Nevada Tobacco Users Helpline

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Drug Treatment Model in a Quitline Setting
Elizabeth E. Fildes, EdD Education and Research
Director
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Nevada Tobacco Users Helpline

• Provides an integrated approach, combining the
  disciplines of medicine and counseling
• Professional counselors who are Licensed,
  Certified, or Certified Interns with the State
  of Nevada Board of Examiners for Alcohol, Drug
  and Gambling Counselors
• The Helpline follows federal (42 C.F.R. Part 2
  and HIPAA) and state regulations (NRS 641.C)

• Our Medical Director is an Associate Professor
  with the University of Nevada School of Medicine,
  Department of Internal Medicine. He is an
  Addictionologist, and specializes in the
  treatment of addiction to nicotine.
• Our education and research director holds a
  doctorate in health education, and is a
  registered nurse.
• Counselors are equipped to recognize co- or tri-
  morbid issues and to consult with health care
  providers on nicotine replacement therapies.

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Nevada Tobacco Users Helpline Services

• Treatment is delivered in Spanish and English
• Treatment is for adults 18 and older

• Nicotine Dependence Treatment
• Living Tobacco-Free (2 formats)
• Starter Kit (Mailer)
• Public Education Outreach
• Information-Only (Brochure)
• Health Care Professional
• Training (CEU CME credits)
• Public Information Outreach

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Treatment of Nicotine Dependence in Nevada

• In 1999, the State of Nevada Board of Examiners
  for Alcohol, Drug, and Gambling Counselors came
  into existence
• The Board stated
• Nicotine is a drug and treatment falls under the
  scope of practice of an Alcohol and Drug
  Counselor

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Nicotine Dependence

• Nicotine is a highly addictive substance,
  comparable in its physiological and psychological
  properties to other addictive substances of
  abuse.
• Surgeon Generals Report on Smoking and Health,
  1988

• We all know nicotine is the addictive substance
  found in tobacco.
• If tobacco did not contain nicotine, people would
  not be dependent. Everyone would easily be able
  to quit.

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Nicotine and Addiction

• Nicotine, cocaine, heroin, and alcohol all meet
  criteria as addictive and dependence producing
  drugs the risk of addiction following any use,
  the prevalence of frequent use among current
  users, and the occurrence of American Psychiatric
  Association, DSM-defined dependence among current
  users range from 2 to 10 times greater for
  cigarettes than for these other drugs

• In the DSM IV, drug use can be diagnosed as abuse
  or dependence. For nicotine, there is no
  diagnosis of abuse provided- only dependence.
• With alcohol, approximately 30 of users become
  dependent. With nicotine, 92 of users become
  dependent. It only takes 10 cigarettes for a
  tobacco user to become dependent on nicotine
• I want to pause here and acknowledge that some
  cultures, such as First Nations People, use
  tobacco as a medicine in ceremonial practice, and
  we are making a distinction between nicotine
  dependence and ceremonial tobacco use

Anthony et al. 1994, Exp. Clin. Psychopharm
NIDAs Monitoring The Future Survey, FDA in Fed
Register, Aug. 11, 1995 Surg. Gen 1988
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Addiction Defined

• The essence of addiction can be described as
  uncontrollable, compulsive drug seeking and use
  in spite of negative health and social
  consequences. The focus of treatment for
  substance addiction must address uncontrollable
  drug seeking and use, management of withdrawal
  symptoms
• (www.nida.nih.gov)

• These patients do not have a bad habit. They are
  not unconcerned about their health, they do not
  lack the discipline required to kick the habit.
  They are addicted to nicotine. The addiction
  is stronger than heroine or cocaine addiction,
  and abstaining from tobacco requires treatment.
• Most people who quit nicotine say it is the
  hardest thing they have ever done.
• ltBRIDGEgt This is why Nevada Tobacco Users
  Helpline uses credentialed professional drug and
  alcohol counselors who specialize in the drug
  nicotine

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Treatment supported by

• 1 year Proactive Professional Counseling
• Quit Kit w/individualized support literature
• Medication Assistance
• Psycho Education (2 formats)
• Group Therapy
• Home Study

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Whats covered in treatment?

• Initial Intake
• Demographic and Marketing Indicators
• Informed consent, Office Practices and HIPAA
  Notice of Privacy
• Release of information, as indicated
• Bio/Emotional/Social Intake
• Tobacco use History
• Co-existing medical, psychiatric and addictions
  disorders, medication use

• Why do we assess co-morbidity?
• Co-morbid conditions impact treatment
• Outcomes
• Tobacco use impacts medical treatment
• Tobacco use impacts medication metabolism
• Psychiatric medication dosages
• COPD medications
• Cardiac medications

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Assessment

• Counselor completes
• Second Edition Revised American Society of
  Addictions Medicine (ASAM PPC-2R) Severity Index
  Profile
• Rates 6 Dimensions
• Acute intoxication and/or withdrawal potential
• Biomedical conditions and problems
• Emotional, behavioral, cognitive conditions and
  problem
• Readiness to change Treatment acceptance/resistan
  ce
• Relapse, continued use or continued problem
  potential
• Recovery/living environment.

• Counselor determines a diagnosis following the
  criteria of the DSM-IV
• Counselor determines a level of care based on the
  ASAM Rating
• Counselor creates an individualized Treatment
  Plan

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After initial Intake

• Treatment book uses a wellness paradigm to
  address nicotine dependence
• Psycho educational information is delivered in a
  group therapy or a home study format
• Support literature includes
• Spanish,
• Special Populations,
• Pregnant women,
• Smokeless tobacco users,
• Cardiac patients, etc.
• Referral List provides a list of medical, mental
  health, addictions, and social services as well
  as support

• Patient Receives a Quit Kit
• Quit kit includes
• Treatment Overview
• 85 page Treatment Book
• HIPAA Notice of Privacy
• Medication Assistance Program Information
• Psycho Educational
• Support literature to special populations
• Statewide Non-Smoking Establishments
• Referral Listing

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What happens during proactive call backs?

• Call backs are utilized to provide continual
  assessment and adjustment of treatment plan
  according to individual needs and to ensure
  effective outcomes
• Solution-Focused Theoretical framework is
  enhanced through motivational interviewing to
  move the patients through stages of change and
  promotes the therapeutic bond between counselor
  and patient. This includes, but is not limited
  to how nicotine has affected an individual
  physically, emotionally, mentally, and
  spiritually
• These four treatment components are accompanied
  with specific clinical interventions to effect
  change. The treatment interventions include but
  are not limited to weight management, exercise,
  medication, stress management, fear and anger
  management, cognitive restructuring, problem
  solving skills, self esteem, relapse prevention,
  true purpose, balance, meditation and prayer

• Call backs provide continual adjustment of
  treatment plan according to individual needs
• Motivational interviewing using Solution-Focused
  theoretical framework
• Four Treatment Components include but are not
  limited to how nicotine has affected an
  individual
• Physically
• Emotionally
• Mentally
• Spiritually

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Anything else?

• Patients are encouraged to call their counselor
  at anytime during the course of treatment
• Patients may participate in the Medication
  Assistance Program (MAP)
• Patient may participate in Psycho Education (2
  formats) Group Therapy and/or Home Study
• Patient are encouraged to complete treatment book
  activities
• Patients are encourage to attend community
  support groups (i.e. Nicotine Anonymous)

• Encouraged to call their counselor at any time
• May participate in the Medication Assistance
  Program (MAP)
• Psycho Education
• Treatment Book Activities
• Community support encouraged

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Treatment Evaluation

• Aggregate Demographic Report
• Aggregate Co-existing Conditions Report
• Quit rates at 3, 6, 9, and 12 months
• Patient satisfaction telephone survey at 14, 30,
  90, 180 and 365 days post enrollment
• 210 days post enrollment (MDS 7-month Follow up
  Questionnaire)

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Addictions Co-morbidity
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Medical Co-Morbidity
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Mental Health Co-morbidity
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Treatment Quit Rates

• 25.76 (556/2,158) at three months
• 29.45 (529/1,796) at six months
• 30.26 (472/1,560) at nine months
• 27.69 (376/1,358) at twelve months