Are the 5As Enough Tobacco Dependence Treatment for Smokers

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 Smokers 20 10 0 0 1 2 3 4 >4 No. of Lifetime Psychiatric Diagnoses % Heavy Smokers % Light-Moderate Smokers 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 Health care Tobacco user Referral Referral Quitlines Community Cessation Programs Summary: Reaching tobacco users with mental illness and substance use disorders Referral Health care Quitlines Referral Referral Tobacco user Mental Health Facilities Community Cessation Programs Substance Use Facilities Referral Referral 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. 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. 2. 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. TCLN/BEA conference call series, winter 2007/2008 Workshops, 2008  Training and technical support    www.tcln.org/bea BEA Expert Advisory Committee Dale P Svendsen, MD Medical Director Ohio Department of Mental Health Karen Seiner, MPH Project Officer, Program Services Branch Centers for Disease Control and Prevention, Office on Smoking and Health Aimee Maychack Statewide Coordinator / Trainer Ohio Tobacco Dependence Project Matt Barry Vice President Edelman Douglas M. Ziedonis, MD, MPH Professor and Chair, Department of Psychiatry University of Massachusetts Medical School Pam Redmon, BS, MPH Managing Director Tobacco Technical Assistance Consortium Rollins School of Public Health, Emory University Gary J. Tedeschi PhD Clinical Director California Smokers’ Helpline University of California, San Diego Janet Smeltz, MEd Director, TAPE Project Institute for Health and Recovery Connie Revell Deputy Director Smoking Cessation Leadership Center University of California, San Francisco Chad Morris, PhD Assistant Professor University of Colorado at Denver and Health Sciences Center, Department of Psychiatry Eric Heiligenstein, MD 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 Client contact with prescribing physician Clinical supervision Proactive follow-up Reassessment  If yes, provide cessation treatment    If no, provide referral for psychiatric treatment   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 Mortality  Increased Morbidity  Increased use of health care resources  Decreased Quality of Life  Increased Societal Costs, including costs to employers  Increased 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 12Step 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 about history of treatment  Ask about specific diagnoses  Screening using K-6  Use same screening tool to monitor/evaluate changes in mental health  Ask 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