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					Are the 5A's Enough?:
Tobacco Dependence
Treatment for Smokers
with Mental Illness
National Conference on Tobacco
or Health
October 25, 2007
The Panelists

   Wendy Bjornson, OHSU, TCLN
   Eric Heiligenstein, UW-Madison
   Gary Tedeschi, UCSD, CSSH
   Jonathan Foulds, UMDNJ School of
    Public Health
   Connie Revell, UCSF, SCLC
Our Aim

   A brief overview of mental health and
    smoking cessation
    – How to tailor cessation services for this
      population
    – Promising practices and case studies
    – New resources available
    – New strategies for reaching this
      underserved population
Reaching Smokers with Mental Illness
and Substance Use Disorders
Wendy Bjornson, MPH
Director, Tobacco Cessation Leadership Network
Funded by the American Legacy Foundation
Relationship of Smoking, Mental
Illness and Substance Use Disorders
   People with mental illness and substance use
    disorders consume 45% of cigarettes smoked in
    U.S.1
   Rates of smoking are 2-4 times higher than
    among the general population.2
   Nearly 41% of current smokers report having a
    mental health diagnosis in the last month.3
   60% of current smokers report a past or current
    history (ever history) of a mental health
    diagnosis sometime in their lifetime.2

1 Breslau, 2003, 2. Kalman, 2005 3. Lasser, 2000
Smoking Rates Compared to the
Number of Lifetime Psychiatric
Diagnoses
             60
             50
             40
% Who Are
          30                                    % Heavy Smokers
 Smokers
          20
                                                % Light-Moderate
             10                                 Smokers
              0
                  0    1    2    3    4    >4
                  No. of Lifetime Psychiatric
                          Diagnoses
Adapted from Lasser, 2000
Bringing Everyone Along
   Help address a growing need within tobacco
    dependence treatment to better serve clients with
    mental health and substance use disorders.
   Aim is to:
       Combine existing literature with professional experience
        (gathered through online and interview surveys) into a
        Resource Guide.
       Disseminate the Resource Guide to key audiences;
       Provide training and technical support to help adapt
        programs to better assist patients/clients with mental
        illness and substance use disorders.
Online Survey
   Online surveys were sent to 3 tobacco cessation
    professional groups identified and selected for
    participation.
     Tobacco Cessation Leadership Network (TCLN).

     Association for Tobacco Use and Dependence
      (ATTUD).
     North American Quitline Consortium (NAQC).

   104 Online surveys completed.
   Respondents from public health agencies, alcohol and
    substance abuse treatment programs, mental health
    agencies, tobacco dependence treatment programs,
    and others.
Interview Survey
    Population drawn from online survey.
    28 interviews were completed.
    Respondents were from:
    1. Tobacco treatment programs with tailored substance
       abuse and mental health protocols.
    2. Quitlines.
    3. Mental health programs that include tobacco dependence
       treatment.
    4. Substance abuse programs that include tobacco
       dependence treatment.
     BEA Expert Advisors
Interpretation of Survey Data and
   Program Recommendations
Summary: Reaching Tobacco Users

                   Referral

                                Quitlines
         Health
          care
                     Tobacco
                       user

        Referral                Referral




                    Community
                    Cessation
                    Programs
Summary: Reaching tobacco
users with mental illness and
substance use disorders        Referral

                      Health
                       care                Quitlines



     Referral                                          Referral
                               Tobacco
                                 user
                 Mental
                                               Substance
                 Health
                                              Use Facilities
                Facilities

                                               Referral
                               Community
                 Referral
                               Cessation
                               Programs
Summary: Trends and Gaps
Seven Recommendations for All Programs
1.   Change old beliefs.
       Belief still exists that tobacco users with mental illness and
        substance use disorders don’t want to or can’t quit.
       These beliefs are outdated and serve as barriers, even
        preventing treatment from being offered. There is ample
        evidence that they both want to and can quit.
2.   Provide tailored and more intensive treatment programs.
       Programs and services need to be tailored both behaviorally
        and pharmacologically to the specific needs of the
        patient/client and to their usual treatment setting.
       Coordination among the key care providers is necessary for
        integrated care.
       Referral networks and/or partnerships between primary care
        providers, quitlines, tobacco treatment specialists, and mental
        health and substance use professionals are necessary.
Seven Recommendations for All Programs

3. Use a comprehensive assessment to tailor
   services.
     Tailoring treatment services and referrals is based on an
      initial individualized, detailed assessment.
     Training is needed to complete the assessment,
      determine functional status, and make appropriate
      treatment and referral decisions.
4. Recommend cessation pharmacotherapy;
   monitor psychiatric medications.
     Most will need cessation pharmacotherapy.
     Smoking cessation can increase effect of some
      psychiatric medications. Monitoring of symptoms is
      important; potential dose adjustment may be needed.
Seven Recommendations for All Programs
5.  Tailor behavioral treatment.
      Often need more intensive behavioral treatment, e.g.
       more and longer sessions, more follow-up.
      Often need protracted preparation time prior to quitting.
       Need more education and time to master coping skills.
      Need flexibility; predetermined schedules for quitting and
       follow up may be too structured.
6. Increase training and supervision for counseling staff.
      Treatment specialists need to make clinical judgments,
       have more contact with healthcare providers, participate
       in case management, and make referrals.
      Survey shows:
          More training increased comfort in assessing
           symptoms and previous history directly.
          Less training caused discomfort, sometimes
           avoidance.
Seven Recommendations for All Programs

7. Consider the effect of smoke-free
   policies.
     Smoke free/tobacco-free policies drive increase
      in development of services for mental health
      and substance use facilities.
     Smoke free policies increase demand from
      clients with mental illness and substance use
      disorders.
BEA Resource Guide
   Content
       Section One: overview of development process.
       Section Two: Summary and recommendations of Expert
        Advisory Committee.
       Section Three: expert advice for each treatment setting.
         Tobacco cessation programs in community settings;
         Tobacco quitlines;
         Tobacco cessation services in mental health settings;
         Tobacco cessation services in substance abuse settings.
       Section Four: toolkits, resources, references.
   Training and technical support
       TCLN/BEA conference call series, winter 2007/2008
       Workshops, 2008
   www.tcln.org/bea
BEA Expert Advisory Committee
Dale P Svendsen, MD                             Karen Seiner, MPH
Medical Director                                Project Officer, Program Services Branch
Ohio Department of Mental Health                Centers for Disease Control and Prevention, Office on
                                                Smoking and Health
Aimee Maychack
Statewide Coordinator / Trainer                 Matt Barry
Ohio Tobacco Dependence Project                 Vice President
                                                Edelman
Douglas M. Ziedonis, MD, MPH
Professor and Chair, Department of Psychiatry   Pam Redmon, BS, MPH
University of Massachusetts Medical School      Managing Director
                                                Tobacco Technical Assistance Consortium
Gary J. Tedeschi PhD                            Rollins School of Public Health, Emory University
Clinical Director
California Smokers’ Helpline                    Janet Smeltz, MEd
University of California, San Diego             Director, TAPE Project
                                                Institute for Health and Recovery
Connie Revell
Deputy Director                                 Chad Morris, PhD
Smoking Cessation Leadership Center             Assistant Professor
University of California, San Francisco         University of Colorado at Denver and Health Sciences
                                                Center,
Eric Heiligenstein, MD                          Department of Psychiatry
Clinical Director, Psychiatry
University Health Services
University of Wisconsin-Madison
  Are the 5 A’s Enough?
Tobacco Dependence Treatment
  for Smokers with Psychiatric
          Disorders


       Eric Heiligenstein, M.D.
   University Of Wisconsin-Madison
    Smoking Cessation Activities
         of Psychiatrists
   Identify and document smoking status
    (Ask); 35% (90)
   Advice to Quit; 60% (71)
   Assess willingness to quit; 40% (56)
   Assist; 10-30% (49)
   Arrange follow up; 0% (9)
                                    Price, 2007; Quinn, 2005
 Smoking Cessation Activities
Child/Adolescent Psychiatrists
   Identify and document smoking status
    (Ask); 14% (90)
   Advice to Quit; 30% (71)
   Assess willingness to quit; 18.5% (56)
   Assist; 1-33% (49)
   Arrange follow up; 8-10% (9)

                                    Price, 2007; Quinn, 2005
Preparation of Psychiatry Residents for
    Treating Nicotine Dependence

   Training in tobacco cessation
      Medical school; 26%
      Residency; 21%
   Interest in learning more about
    helping their patients to quit; 94%


                                      Prochaska, 2005
     Smoking Cessation Activities
           Psychologists

   Ask; Often=8%, Never=41%
   Advice to Quit; Often=9%,
    Never=48%
   Give cessation support; Often=1,
    Never=81%
                                 Hjalmarson, 2004
    Smoking Cessation Activities
          Psychologists

   Identify and document smoking
    status (Ask); 20%
   Identification added as “vital sign”;
    87%

                                    Heiligenstein, 2004
Perceived Barriers to Using the
            5 A’s
   Lack of time
   Patients do not want to quit
   Preoccupation with other problems
   Low confidence in provider’s ability to help
   Lack of familiarity with treatment resources

                                        Price, 2007
                                        Heiligenstein, 2004
     Necessary Mental Health Care
     System Interventions (5 A’s)
   Inservice training of mental health staff
   Integration of smoking cessation best practices
    into training programs
   Requiring smoking status as a “vital sign”
   Chart reminders on how to move patients through
    stages of change
   Development of comprehensive intervention
    resources
  Bringing Everyone Along:
  The Role of Quitlines




Gary J. Tedeschi, Ph.D.
University of California, San Diego
California Smokers’ Helpline
Comorbidity in a Quitline setting
   Depressive disorder
   Bipolar disorder
       Manic-depression (older term)
   Thought disorder
       e.g., Schizophrenia
   Anxiety disorder
   Post traumatic stress disorder (PTSD)
   Other chemical abuse/dependency
       e.g., Drug, alcohol
Assessment
   At intake or counseling?
   Type of assessment
       Client report
       Psychiatric treatment question
       Medication question
       Other diagnostic questions/instruments
    Treatment Considerations

   Is the quitline an appropriate setting?
       Level of functioning
       Concurrent psychiatric treatment
   If yes, provide cessation treatment
       Client contact with prescribing physician
       Clinical supervision
   If no, provide referral for psychiatric treatment
       Proactive follow-up
       Reassessment
Quitline as Portal to Other Services

   Refer back to primary care provider
    and/or mental health treatment
    provider
   Identify mental health care providers
    in community with expertise in
    addictive behavior
   Assist client in finding mental health
    services in local area
    Conclusion
   Clients with psychiatric health issues call
    Quitlines.
   Clients with psychiatric health issues have
    different levels of functioning.
   Quitlines can serve this clientele based on
    client level of functioning & local
    professional support:
       Full protocol
       Single session and referral
       Referral
People With Mental Health and Addiction
 Problems – The Forgotten Smokers?
 Jonathan Foulds PhD
 Director, Tobacco Dependence Program
 UMDNJ-School of Public Health

 Jonathan.foulds@umdnj.edu
 www.tobaccoprogram.org
 732-235-8213
                Why Forgotten?
   40 years of reducing smoking rates EXCEPT for
    smokers with mental illness or addiction
   Unidentified high risk group?
       Little data on tobacco use in this group
       Little data on tobacco-caused disease in these groups
   Assumption: they don’t really want to quit?
   Assumption: none of them are able to quit?
   Assumption: their behavioral health problems
    will worsen if they give up tobacco
   False beliefs and Stigma leads to no change
Barriers to Addressing Smoking
 Provider Resistance
 Patient Resistance
 Family Resistance
 Concern about exacerbation of symptoms,
  relapse, and increased acting out
 Concern about interaction with psych
  meds
 Easy Access
 Taking away their only pleasure
 Consequences & Costs of Not
   Treating Tobacco in the
  Behavioral Health System
 Increased Mortality
 Increased Morbidity
 Increased use of health care
  resources
 Decreased Quality of Life
 Increased Societal Costs, including
  costs to employers
    This is a health disparity issue
 A sizeable segment of the population is
  consuming tobacco 2-3x the rate of the rest
  of the population.
 The system in which they receive care
  currently does little to change tobacco use.
 The behavioral health system needs a
  radical change to solve this problem.
 Tobacco control has largely ignored this
  issue
This is a systems issue affecting
many more than just the clients
 Smoking prevalence is high among staff in
  the behavioral healthcare system and their
  families
 It also has a knock-on effect on the families
  of clients in the behavioral healthcare
  system
 It is the system and the culture within the
  system that needs to be changed. This will
  create a lasting effect.
     Barriers to Tobacco Dependence
                 Treatment
   Lack of staff training
   “not my role” – go to primary care
   Staff fear that patient’s will misuse NRT or
    smoke while taking NRT
   Staff who smoke – normalize smoking, staff
    may help patient’s access cigarettes, program
    may sell cigarettes
   Restrictive formulary or coverage of the cost of
    medications
   Limited income and cannot afford OTC
    medications
The Steps for Becoming
a Tobacco-Free Facility
1. Acknowledge the profound challenge
tobacco creates for the treatment
community

2. Establish a leadership group or
committee and secure the commitment
of the organization in writing

3. Develop a tobacco-free policy

4. Establish a policy implementation
timeline with measurable goals &
objectives
5. Conduct staff training
6. Provide ongoing recovery
options for staff who use tobacco
7. Assess and diagnose tobacco
use in patients and use this in
treatment planning
8. Incorporate tobacco & nicotine
information in patient education
curriculum
9. Establish ongoing communication with 12-
Step recovery groups, professional
colleagues, and referral sources about policy
changes.

10. Require staff to not be identifiable as
tobacco users

11. Establish tobacco-free facility and
grounds

12. Implement comprehensive nicotine
dependence treatment throughout program
     Some recent publications on tobacco
        treatment and mental health
   http://www.tobaccoprogram.org/staffarticles.htm
   Foulds J, Williams J. Tobacco use, cataracts and schizophrenia. American Journal
    of Psychiatry 2005; 161:1113-1115 (let)
   Foulds J, Gandhi KK, Steinberg MB, Richardson D, Williams J, Burke M, Rhoads
    GG. Factors associated with quitting smoking at a tobacco dependence treatment
    clinic. American Journal of Health Behavior 2006; 30:400-412
   Han ES, Foulds J, Steinberg MB, Gandhi KK, West B, Richardson D, Zelenetz S,
    Dasika J. Characteristics and smoking cessation outcomes of patients returning
    for repeat tobacco dependence treatment. International Journal of Clinical Practice
    2006 September; 60(9): 1068-1074.
   Ziedonis DM, Guydish J, Williams J, Steinberg M, Foulds J. Barriers and solutions
    to addressing     tobacco dependence in addiction treatment programs. Alcohol
    Research and Health 2006; 29(3): 228-235.
   Foulds J, Williams JM, Order-Connors B, Edwards N, Dwyer N, Kline A, Ziedonis
    DM. Integrating tobacco dependence treatment and tobacco-free standards into
    addiction treatment: the New Jersey experience. Alcohol Research and Health
    2006; 29(3): 236-240
   Williams J, Foulds J. Successful tobacco dependence treatment in schizophrenia.
    American Journal of Psychiatry 2007 February; 164(2):222-227
       Screening for behavioral
       problems at assessment
   http://www.tobaccoprogram.org/questionnaires.htm


 Ask about history of treatment
 Ask about specific diagnoses
 Screening using K-6
 Use same screening tool to
  monitor/evaluate changes in mental
  health
            What did we learn?
   Tobacco treatment can be successfully integrated
    into addictions treatment
   Most clients want to address tobacco
   Treating tobacco did not cause clients to leave
    treatment early
   The greatest resistance comes from staff
   Tobacco-free grounds were cited as the most
    challenging aspect of implementation
   Enforcement of licensure standards is key
   NRT helps treat withdrawal symptoms
   Now is the time for behavioral services to treat
    tobacco with the seriousness it deserves
                   Conclusions
   Combining policy change, staff training and
    treatment integration can successfully change the
    tobacco culture in behavioral health settings.
   Other behavioral health facilities have made the
    transition to a tobacco-free facility relatively
    smoothly (e.g. Ann Klein and Princeton House). It
    is not a small change, but it is doable. The time is
    right.
   Behavioral health patients can quit smoking but
    may require more intensive face-to-face treatment
    and pharmacotherapy from someone trained to
    provide tobacco dependence treatment.
New Partnerships
The Field Moves Forward
The Smoking Cessation
Leadership Center
   Began in 2003 as a Robert Wood Johnson
    National Program Office with a $10-million,
    five-year grant
   Aimed at helping clinicians do a better job
    intervening with tobacco users
   Additional funding from VA, American
    Legacy Foundation
   New foray into behavioral health arena,
    from Legacy grant
SCLC’s Aim
   We want more people who want to quit smoking to
    get the help and support they need to succeed
   Access to cessation tools and resources needs to be
    widened for all groups
   Health care providers have a special role, as the
    many partners we have already enlisted will attest
   Examples: dental hygienists, nurses, physicians,
    respiratory therapists, physician assistants,
    pharmacists
The First Summit

   April 2006 in San Francisco
   NASMHPD medical directors,
    commissioners tackled smoke in psych
    facilities
   Set target to go 100% smoke free in
    three years
   Have gone from 41 to over 50 percent
The Second Summit

   March 2007 in Virginia
   First summit of mental health leaders
    focused on smoking cessation
The First Summit

   April 2006 in San Francisco
   NASMHPD medical directors,
    commissioners tackled smoke in psych
    facilities
   Set target to go 100% smoke free in
    three years
   Have gone from 41 to over 50 percent
The Second Summit

   March 2007 in Virginia
   First summit of mental health leaders
    focused on smoking cessation
National Mental Health
Partnership for Wellness and
Smoking Cessation
   Members include:
    – 26 organizations and growing
    – National mental health advocacy, governmental,
      consumer, and provider organizations and
      smoking cessation experts
   Mission Statement:
    – We the undersigned resolve to bring forth and lead a
      national partnership campaign to make health and
      wellness a priority for people with mental illnesses and for
      the providers who serve them. As a first and immediate
      focus, we commit ourselves to addressing the serious
      consequences of smoking and to emphasize smoking
      cessation in all mental health service delivery settings.
The Third Summit

   Sponsored by SAMHSA and CMHS
   National Wellness Summit for People
    with Mental Illness
   Sept. 17-18, 2007, in Rockville, MD
   Goal is 10 x 10
New Tools Available
   NASMHPD tool kit on taking facilities smoke
    free
   Colorado provider tool kit
   Rx Lite training module for mental health
    professionals, including certified peer
    specialists
   Quitline cards, especially for staff who
    smoke
   Others
The Blue Card
Pocket guide
Rx for Change
Los Angeles– Chicago -
Seattle
   Help 200,000 (out of a million)
    smokers quit over 3 years (2010 goal)
http://smokingcessationleadership.ucsf.edu

Contact us for more information

				
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