Use

• Psychological
• Behavioral
• Social
• Treatment / Recovery
• Large System (Tobacco Industry, Media, etc).

PM 34 - 35
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Interaction between Tobacco Dependence and Other
Substance Use Disorder
Other Substance Use Disorder
Tobacco Dependence
PM 36
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Interaction between Substance Use Disorder and
Mental Health Disorder
Substance Use Disorder
Mental Health Disorder
PM 37
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Interaction between Tobacco Dependence Mental
Health Disorder and
Mental Health Disorder
Tobacco Dependence
PM 38
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Interaction between Tobacco Dependence, Mental
Health Disorder, and Substance Use Disorder
Substance Use Disorder
Tobacco Dependence
Mental Health Disorder
PM 39
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Discussion

• What are the common factors between tobacco
  dependence, substance use disorders, and mental
  health disorders?

PM 40 - 41
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Summary
All have common chemical pathways affecting the
brain All are chronic, biopsychosocial
diseases The disorders negatively interact and
result in co-morbid conditions Treatment using
medication, behavioral, psychoeducation, and
supportive therapies Recovery is possible and
requires lifestyle changes

PM 42
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Unit 3Treatment Strategy Review and Case Studies
PM 43
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Tobacco Treatment Review

• First Line Tobacco Medications
• OTC (patch, gum, lozenge)
• Prescription (inhaler and nasal spray)
• Chantix
• Bupropion
• Second Line Tobacco Medications
• Nortriptyline
• Clonidine

PM 44
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Tobacco Treatment Review, contd

• Nicotine medications are well-tested and have
  high margin of safety.
• Tobacco medications often used incorrectly, not
  often enough, or doses used are too low.
• As a result when people have withdrawal symptoms,
  they think the medications dont work and/or
  stop using them.
• Some people need higher doses of nicotine
  medications and/or long-term medication.

PM 45 - 47
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Tobacco Treatment Review, contd

• Combinations of two or more medications works
  work better than a single medication.
• MI, CBT, and RPT are effective first line
  methods.
• Medication plus counseling is more effective,
  than either alone.
• Peer counseling and peer support may be helpful.

PM 48
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Important Reminders

• Tobacco dependence is a biopsychosocial disease
  that aggravates and complicates SUDs and MHDs
• People with COD often need more engagement,
  and longer and more frequent treatment
• Not addressing tobacco use for all patients sends
  an unhealthy and wrong message

PM 49
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Case Studies

• Three cases studies
• Read the assigned case
• Answer the questions related to that case

PM 50
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Case Studies
PM 53 - 54
PM 55 - 56
Smoking/Drug Chart PM 57
PM 51 - 52
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Discussion of Case Study Questions

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Summary
Tobacco dependence treatment for people with MHD
or COD is not different from other populations
Often requires higher intensity and frequency of
treatment episodes, and often more engagement
Tobacco treatment medications are important to
use along with counseling, psychoeducation, and
supportive therapies Anticipate possible need
to modify medication dosage

PM 58
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Revisit Confidence, Attitudes and Beliefs

• Revisit your confidence, attitudes, and beliefs
  from the questions posed earlier

PM 59
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Resources

• The Tobacco Recovery Resource Exchange
  http//www.tobaccorecovery.org
• E-Learning and Online Resources
• OASAS http//www.oasas.state.ny.us/tobacco/index.c
  fm
• Email TobaccoFree_at_oasas.state.ny.us
• BeBetter Networks (NRT)
• http//www.nrtdistribution.com/Welcome.aspx

PM 61-62
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Workshop Evaluation