Smoking Cessation

1. Smoking Cessation

2. Nicotine Replacement Therapy (NRT) • Available in gum, lozenge, patch and inhaler • Aims to replace the nicotine obtained from cigarettes, reducing withdrawal symptoms when stopping smoking • Use of NRT is preferable to smoking, because it does not: • contain non-nicotine toxic substances such as carbon monoxide and 'tar' • produce dramatic surges in blood nicotine levels • produce strong dependence

3. Nicotine Replacement Therapy • Odds ratio for abstinence with NRT compared to control is 1.73 (patch 1.76, gum 1.66, inhaler 2.08) (4mg lozenge 3.69) • Odds are independent of intensity of additional support provided to smoker or setting in which NRT offered • In highly dependent smokers there is significant benefit of 4mg gum over 2mg gum (odds ratio 2.67) • Increases quit rates 1.5 - 2 fold, regardless of setting • NRT is safe, should be routinely recommended to smokers, product choice depends on practical & personal considerations

4. Level of nicotine dependence and NRT dosage • As a general rule, smokers who are nicotine dependent will have less intense withdrawal symptoms if provided with an adequate dosage of NRT • For example: • A trial for the nicotine lozenge used the ‘TTFC’ (time to first cigarette) measure of dependence to allocate dosage: • those who smoke within 30 mins of waking - 4mg lozenge • those who wait longer than 30 mins - 2mg lozenge • (Note: the lozenge provides 25% more nicotine than the gum as it dissolves completely)

5. Smoking produces much higher nicotine levels than NRT 14 12 10 8 Increase in nicotine concentration ( ng/ml ) Cigarette Gum 4 mg Gum 2 mg Inhaler Patch 6 4 2 0 5 10 15 20 25 30 Minutes Source: Balfour DJ & Fagerström KO. Pharmacol Ther 1996 72:51-81.

6. NRT Dosage • Plasma nicotine levels significantly lower from NRT than smoking • MIMS recommended dosages: • Gum: maximum 40 per day • Lozenge: maximum 15 per day • Patch:healthy people > 10 cigs/day >45 kgs: one patch daily 2 1mg/24 hr or 15mg/16hr • cardiovascular disease <10 cigs/day, <45 kgs: one patch daily 14mg/24hr or 10mg/16hr • Inhaler: Self-titrate dose, according to withdrawal symptoms. 6-12 cartridges/day.

7. Directions for use of NRT products Gum: nicotine absorbed through oral mucosa, chew till a peppery/tingling feeling, flatten gum and ‘park’ between gum & cheek, or under tongue Lozenge: nicotine absorbed through oral mucosa, move round mouth from time to time and suck until dissolved (takes 20-30 minutes) Patch: nicotine absorbed through skin, place on clean, non-hairy site on chest or upper arm on waking, place new patch on new site each day to prevent skin reaction Inhaler: nicotine absorbed through oral mucosa, inhale air through cartridge for 20 minutes

8. Bupropion(Zyban) • First non-nicotine medication shown effective for cessation • Blocks neural re-uptake of dopamine and/or noradrenaline • Start one week prior to quit day, limited application for inpatients • An option for patients after discharge and patients can be referred to their GP to discuss their options • The only pharmacotherapy available on PBS • Contraindications include patients with seizure disorder, current or prior bulimia or anorexia nervosa, use of a MAO inhibitor within the previous 14 days

9. Combination therapy • Highly dependent smokers may benefit from combining patch with self-administered form of NRT (lozenge/gum/inhaler) • More effective than single form of NRT • Use combined treatments if unable to remain abstinent or if still experiencing withdrawal symptoms using single therapy • Increased success depends on the use of two distinct delivery systems: one passive (ie: patch) + one active or ‘at liberty’(ie: gum/lozenge/inhaler)

10. Opioids

11. Basic Opioid Facts Description: Opium-derived, or synthetics which relieve pain, produce morphine-like addiction, and relieve withdrawal from opioids Medical Uses: Pain relief, cough suppression, diarrhea Methods of Use: Intravenously injected, smoked, snorted, or orally administered

12. Agonist Partial Agonist Antagonist Morphine-like effect (e.g., heroin) Maximum effect is less than a full agonist (e.g., buprenorphine) No effect in absence of an opiate or opiate dependence (e.g., naloxone) Agonists, Partial Agonists, and Antagonists

13. Opioid Agonists • Natural derivatives of opium poppy - Opium - Morphine - Codeine • Synthetics - Propoxyphene – Darvon®, Darvocet® - Meperidine – Demerol® - Fentanyl citrate – Fentanyl® - Methadone – Dolophine® - Levo-alpha-acetylmethadol – ORLAAM®

14. Opioid Partial Agonists • Buprenorphine – Buprenex®, Suboxone®, Subutex® • Pentazocine – Talwin®

15. Opioid Antagonists • Naloxone – Narcan® • Naltrexone – ReVia®, Trexan®

16. SOURCE: National Institute on Drug Abuse, www.nida.nih.gov.

17. Partial vs. Full Opioid Agonist death Opiate Full Agonist (e.g., methadone) Effect Partial Agonist (e.g.buprenorphine) Antagonist (e.g. Naloxone) Doseof Opiate

18. What Happens When You Use Opioids? • Acute Effects: Sedation, euphoria, pupil constriction, constipation, itching, and lowered pulse, respiration and blood pressure • Results of Chronic Use: Tolerance, addiction, medical complications • Withdrawal Symptoms: Sweating, gooseflesh, yawning, chills, runny nose, tearing, nausea, vomiting, diarrhea, and muscle and joint aches

19. Possible Acute Effects of Opioid Use • Surge of pleasurable sensation = “rush” • Warm flushing of skin • Dry mouth • Heavy feeling in extremities • Drowsiness • Clouding of mental function • Slowing of heart rate and breathing • Nausea, vomiting, and severe itching

20. Heroin Withdrawal Syndrome • Intensity varies with level & chronicity of use • Cessation of opioids causes a rebound in function altered by chronic use • First signs occur shortly before next scheduled dose • Duration of withdrawal is dependent upon the half-life of the drug used: • Peak of withdrawal occurs 36 to 72 hours after last dose • Acute symptoms subside over 3 to 7 days • Protracted symptoms may linger for weeks or months

21. Opioid Withdrawal SyndromeAcute Symptoms • Pupillary dilation • Lacrimation (watery eyes) • Rhinorrhea (runny nose) • Muscle spasms (“kicking”) • Yawning, sweating, chills, gooseflesh • Stomach cramps, diarrhea, vomiting • Restlessness, anxiety, irritability

22. Opioid Withdrawal SyndromeProtracted Symptoms • Deep muscle aches and pains • Insomnia, disturbed sleep • Poor appetite • Reduced libido, impotence, anorgasmia • Depressed mood, anhedonia • Drug craving and obsession

23. Treatment Options for Opioid-Addicted Individuals • Behavioral treatments educate patients about the conditioning process and teach relapse prevention strategies. • Medications such as methadone and buprenorphine operate on the opioid receptors to relieve craving. • Combining the two types of treatment enables patients to stop using opioids and return to more stable and productive lives.

24. Opioid Dependence TreatmentMedically-Assisted Withdrawal • Relieves withdrawal symptoms while patients adjust to a drug-free state • Can occur in an inpatient or outpatient setting • Typically occurs under the care of a physician or medical provider • Serves as a precursor to behavioral treatment, because it is designed to treat the acute physiological effects of stopping drug use SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

25. Agonist Maintenance Treatment • Patients stabilized on adequate, sustained dosages of these medications can function normally. • They can hold jobs, avoid crime and violence of the street culture, and reduce their exposure to HIV by stopping or decreasing IV drug use and drug-related sexual behavior. • Can engage more readily in counseling and other behavioral interventions essential to recovery and rehabilitation SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

26. Agonist Maintenance Treatment • Usually conducted in outpatient settings • Treatment provided in opioid treatment programs or, with buprenorphine, in office-based settings • Use a long-acting synthetic opioid medication, usually methadone • Administer the drug orally for a sustained period at a dosage sufficient to prevent opioid withdrawal, block the effect of illicit opiate use, and decrease opioid craving SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

27. Agonist Maintenance Treatment • The best, most effective opioid agonist maintenance programs include individual and/or group counseling, as well as provision of, or referral to other needed medical, psychological, and social services. SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

28. Benefits of Methadone Maintenance Therapy • Used effectively and safely for over 30 years • Not intoxicating or sedating, if prescribed properly • Effects do not interfere with ordinary activities • Suppresses opioid withdrawal for 24-36 hours

29. Antagonist Maintenance Treatment • Usually conducted in outpatient setting • Initiation of naltrexone often begins after medical detoxification in a residential setting • Individuals must be medically detoxified and opioid-free for several days before naltrexone is taken (to prevent precipitating an opioid withdrawal syndrome). SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

30. Antagonist Maintenance Treatment • Repeated lack of desired opioid effects, as well as the perceived utility of using the opiate, will gradually over time result in breaking the habit of opiate addiction. • Patient noncompliance is a common problem. A favorable treatment outcome requires that there also be a positive therapeutic relationship, effective counseling or therapy, and careful monitoring of medication compliance. SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

31. The 12 Step Programs

32. 12 STEP PROGRAMS Best Known • Alcoholics Anonymous (AA) • Alanon • Narcotics Anonymous (NA) • Cocaine Anonymous (CA) • Gamblers Anonymous (GA) • Overeaters Anonymous (OA) • Debtors Anonymous (DA) • Sex and Love Addicts Anonymous (SLAA)

33. History of AA • 1935 two hopeless drinkers, Bill W. and Dr. Bob S., managed to stay sober by talking to each other • They worked with other alcoholics • Three year period empirical field research • approximately 100 were staying sober • Method of maintaining sobriety

34. History of AA • Bill W and Dr Bob decided they needed to talk to other alcoholics 6/35 • 6/36 5 recovered • 6/37 15 recovered • 6/38 40 recovered • 6/39 100 recovered • Big Book written with help of 3 groups, separated from Oxford group (Tiebout, 1944)

35. History of AA • Research in 1980’s and 1990’s • AA most effective way for alcoholics to maintain long term sobriety • AA/NA compatible with treatment of all medical and mental disorders • Should be considered essential in treatment of addictive disorders

36. Going To Meetings • Acceptance of newcomers is warm and genuine • Core is sharing of experience – honesty, openness, and a willingness to change • Many meetings to choose from • Open, Closed, Beginners, Step Study, Big Book Study, Speaker, Discussion

37. Choosing a Home Group • Can serve as both an extended family and a recovery support system • A phone list is of great benefit • shown significantly to reduce the risk of relapse • Introduces service and responsibility

38. Choosing a Sponsor • Until a sponsor is acquired ask for temporary contact who will introduce patient to the fellowship and take them to meetings. • Main task of sponsor is to help work the steps and develop a personal program of recovery. • Having a sponsor significantly reduces the risk of relapse (Sheeren, 1988) • A sponsor will help work on being Honest, Open, and Willing (H.O.W.)

39. Working the Steps • Originally discovered through empirical research to help hopeless, chronic alcoholics maintain sobriety • Useful to problems other than alcohol or drug addiction

40. Step 1: “We admitted we were powerless over alcohol--that our lives had become unmanageable” • Addresses denial • Promotes honesty and self examination, resistance can be great • Accepts identity as an alcoholic or addict • Principle: Honesty

41. Step Two: “Came to believe that a Power greater than ourselves could restore us to sanity” • The person recognizes that they need help. “I alone can do it, but I can’t do it alone.” • Sanity is recognition that continued use of alcohol or other drugs will have continued negative effects • Helps open the person to new internal experience • Principle: Hope

42. Step Three: “Made a decision to turn our will and our lives over to the care of God as we understood Him” • Difficult for atheist, helped by thinking of an accepting and loving life force within • Practicing “letting go” weakens the grip of obsessions, craving, worries, resentments • Principle: Faith

43. Step Four: “Made a searching and fearless moral inventory of ourselves” • Done by many healthy individuals, fundamental part of psychotherapy • Arouses guilt, shame, grief, and other powerful negative emotions. A sponsor is necessary in working this step. • Gets prepared for honest sharing in human relationships • Principle: Courage

44. Step Five: “Admitted to God, to ourselves, and to another human being the exact nature of our wrongs” • Arouses anxiety, reactions of anger, disgust, and rejection • Usually to one's sponsor, home group member or clergy person • great relief that reaction not rejecting or punitive • Helps develop honesty with oneself and others • Principle: Integrity

45. Step Six: “Were entirely ready to have God remove all these defects of character” • Characterologic and personality problems continue • Simply getting ready to have a Higher Power, something other than self, remove selfishness, dishonesty, impulsiveness, blaming, and other dysfunctional behaviors. • Principle: Willingness

46. Step Seven: “Humbly asked Him to remove our shortcomings” • Recognizes the fact that I am a fallible human being who needs help • Antisocial, narcissistic, avoiding, and borderline personality disorders slowly subside and even disappear • Principle: Humility

47. Step Eight: “Made a list of all persons we had harmed and became willing to make amends to them all” • Painful, but a valuable preparation for repairing damaged relationships. • A sponsor is necessary in working this step. • “If you have an unresolvable resentment about someone, pray for the son of a bitch.” • Essential part of capacity for empathy • Helps develop skill in maintain relationships • Principle: Brotherly/Sisterly Love

48. Step Nine: “Made direct amends to such people wherever possible, except when to do so would injure them or others” • Arouses anxiety which may be extreme • Support necessary • Helps repair damaged relationships • Principle: Justice

49. Step Ten: “Continued to take personal inventory and when we were wrong promptly admitted it” • Self observation, associational problem solving, and honesty with oneself and others • Self observation and admission of problems • Set the stage of redeveloping both intimacy and generativity • Principle: Perseverance

50. Step Eleven: “Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out” Emphasis is on developing the experience one is capable of Knowledge & power are for taking responsibility for one’s own life - solving one’s own problems Developing one’s own experience leads to tolerance for others. Atheists and agnostics are welcome Principle: Spiritual Awareness