Treating Nicotine Addiction in Mental Health Facilities

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Treating Nicotine Addiction in Mental Health
Facilities

• Paul Zemann
• 206-263-8268
• tobacco.prevention_at_kingcounty.gov
• paul.zemann_at_kingcounty.gov

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Overview

• Importance of nicotine treatment for clients-the
  science
• Why treat in residential setting
• What nicotine dependency treatment look like 5
  As and 5 Rs, 2 As and R

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Tobacco-Free Treatment Provides Quality of Care

• Public Health Service Clinical Practice
  Guidelines 2000 (pg 99-100)
• Smokers with co-morbid psychiatric conditions
  should be provided with effective treatment for
  nicotine dependency
• Consider Bupropion or Welbutron for those with
  current or history depression
• (evidence level C-Consensus but no randomized
  trials)

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Tobacco-Free Treatment Provides Quality of Care

• Evidence based - Public Health Service Clinical
  Practice Guidelines (pg 99-100)
• Stopping smoking does not interfere with
  recovery from chemical dependence
• Smokers being treated for CD should receive
• approved cessation treatments
• (evidence level c-Consensus but no randomized
  trials)

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Tobacco-Free Treatment Provides Quality of Care

• NIAA National Institute on Alcohol Abuse and
  Alcoholism
• We now have research evidence showing
  that both alcoholism and smoking can be
  treated simultaneously without endangering
  alcoholism recovery.
• Alcohol Alert, January 1998

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Tobacco-Free Treatment Provides Quality of Care

• American Psychiatric Association Practice
  Guidelines for the Treatment of Patients with
  Nicotine Dependence
• All Mental Health providers should assess
  smoking status, provide motivational
  interventions and assist patients who want to
  quit

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Tobacco-Free Treatment Provides Quality of Care

• Substance Abuse Treatment for Persons With
  Co-Occurring Disorders SAMHSA TIP 42
• all clients who smoke should have tobacco
  dependence as problem listed in their treatment
  plans and motivation-based treatment plans
  written to match their motivation to address
  tobacco (pg. 343)
• For a free manual call NCADI 1-800-729-6686

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Creates a Culture of Recovery

• Provides choices and options.
• Empowerment is another critical dimension of
  recovery
• Promotes self agency in recovery.
• A shift to a recovery orientation will require
  attention to wellness and health promotion
• Increases access and support for basic needs to
  include healthcare.
• (Mental Health Recovery What Helps and What
  Hinders?)

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Benefits of Tobacco-Free Residential Treatment

• Clients are not triggered to smoke by
  environmental cues
• Clients learn to cope without nicotine
• Staff learn to teach/mentor clients concerning
  alternatives to smoking

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MH / AOD

• Higher rates of smoking than the general
  population
• General population 23
• 13 King County
• 17.7 Washington
• MH populations 36 - 69
• Lasser K. JAMA Nov. 22/29 2000

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Prevalence of Smoking among Mentally Ill and
Chem. Dependent

• Schizophrenia 80
• Depression 60
• Anxiety Disorder 45
• Alcohol / Drug 69

DASA client data
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MH / AOD

• Higher rates of death due to smoking than the
  general population
• Tobacco use is the leading cause of death in
  substance abusers and those with mental health
  diagnoses

- About 1 in 4 of DASAs Clients were also
diagnosed with a co-occurring mental health
condition - No state data available for MH
clients re tobacco use
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Nicotine and Mental Health

• Nicotine can improve some symptoms in
  schizophrenia
• Same symptoms usually improved by atypical
  neuroleptics
• Hydrocarbons in tobacco increase metabolism of
  some neuroleptic antipsychotic, anti-anxiety meds
  resulting in altered drug levels and poor symptom
  control

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Why Tobacco-Free Residential Treatment

• Many patients want to address their tobacco
  addiction (30-70 express interest)
• Because clients are already presently receiving
  services
• Cost effective
• First drug / hard to quit
• Failing to address tobacco dependency contradicts
  treatment for addiction

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Dual Diagnosis and Integrated Treatment

• Roughly 50 of individuals suffering from severe
  mental disorders are affected by substance abuse
• 37 of Alcohol abusers and 53 of drug abusers
  have at least 1 serious mental illness
• 30 of all diagnosed as mentally ill abuse
  alcohol or drugs
• 70 to 90 are addicted to nicotine
• National Alliance on Mental Illness

N
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Serious Mental Illness among Illicit Drug
Users, Nicotine and Alcohol Users

• 16.7 of marijuana users
• 22.0 of cocaine users
• 29.9 of crack cocaine users
• 31.8 of methamphetamine users
• 15.5 of nicotine users
• 8.5 Alcohol Users
• National Alliance on Mental Illness

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Why Address?

• Nicotine Dependence is an addiction a mental
  illness
• Major Public Health concern need to reduce
  tobacco-caused medical illness and death, improve
  QOL and recovery
• Second Hand Smoke Impacts Non-smokers
• Smokers have a right to smoke (its legal)
  smokers also should have the right to compassion
  from others and the right for treatment client
  centered

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Mental Health and Nicotine Dependence

• Most common co-occurring addiction (dual
  diagnosis)
• High smoking rates due to patient system issues
  
• Accounts for a BIG increase in medical illnesses
  mortality rates in this population
• Tobacco effects medication levels effectiveness
• Nicotine may have some beneficial aspects, but
  can be delivered without tobacco

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Mental Health and Nicotine Addiction (page 2)

• Treatment works patients are grateful for the
  help
• Medications Behavioral therapy are effective
• Also need Program System changes culture,
  policy enforcement, training, funding, and
  staff training

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Mental Health and Nicotine Addiction (page 3)

• 44 of all cigarettes consumed in the US are by
  individuals with a current mental disorder

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Mental Health and Nicotine Addiction (page 4)

• Most die due to smoking caused diseases
• Nicotine use is a trigger for other substance use

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Reduced life expectancy

• 20 shorter life span in people suffering from
  mental illness versus the general population
• Tobacco caused diseases that also lead to death
  are more prominent in MI than the general
  population
• Higher standardized mortality rates than general
  pop for
• Cardiovascular disease 2.3x
• Respiratory disease 3.2x
• -Brown et al., 2000 Br J Psychiatry

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An Unfair Share of Mortality
Number of Deaths (thousands)
Est. 200,000 per year for mentally ill and SA
AIDS Alcohol Motor Homicide
Drug Suicide Smoking
Vehicle
Induced
Source CDC
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Steinberg, M. L., Williams, J. M., Ziedonis, D.
M. (2004). Financial Implications of Cigarette
Smoking Among Individuals With Schizophrenia.
Tobacco Control, 13(2).
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Why Tobacco Free Hospitals?

• Well planned and implemented policy change will
• Provide leadership on innovative policy and best
  practice strategies for hospitals
• Improved outcomes for patients-improved quality
  of care
• Improve employee health by reducing tobacco use
  and exposure to Secondhand Smoke
• Reduce employer costs for absenteeism and health
  care

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Initiative 901

• Smoking is now banned within 25 feet of any door,
  window, or air intake
• Smoking is now prohibited in all public places
  and workplaces
• Public place means any place open to the public
  regardless of ownership
• Workplace means any area which employees are
  required to pass through in the course of
  employment
• http//www.doh.wa.gov/tobacco/other/901_faq_public
  _version.pdf

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WSMA Resolution

• Resolution A-19-Smoke-Free Hospital Campuses
• RESOLVED, that the WSMA (the Washington State
  Medical Association) approach the Washington
  State Hospital Association to explore ways to
  work towards establishing entirely smoke-free
  hospital campuses
• www.wsma.org

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Joint Commission on Accreditation of Healthcare
Organizations

• Smoke-free Hospital standard enacted by JCAHO
  effective December 31,1993
• By 1994 more than 96 of hospitals complied with
  the smoking ban standard
• 41 enacted policies that where even stricter
• Requires that all hospitals/healthcare
  organizations must document adult smoking
  history/cessation advise for three diagnoses
  myocardial infarction, heart failure, pneumonia
  2005
• www.jointcommission.org

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Myths About Smoking and Hospitals

• Most doctors and nurses smoke
• People think its too much to expect someone to
  quit or delay smoking while they are being
  treated for illness, or visiting someone at a
  hospital (stress)
• We have work to do! It shouldnt be staff role
  to regulate smokers
• Most people dont want to quit smoking

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Institutional Barriers to Nicotine Dependence
Treatment

• Lack of staff training
• not my role go to primary care
• Staff fear that patients will misuse NRT or smoke
  while taking NRT
• Staff who smoke normalize smoking, staff may
  help patients access cigarettes, program may sell
  cigarettes
• Restrictive formulary or insurance coverage of
  the cost of medications
• Limited income and cannot afford OTC medications

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Systems Challenges

• Training and opportunities for staff to quit
  ahead of time takes an investment of time by
  technical coordinators and hospital staff
• Fundingwhere does it come from? How much does
  it cost? What are the ongoing costs? And what
  are the gains?
• Very political processmust be responsive to
  where the organization is at in terms of readiness

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Traditional Tools
The 5A Intervention

• ASK about tobacco use.

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ADVISE to quit.
?
ASSESS willingness to make a quit attempt.
?
ASSIST in quit attempt.
?
ARRANGE follow-up.
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New Tools
The 2A and R Intervention

• ASK about tobacco use

?
ADVISE to quit
?
REFER to an internal or external entity that
completes the rest of the 5As
ASSESS ASSIST ARRANGE
?
Schroeder (2005), JAMA.
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Who is Ready to Quit?

• 20-40 Not ready to quit (Motivational
  Interviewing)
• 40 Think about quitting
• 20 Ready

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Why Dont They Just Quit?

• Chain of Addiction
• Biologically Addictive
• Psychologically Addictive
• Culturally Addictive

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Three-Link Chain

• 1. Biological addiction to nicotine
• Feeling of pleasure, decrease in anxiety
• Lasting chemical changes in brain
• Quitting produces withdrawal symptoms

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Whats in a Smoke
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Nicotine/other addictive drugs

• 85 who use nicotine, use daily
• 10 of cocaine/alcohol users
• Withdrawal not life-threatening
• Can be for alcohol
• Most severe consequences delayed

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The Three-Link Chain

• 2. Psychological addiction to smoking
• Triggered by other behaviors
• Self-medication

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Weight Control
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Three-Link Chain (contd)

• 3. Cultural/Environmental link to nicotine
  addiction
• Friends who smoke
• Activities that involve smoking
• Advertising
• Movies

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Come to Where the Flavor IS
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VM Find Your Voice
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Lung Cancer Rates - Women
Centers for Disease Control Tobacco Lung Cancer
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Systematic Approach

• Client-centered
• Specific to your audience
• Evidence-based
• Integrated into existing structure

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Cessation Tools

• Counseling
• Doubles quit rates
• More counseling (time, modes, different people)
  increases quit success
• Brief 3-10 minutes at a time
• Nicotine Replacement Therapy (NRT)
• With counseling, can double quit rates
• Available free from Public Health
• Reduces withdrawal symptoms

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Our Approach to Change
Smoking ban Staff policies
Client attitudes Staff attitudes
Staff training NRT supply
Change in one of these areas leads to change in
the others The best results come from changing
all areas at once