TREATMENT OF ASTHMA by Reileyfan

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									Cease Smoking Today (CS2day)
    An Evidence-Based Approach To
     Treating Tobacco Dependence
        Focus on the Psychiatric Patient



            Scott M. Strayer, MD, MPH, FAAFP
                   Associate Professor
 Departments of Family Medicine and Public Health Sciences
           University of Virginia Health System
         Question
Which of the following statements
regarding tobacco dependence and
smoking cessation in patients with
psychiatric disorders is/are correct?
              Answers
A. Rates of smoking are similar to individuals
   without psychiatric illness.
B. Because of possible decompensation,
   smoking cessation is discouraged.
C. Most psychiatric patients are highly motivated
   to quit smoking.
D. Risks of most pharmacologic interventions
   outweigh the benefits.
E. Smoking cessation may cause adverse
   reactions to psychiatric medications.
 Smokers With Psychiatric Disorders
• Consume nearly ½ cigarettes smoked in US
• Spend nearly 40% of income on cigarettes
• Patients seeking tobacco dependence
  treatment
   • 30 – 60% with past history of depression
   • ≥ 20% with history of alcohol abuse or
     dependence
  Fiore MC, et al. U.S. DHHS Public Health Service 2008
Smokers With Psychiatric Disorders

• Chemical dependence
  • > 70% smoke
  • Increased mortality from
    tobacco-related diseases
     • 1 study

Fiore MC, et al. U.S. DHHS Public Health Service 2008
Smokers With Psychiatric Disorders

• May have greater sensitivity to
  nicotine dependence symptoms at
  lower levels of smoking
• Failing to address nicotine withdrawal
  may compromise psychiatric care for
  inpatients on smoke-free units.

Fiore MC, et al. U.S. DHHS Public Health Service 2008
              Answers
A. Rates of smoking are similar to individuals
   without psychiatric illness.
B. Because of possible decompensation,
   smoking cessation is discouraged.
C. Most psychiatric patients are highly motivated
   to quit smoking.
D. Risks of most pharmacologic interventions
   outweigh the benefits.
E. Smoking cessation may cause adverse
   reactions to psychiatric medications.
              Answers
A. Rates of smoking are similar to individuals
   without psychiatric illness.
B. Because of possible decompensation,
   smoking cessation is discouraged.
C. Most psychiatric patients are highly motivated
   to quit smoking.
D. Risks of most pharmacologic interventions
   outweigh the benefits.
E. Smoking cessation may cause adverse
   reactions to psychiatric medications.
      Outline
• Assessment
   • 5 As
• Interventions
   • Counseling
   • Pharmacotherapy
               Case
• 22 yo Latino M, psychology student at
  local college, here for medication refill
• History of bipolar disorder
   • Currently stable
   • Several full blown episodes of mania
     and depression
      • Hospitalized at age 19 during manic
        episode
   • Depakote, Lithium
              Case
• Past medical and surgical history
  • Otherwise unremarkable
• Lives in an apartment with his
  girlfriend who smokes and a 2 year-
  old daughter
               Case
• Smokes 1 pack/day cigarettes since 16 yo
• Recently increased to 2 packs/day
  • Cope with stress at college
• Smokes when he drinks alcohol
• Wants to quit
  • Unsure if he can
  • Concerned about impact on bipolar
    disorder
            Question
At this time, all of he following interventions
are recommended EXCEPT:
A. Decrease cigarette intake by 25% every
   1 to 2 weeks
B. Initiate pharmacotherapy
C. Follow-up with phone call 1 week after
   stopping
D. Abstain from drinking beer
E. Convince wife to stop smoking
   Assessment of Tobacco Use
                          Patient presents to a
                          healthcare provider


                              Does patient
                                currently
                              use tobacco?
                    Yes                           No
          Is the patient                          Did the patient
       currently willing to                         previously
               quit?                              use tobacco?

 Yes                          No         Yes                         No
   Provide            Promote
                                                              Encourage
appropriate          motivation            Prevent
                                                              continued
 treatments            to quit             relapse
                                                              abstinence
    (5 As)             (5 Rs)
                            The 5 As
           For Patients Willing to Quit
• ASK about tobacco use
• ADVISE to quit
• ASSESS willingness to make a quit
          attempt
• ASSIST in quit attempt
• ARRANGE for follow-up
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
                                  Ask
• 70% of smokers want to quit
• 81% have tried to quit at least once
• Only 7 to 15% very reluctant to
  discuss quitting smoking
• EVERY patient at EVERY visit

 Fiore MC, et al. U.S. DHHS Public Health Service 2008
            Vital Signs Stamp
                                  VITAL SIGNS
Blood Pressure:

 Pulse:                                       Weight:

Temperature:

Respiratory Rate:

Tobacco Use:                    Current                 Former         Never
                                                        (circle one)
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                         Advise
• Advice should be clear,
  strong and personalized.


Fiore MC, et al. U.S. DHHS Public Health Service 2008
                          Advise
• 37.5% of preventable causes of
  death are tobacco-related
• 1/3 of all tobacco users will have a
  decreased life span
  • 13.2 years in men
  • 14.5 years in women
• Someone dies from tobacco use
  every 8 seconds
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
                        Advise
Smokers With Psychiatric Disorders
• Chemical dependence
  • Increased mortality from tobacco-
    related diseases versus other patient
    populations
     • 1 study

Fiore MC, et al. U.S. DHHS Public Health Service 2008
                         Advise
• Never too late to quit
  • Age 40: gain 9 years
  • Age 50: gain 6 years
  • Age 60: gain 3 years

Fiore MC, et al. U.S. DHHS Public Health Service 2008
                          Assist
• S et a quit date to stop completely
   • Ideally within 2 weeks
• T ell family & friends
• A nticipate challenges
• R emove tobacco products from
  environment (home, work, car)
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                            Assist
         Triggers & Challenges
• Where, when, why does patient smoke
  • Alcohol
  • Other smokers
  • “Urges” and “Cues”
• Withdrawal symptoms
• Prior quit experience
  • Build on success
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                           Assist
        Triggers & Challenges
• Concern about weight gain
• Negative affect, stressors
• Mental illness
  • Increased risk of relapse
• Lack of support
• Lack of self efficacy
• Lack of knowledge
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                          Assist
• Counseling & behavioral
  therapies
• Pharmacotherapy


Fiore MC, et al. U.S. DHHS Public Health Service 2008
                           Assist
Smokers With Psychiatric Disorders
• Smoking cessation and/or nicotine
  withdrawal may exacerbate underlying
  psychiatric condition.
  • Consider waiting until psychiatric
    symptoms stabilized before initiating
    smoking cessation interventions.
     • Case by case basis
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
                     Arrange
• Relapse
  • Most likely within 1st 3 months
     • Especially 1st 2 weeks
• Recommended follow-up
  • Ideally within 1st week after quitting
  • 2nd contact within 1st month
  • Further follow-up based on need
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                     Arrange
Smokers With Psychiatric Disorders

• Increased risk of relapse



Fiore MC, et al. U.S. DHHS Public Health Service 2008
  The “5 As” Model – 2008 Update
Ask about tobacco use.
Advise to quit.
Assess willingness to make a quit attempt.
Assist in quit attempt. For patients unwilling to quit at
  the time, provide motivational interventions designed to
  increase future quit attempts.
Arrange follow-up. For patients unwilling to make a quit
  attempt at the time, address tobacco dependence and
  willingness to quit at next clinic visit.
   Fiore MC, et al. U.S. DHHS Public Health Service 2008
            Question
At this time, all of he following interventions
are recommended EXCEPT:
A. Decrease cigarette intake by 25% every
   1 to 2 weeks
B. Initiate pharmacotherapy
C. Follow-up with phone call 1 week after
   stopping
D. Abstain from drinking beer
E. Convince wife to stop smoking
            Question
At this time, all of he following interventions
are recommended EXCEPT:
A. Decrease cigarette intake by 25% every
   1 to 2 weeks
B. Initiate pharmacotherapy
C. Follow-up with phone call 1 week after
   stopping
D. Abstain from drinking beer
E. Convince wife to stop smoking
         Question
Of the following statements
regarding the non-pharmacologic
treatment of this patient’s tobacco
dependence, which is correct?
             Answers
A. Quit lines alone are effective in achieving
   abstinence.
B. The addition of counseling to medications
   does not increase abstinence rates.
C. Physicians are much more effective than non-
   physician clinicians at delivering treatment.
D. Individual counseling alone is ineffective in
   achieving abstinence.
E. Teaching problem solving and skills training
   alone is ineffective in achieving abstinence.
           Counseling
• Strong dose-response
  relationship


Fiore MC, et al. U.S. DHHS Public Health Service 2008
                        Counseling
   Intensity of Clinical Interventions
                                                     Estimated             Estimated
                                     Number          Odds Ratio          Abstinence Rate
Level of Contact                     of Arms          (95% C.I.)            (95% C.I.)

No contact                               30                1.0                   10.9

Minimal counseling
                                         19          1.3 (1.01, 1.6)      13.4 (10.9, 16.1)
(< 3 minutes)

Low-intensity counseling
                                         16          1.6 (1.2, 2.0)       16.0 (12.8, 19.2)
(3-10 minutes)
Higher intensity
counseling                               55          2.3 (2.0, 2.7)       22.1 (19.4, 24.7)
(> 10 minutes)

Fiore MC, et al. U.S. DHHS Public Health Service 2000. Meta-analysis (n = 43 studies).
Estimating Likelihood of Abstinence




    Fiore MC, et al. U.S. DHHS Public Health Service 2008
Smokers With Psychiatric Disorders

• May have greater sensitivity to
  nicotine dependence symptoms at
  lower levels of smoking
• Increased risk of relapse



 Fiore MC, et al. U.S. DHHS Public Health Service 2008
                     Counseling
Components of Intensive Treatment
• Population
• Program clinicians
• Program intensity
• Program format
• Type of counseling and behavioral
  therapies
• Medication
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                      Counseling
Components of Intensive Treatment
• Population
  • All tobacco users willing to
    participate in such efforts
     • Optimizes likelihood of
       abstinence
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                      Counseling
Components of Intensive Treatment

• Program clinicians
  • Physicians and non-physician
    clinicians equally effective
  • 2 clinician types optimal

Fiore MC, et al. U.S. DHHS Public Health Service 2008
                     Counseling
Components of Intensive Treatment
• One counseling strategy
  • Physician
     • Delivers strong message to quit
     • Discusses health benefits of quitting
     • Prescribes medications
  • Non-physician clinician
     • Delivers additional counseling &
       behavioral interventions
  Fiore MC, et al. U.S. DHHS Public Health Service 2008
                      Counseling
Components of Intensive Treatment
• Program intensity
  • Session length
     • > 10 minutes
  • Number of sessions
     • ≥ 4 sessions
  • Total contact time
     • 30 – 90 minutes
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                      Counseling
Components of Intensive Treatment
• Program format
  • Effective
     • Individual or group counseling
     • Proactive telephone counseling,
       including Quit lines
        • 1 – 800 – QUIT – NOW
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                      Counseling
Components of Intensive Treatment
• Program format
  • Optional
     • Self help materials and cessation
       Web sites
  • Multiple formats optimal, with use of
    3 – 4 types especially effective
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                      Counseling
Components of Intensive Treatment
• Type of counseling & behavioral
  therapy
   • Practical counseling
      • Problem solving/skills
        training/stress management
   • Intra-treatment social support
      • Direct contact with clinician
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                      Counseling
Components of Intensive Treatment
• Types of counseling & behavioral
  therapies recommended by 2000 but
  not 2008 guideline
   • Extra-treatment social support
      • Smoker’s environment
   • Aversive smoking procedures
      • Rapid smoking, rapid puffing,
        other smoking exposure
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                   Practical Counseling
          Problem Solving/Skills Training
Practical Counseling
(Problem Solving/ Skills
Training) Treatment
Component                            Examples
Recognize danger                        Negative affect and stress
situations –                            Being around other tobacco users
Identify events, internal states,       Drinking alcohol
or activities that increase the         Experiencing urges
risk of smoking or relapse              Smoking cues and availability of cigarettes

Develop coping skills–                Learning to anticipate and avoid temptation and trigger situations
Identify and practice coping or       Learning cognitive strategies that will reduce negative moods
problem-solving skills; typically,    Accomplishing lifestyle changes that reduce stress, improve quality of
these skills are intended to cope      life, and reduce exposure to smoking cues
with danger situations                Learning cognitive and behavioral activities to cope with smoking urges
                                       (eg, distracting attention; changing routines)

Provide basic information             The fact that any smoking (even a single puff) increases the likelihood of
About smoking and successful           a full relapse
quitting                              Withdrawal symptoms typically peak within 1-2 weeks after quitting but
                                       may persist for months; these symptoms include negative mood, urges
                                       to smoke, and difficulty concentrating
                                      The addictive nature of smoking


Fiore MC, et al. U.S. DHHS Public Health Service 2008
                                  Counseling
 Intra-treatment Supportive Treatment
Supportive Treatment
Component                Examples
Encourage the patient in • Note that effective tobacco dependence treatments are
the quit attempt                  now available
                              •   Note that one-half of all people who have ever smoked have now
                                  quit
                              •   Communicate belief in patient’s ability to quit
Communicate caring            • Ask how patient feels about quitting
and concern                   • Directly express concern and willingness to help as often
                                  as needed
                              •   Ask about the patient’s fears and ambivalence regarding quitting

Encourage the patient         • Ask about
to talk about the                  • Reasons the patient wants to quit
quitting process                   • Concerns or worries about quitting
                                   • Success the patient has achieved
                                   • Difficulties encountered while quitting
Fiore MC, et al. U.S. DHHS Public Health Service 2008
Combination of Counseling and Medication
   Superior to Either Treatment Alone
                                                 Estimated             Estimated
                                Number           Odds Ratio          Abstinence Rate
Treatment                       of Arms           (95% C.I.)            (95% C.I.)
Medication alone                    8                 1.0                    21.7

Medication and
                                   39            1.4 (1.2, 1.6)        27.6 (25.0, 30.3)
counseling

                                                 Estimated             Estimated
                                Number           Odds Ratio          Abstinence Rate
Treatment                       of Arms           (95% C.I.)            (95% C.I.)
Counseling alone                    11                1.0                    14.6

Medication and
                                    13           1.7 (1.3, 2.1)        22.1 (18.1, 26.8)
counseling

Fiore MC, et al. DHHS Public Health Service 2008. Meta-analysis, Combination vs
medication alone (n = 18 studies) and vs counseling alone (n = 9 studies).
             Answers
A. Quit lines alone are effective in achieving
   abstinence.
B. The addition of counseling to medications
   does not increase abstinence rates.
C. Physicians are much more effective than non-
   physician clinicians at delivering treatment.
D. Individual counseling alone is ineffective in
   achieving abstinence.
E. Teaching problem solving and skills training
   alone is ineffective in achieving abstinence.
             Answers
A. Quit lines alone are effective in achieving
   abstinence.
B. The addition of counseling to medications
   does not increase abstinence rates.
C. Physicians are much more effective than non-
   physician clinicians at delivering treatment.
D. Individual counseling alone is ineffective in
   achieving abstinence.
E. Teaching problem solving and skills training
   alone is ineffective in achieving abstinence.
         Question
Of the following pharmacologic
treatment options for this patient’s
tobacco dependence, which would
you choose?
        Question
A. Nicotine patch (21 mg)
B. Nicotine gum (4 mg)
C. Bupropion SR 150 mg bid
D. Sertraline 100 mg once a day
E. Nortriptyline 50 mg qhs
F. Varenicline 1 mg bid
G. Clonidine 0.2 mg patch/24 hrs
         Question
Of the following statements
regarding the pharmacologic
treatment of this patient’s tobacco
dependence, which is correct?
            Question
A. 2nd line agents are contraindicated because
   of drug-drug interactions.
B. Varenicline is contraindicated because of
   the risk of suicide.
C. Bupropion SR may cause mood
   destabilization.
D. Pharmacotherapy should be initiated at
   lower than usual doses.
E. Pharmacotherapy tailored to the psychiatric
   disorder is superior to standard therapy.
            Pharmacotherapy
• 1st line agents
   • Nicotine replacement therapy (NRT)
      • Patch, gum, nasal spray, inhaler,
        lozenge
   • Sustained-release bupropion (Zyban)
   • Varenicline (Chantix)
• 2nd line agents
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
            Pharmacotherapy
• 2nd line agents
   • Nortriptyline, Clonidine
      • Contraindications to, failure of 1st line
        agents
         • Not FDA approved
         • Concern about potential side
           effects
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
Candidates for Pharmacotherapy
• All smokers trying to quit except
  • When contraindicated
  • Pregnant women
  • Smokeless tobacco users
  • Adolescent smokers
  • Patients smoking <10 cigarettes/day
     • If prescribe NRT, ½ usual dose
Fiore MC, et al. U.S. DHHS Public Health Service 2008
           Pharmacotherapy
• Summary of results
  • 6 month abstinence rate
     • 19.0 to 33.2%
  • Odds Ratio
     • 1.5 to 3.1

 Fiore MC, et al. U.S. DHHS Public Health Service 2008
Meta-analysis of Abstinence Rates for Monotherapies Compared to
                   Placebo at 6-Months Postquit


                                     40

                                     35
Estimated Abstinence Rate




                                     30

                                     25
                        (+ 95% CI)




                                     20

                                     15

                                     10

                                      5
                                             80          5             4            4           6            3            6          3          26           32           10             5            15
                                      0
                                           Placebo   Varenicline    Nicotine     High Dose   Long-term   Varenicline   Nicotine   Clonidine   Bupropion   Nicotine     Long-term    Nortriptyline   Nicotine
                                                     (2 mg/day)    Nasal Spray   Nicotine    Nicotine    (1 mg/day)    Inhaler                   SR       Patch (16-   Nicotine                     Gum (6-14
                                                                                 Patch (25   Gum (>14                                                      14wks)      Patch (>14                    weeks)
                                                                                   mg)        weeks)                                                                    weeks)



                                          Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD:
                                          U.S. Department of Health and Human Services. Public Health Service.; 2008.
                                          Number of study arms indicated within the bar.
                                          This information concerns a use that has not been approved by the US Food and Drug Administration.
           Pharmacotherapy
• Recommended combination therapy
  • Long term nicotine patch (> 14 weeks)
    + ad libitum nicotine gum or spray
     • OR: 1.9 (95% CI: 1.3 – 2.7)
  • Nicotine patch + Bupropion SR
     • OR: 1.3 (95% CI: 1.0 – 1.8)
  • Nicotine patch + inhaler
     • OR: 1.1 (95% CI: 0.7 – 1.9)
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
                             Meta-analysis of Abstinence Rates for Combination Therapies
                                      Compared to Placebo at 6-Months Postquit


                                     50
                                     45
Estimated Abstinence Rate




                                     40
                                     35
                                     30
                        (+ 95% CI)




                                     25
                                     20
                                     15
                                     10
                                      5        80                 3                 3                 2                 2                 3
                                      0
                                            Placebo          Patch (>14       Patch (>14         Patch (>14        Patch (>14        Patch (>14
                                                            weeks) + Lib       weeks) +           weeks) +          weeks) +           weeks)
                                                            NRT (gum or      Bupropion SR       Nortriptyline        Inhaler          +Second
                                                               spray)                                                              Generation AD
                                                                                                                                    (paroxetine,
                                                                                                                                    venlafaxine)

                                          Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD:
                                          U.S. Department of Health and Human Services. Public Health Service.; 2008.
                                          Number of study arms indicated within the bar.
                                          This information concerns a use that has not been approved by the US Food and Drug Administration.
   Tobacco Dependence Treatment
          Impact on Concurrent Medications

• Nicotine
  • Metabolized by CYP2A6
  • Does not induce liver enzymes
     • Nicotine replacement therapy does
       not impact drug metabolism

 Fiore MC, et al. U.S. DHHS Public Health Service 2008
   Tobacco Dependence Treatment
          Impact on Concurrent Medications

• Nicotine
  • Activates sympathetic nervous system
     • Decreases sedative effects of
       benzodiazepines, opioid analgesia,
       effect of beta blockers, subcutaneous
       absorption of insulin
     • NRT not contraindicated in patients
       with cardiovascular disease
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
  Tobacco Dependence Treatment
         Impact on Concurrent Medications
• Polycyclic aromatic hydrocarbons in
  cigarette smoke
   • Induce isoforms of CYP450
      • Metabolizes
         • Fluvoxamine, olanzapine,
           clozapine
         • Caffeine, theophylline
Fiore MC, et al. U.S. DHHS Public Health Service 2008
  Tobacco Dependence Treatment
         Impact on Concurrent Medications
• Bupropion SR
  • Metabolized by CYP2B6
  • Inhibits CYP2D6
     • Metabolizes tricyclic antidepressants,
       antipsychotics
  • Contraindications
     • MAO inhibitor last 14 days
     • History of seizures, eating disorder
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
   Tobacco Dependence Treatment
          Impact on Concurrent Medications

• Varenicline
  • Eliminated unchanged in urine
     • No drug-drug interactions
     • Caution with creatinine clearance
       < 30 ml/min
        • Consider 1 mg/day

 Fiore MC, et al. U.S. DHHS Public Health Service 2008
           Pharmacotherapy
                    Factors to Consider
• Contraindications/precautions/warnings/
  side effects/drug-drug interactions
• Patient preference
• Prior effectiveness?
• Clinician familiarity, experience
• Adherence
   • Patch > gum > nasal spray, vapor
     inhaler
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
          Pharmacotherapy
                   Factors to Consider

• Highly dependent/severe
  withdrawal symptoms
  • Nicotine replacement therapy
     • 4 mg gum & lozenge
     • 21 mg patch
     • Combination therapy
Fiore MC, et al. U.S. DHHS Public Health Service 2008
 Clues to Nicotine Addiction
• Smokes > 1 pack per day
• 1st cigarette within ½ hour of
  awakening
• Symptoms of withdrawal with
  previous quit attempts
   • Anxiety, irritability, restlessness,
     difficulty concentrating, insomnia,
     depression, craving, hunger
Fiore MC, et al. U.S. DHHS Public Health Service 2008
          Pharmacotherapy
                   Factors to Consider
• Concerned about weight gain
  • Bupropion SR
  • 4mg gum & lozenge
  • Varenicline
• Woman
  • Nicotine replacement therapy may
    be less effective

Fiore MC, et al. U.S. DHHS Public Health Service 2008
        Pharmacotherapy
                 Factors to Consider
• Cardiovascular disease
• Hospitalized patients
  • Nicotine replacement therapy,
    especially patch, safe
• ? ICU patients

Fiore MC, et al. U.S. DHHS Public Health Service 2008
         Pharmacotherapy
                  Factors to Consider
• Long term use
  • ≥ 6 months OK
  • Preferred to continued smoking
• Pragmatic
  • Dentures with gum
  • Dermatitis with patches
  • Insurance coverage
  • Cost
Fiore MC, et al. U.S. DHHS Public Health Service 2008
Smokers With Psychiatric Disorders
• Increased risk of relapse
• Insufficient evidence that treatment
  tailored to psychiatric
  diagnoses/symptoms is superior to
  traditional treatment


Fiore MC, et al. U.S. DHHS Public Health Service 2008
 Smokers With Psychiatric Disorders

• Past history of depression
  • Bupropion SR & nortriptyline vs placebo
    • OR: 3.42 (95% CI: 1.70 – 6.84)
• Bipolar disorder
  • Antidepressants may cause mood
    destabilization

  Fiore MC, et al. U.S. DHHS Public Health Service 2008
 Smokers With Psychiatric Disorders
• Patients being treated for non-nicotine
  chemical dependence
  • Pharmacotherapy and counseling for
    nicotine dependence are effective
    • Treating concurrently does not
      interfere with outcomes
        • Except possibly alcohol abstinence
          outcome (1 study)
  Fiore MC, et al. U.S. DHHS Public Health Service 2008
 Smokers With Psychiatric Disorders
• Schizophrenia
  • Bupropion SR and NRT may be effective
    • May improve negative and depressive
      symptoms
  • Patients on atypical antipsychotics may
    be more responsive to Bupropion SR
    than those on standard antipsychotics

  Fiore MC, et al. U.S. DHHS Public Health Service 2008
 Smokers With Psychiatric Disorders
• Varenicline
  • NOT contraindicated
  • Reports of depressed mood, agitation,
    changes in behavior, suicidal ideation,
    suicide
  • FDA recommendation
    • Elicit psychiatric history
    • Monitor for changes in mood, behavior
  Fiore MC, et al. U.S. DHHS Public Health Service 2008
            Question
A. 2nd line agents are contraindicated because
   of drug-drug interactions.
B. Varenicline is contraindicated because of
   the risk of suicide.
C. Bupropion SR may cause mood
   destabilization.
D. Pharmacotherapy should be initiated at
   lower than usual doses.
E. Pharmacotherapy tailored to the psychiatric
   disorder is superior to standard therapy.
            Question
A. 2nd line agents are contraindicated because
   of drug-drug interactions.
B. Varenicline is contraindicated because of
   the risk of suicide.
C. Bupropion SR may cause mood
   destabilization.
D. Pharmacotherapy should be initiated at
   lower than usual doses.
E. Pharmacotherapy tailored to the psychiatric
   disorder is superior to standard therapy.
        Question
A. Nicotine patch (21 mg)
B. Nicotine gum (4 mg)
C. Bupropion SR 150 mg bid
D. Sertraline 100 mg once a day
E. Nortriptyline 50 mg qhs
F. Varenicline 1 mg bid
G. Clonidine 0.2 mg patch/24 hrs
        Question
A. Nicotine patch (21 mg)
B. Nicotine gum (4 mg)
C. Bupropion SR 150 mg bid
D. Sertraline 100 mg once a day
E. Nortriptyline 50 mg qhs
F. Varenicline 1 mg bid
G. Clonidine 0.2 mg patch/24 hrs
      Obtaining the 2008 Guideline

• The full text of the 2008 Guideline,
  www.ahrq.gov/path/tobacco.htm#clinic

• To order the 2008 Guideline and the various supplemental
  materials go to www.ahrq.gov/clinic/tobacco/order.htm

•   UW-CTRI
    • www.ctri.wisc.edu

• CS2day
   • www.ceasesmoking2day.org
    Patient Unwilling to Quit
          Motivational Interviewing
Express        • Use open ended questions to explore:
Empathy           • The importance of addressing smoking or other tobacco use
                    (eg, “How important do you think it is for you to quit smoking?”)
                  • Concerns and benefits of quitting (eg, “What might happen if
                    you quit?”)
               • Use reflective listening to seek shared understanding:
                  • Reflect words or meaning
                    (eg, “So you think smoking helps you to maintain your weight”)
                   • Summarize (eg, “What I have heard so far is that smoking is
                     something you enjoy. On the other hand, your boyfriend hates
                     your smoking and you are worried you might develop a serious
                     disease”)
               • Normalize feelings and concerns
                 (eg, “Many people worry about managing without cigarettes”)
               • Support the patient’s autonomy and right to choose or reject
                 change
                 (eg, “I hear you saying you are not ready to quit smoking right now;
                 I’m here to help you when you are ready”)

Fiore MC, et al. U.S. DHHS Public Health Service 2008
      Patient Unwilling to Quit
            Motivational Interviewing
Develop           • Highlight the discrepancy between the patient’s present behavior and
                    expressed priorities, values, and goals (eg, “It sounds like you are
Discrepancy         very devoted to your family. How do you think your smoking is
                    affecting
                    your children?”)
                  • Reinforce and support “change talk” and “commitment” language
                      • “So, you realize how smoking is affecting your breathing and
                        making it hard to keep up with your kids”
                     • “It’s great that you are going to quit when you get through this
                       busy time at work”
                  • Build and deepen commitment to change
                      • “There are effective treatments that will ease the pain of quitting,
                        including counseling and many medication options”
                      • “We would like to help you avoid a stroke like the one your father
                        had”


Fiore MC, et al. U.S. DHHS Public Health Service 2008
     Patient Unwilling to Quit
           Motivational Interviewing
Roll with       • Back off and use reflection when the patient expresses resistance
Resistance         • “Sounds like you are feeling pressured about your smoking”
                • Express empathy
                   • “You are worried about how you would manage withdrawal
                     symptoms”
                • Ask permission to provide information
                   •    “Would you like to hear about some strategies that can help
                       you address that concern when you quit?”
Support         • Help the patient to identify and build on past successes
Self-              • “So you were fairly successful the last time you tried to quit”
Efficacy        • Offer options for achievable small steps toward change
                   • Call the quit line (1-800-QUIT-NOW) for advice and information
                   • Read about quitting benefits and strategies
                   • Change smoking patterns (eg, no smoking in the home)
                   • Ask the patient to share his or her ideas about quitting strategies
Fiore MC, et al. U.S. DHHS Public Health Service 2008
                            The 5 Rs
        To Motivate Patients Unwilling
            to Quit at This Time
• RELEVANCE: tailor advice and discussion
                to each patient
• RISKS: outline risks of continued smoking
• REWARDS: outline the benefits of quitting
• ROADBLOCKS: identify barriers to
                  quitting
• REPETITION: reinforce the motivational
               message at every visit
 Fiore MC, et al. U.S. DHHS Public Health Service 2008
  Patient Unwilling to Quit (The 5Rs)
Relevance        Encourage the patient to indicate why quitting is personally relevant, being as
                 specific as possible
                 Motivational information has the greatest impact if it is relevant to a patient’s
                 disease status or risk, family, or social situation (eg, having children in the
                 home), health concerns, age, gender, and other important patient
                 characteristics (eg, prior quitting experience, personal barriers to cessation)
Risks            The clinician should ask the patient to identify potential negative
                 consequences of tobacco use. The clinician may suggest and highlight those
                 that seem most relevant to the patient. The clinician should emphasize that
                 smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (eg,
                 smokeless tobacco, cigars, and pipes) will not eliminate these risks. Examples
                 of risks are
                 • Acute risks: Shortness of breath, exacerbation of asthma, increased risk of
                   respiratory infections, harm to pregnancy, impotence, infertility
                 • Long-term risks: Heart attacks and strokes, lung and other cancers (eg,
                   larynx, oral cavity, pharynx, esophagus, pancreas, stomach, kidney,
                   bladder, cervix, and acute myelocytic leukemia), chronic obstructive
                   pulmonary diseases (chronic bronchitis and emphysema), osteoporosis,
                   long-term disability, and need for extended care
                 • Environmental risks: Increased risk of lung cancer and heart disease in
                   spouses; increased risk for low birth weight, sudden infant death syndrome
                   (SIDS), asthma, middle ear disease, and respiratory infections in children of
                    smokers
Fiore MC, et al. U.S. DHHS Public Health Service 2008
Patient Unwilling to Quit (The 5Rs)
Rewards         The clinician should ask the patient to identify potential benefits of
                stopping tobacco use

                The clinician may suggest and highlight those that seem most
                relevant to the patient
                Examples of rewards follow
                • Improved health
                • Food will taste better
                • Improved sense of smell
                • Saving money
                • Feeling better about yourself
                • Home, car, clothing, breath will smell better
                • Having healthier babies and children
                • Setting a good example for children and decrease the likelihood that
                  they will smoke
                • Feeling better physically
                • Performing better in physical activities
                • Improved appearance, including reduced wrinkling/aging of skin
                  and whiter teeth
Fiore MC, et al. U.S. DHHS Public Health Service 2008
Patient Unwilling to Quit (The 5Rs)
Roadblocks       The clinician should ask the patient to identify barriers or
                 impediments to quitting and provide treatment (problem-solving
                 counseling, medication) that could address barriers

                 Typical barriers might include
                 • Withdrawal symptoms
                 • Fear of failure
                 • Weight gain
                 • Lack of support
                 • Depression
                 • Enjoyment of tobacco
                 • Being around other tobacco users
                 • Limited knowledge of effective treatment options
Repetition       The motivational intervention should be repeated every time an
                 unmotivated patient visits the clinic setting

                 Tobacco users who have failed in previous quit attempts should be
                 told that most people make repeated quit attempts before they are
                 successful

Fiore MC, et al. U.S. DHHS Public Health Service 2008
 Patient Who Has Recently Quit
The former tobacco user should receive congratulations on any success and
strong encouragement to remain abstinent

When encountering a recent quitter, use open-ended questions relevant to the
topics below to discover if the patient wishes to discuss issues related to
quitting:
• The benefits, including potential health benefits, the patient may derive from
 cessation
• Any success the patient has had in quitting (duration of abstinence,
 reduction in withdrawal, etc)
• The problems encountered or anticipated threats to maintaining abstinence
  (eg, depression, weight gain, alcohol, other tobacco users in the household,
   significant stressors)
• A medication check-in, including effectiveness and side effects if the patient
 is still taking medication
Fiore MC, et al. U.S. DHHS Public Health Service 2008
   Patient Who Has Recently Quit
Problems         Responses
Lack of          • Schedule follow-up visits or telephone calls with the patient
support          • Urge the patient to call the national quit line network
for cessation      (1-800-QUIT-NOW) or other local quit line
                 • Help the patient identify sources of support within his or her environment.
                 • Refer the patient to an appropriate organization that offers counseling or
                   support
Negative         • If significant, provide counseling, prescribe appropriate medication, or refer
mood               the patient to a specialist
or depression
Strong or        • If the patient reports prolonged craving or other withdrawal symptoms,
prolonged          consider extending the use of an approved medication or adding/combining
withdrawal         medications to reduce strong withdrawal symptoms
symptoms

Fiore MC, et al. U.S. DHHS Public Health Service 2008
Patient Who Has Recently Quit
Problems        Responses
Weight          • Recommend starting or increasing physical activity
gain            • Reassure the patient that some weight gain after quitting is
                  common and is usually self limiting
                • Emphasize the health benefits of quitting relative to the health risks
                  of modest weight gain
                • Emphasize the importance of a healthy diet and active lifestyle
                • Suggest low-calorie substitutes such as sugarless chewing gum,
                  vegetables, or mints
                • Maintain the patient on medication known to delay weight gain (eg,
                  bupropion SR, NRTs, particularly 4 mg nicotine gum, and lozenge)
                • Refer the patient to a nutritional counselor or program
Smoking         • Suggest continued use of tobacco use medications, which can
lapses            reduce the likelihood that a lapse will lead to a full relapse
                • Encourage another quit attempt or a recommitment to total
                  abstinence
                • Reassure that quitting may take multiple attempts and use the
                  lapse as a learning experience
                • Provide or refer for intensive counseling

Fiore MC, et al. U.S. DHHS Public Health Service 2008

								
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