Module 5 - Co-Occurring Disorders: Integrating Tobacco Use Interventions into Chemical Dependence Services

1. Module 5 - Co-Occurring Disorders:Integrating Tobacco Use Interventions into Chemical Dependence Services

2. Welcome • Add Trainer Name(s)

3. This training was developed by the Professional Development Program, under a contract with the NYS Department of Health, Tobacco Control Program. PDP developed five classroom-based curricula and seven online modules, which are available at www.tobaccorecovery.org

4. Housekeeping • Hours of Training • Breaks • Restrooms • Tobacco Use Policy • Cell Phones • Active Participation • Complete Training Evaluation Form

5. Introductions

6. Training Modules Module 1 - Foundations Module 2 - Assessment, Diagnosis, and Pharmacotherapy Module 3 - Behavioral Interventions Module 4 - Treatment Planning Module 5 - Co-occurring Disorders E-Learning - All Modules PM 9

7. Module 5 Agenda • Review of prior modules • Personal attitudes and beliefs • Prevalence and co-morbidity • Basic neurobiology of tobacco dependence • Review of tobacco treatment strategies • Case Studies PM 10

8. Module 5 Objectives Please review page 10 in your manual PM 10

9. Unit 1Attitudes and Beliefs, Challenges and Barriers PM 11

10. Review Learning points from prior modules New knowledge or skills integrated into practice PM 12

11. Defining Co-occurring Disorders How do you define co-occurring disorders? Co-occurring disorders - when a person has a substance use disorder and mental health disorder at the same time. PM 13

12. Defining Co-morbidity How do you define co-morbidity? Co-morbidity - two or more disorders are present at the same time and they interact in ways that affect the course and/or prognosis of each disorder. PM 13

13. Setting the Context • Currently very little research on co-occurring disorders (COD)and tobacco dependence. • Tobacco treatment is effective for wide range of people, including those with mental health (MHD) and substance use disorders (SUD). • What is known about tobacco users with a MHD or SUD, may be applicable for COD PM 14

14. Activity #1 Confidence, Attitudes, and Beliefs Assess your current confidence, attitudes, and beliefs about tobacco use among people with MHD and SUD PM 15

15. Debriefing Activity #1 Examining how attitudes and beliefs about tobacco, affect staff and patient behavior to examine and address tobacco use.

16. Activity #2 Video - Smoke Alarm Produced by Clubhouse of Suffolk Ronkonkoma, NY www.clubhouseofsuffolk.com PM 16

17. Video - Vignettes 1 to 3 • What is the relationship of tobacco to people’s mental health disorder? • What are common fears about stopping tobacco use? PM 16

18. Vignette #1

19. Vignette #2

20. Vignette #3

21. Video - Vignettes 4 and 5 • What are the barriers and challenges mentioned about stopping tobacco use? • How might treatment for people with COD need to be modified or enhanced? PM 16

22. Vignette #4

23. Vignette #5

24. Summary Definition of co-occurring disorders and co- morbidity Confidence, attitudes, and beliefs Patient perspectives on tobacco use/dependence Challenges and barriers to addressing tobacco use by people with SUDs and MHDs PM 17

25. Unit 2 Prevalence and Co-morbidity Factors PM 19

26. Discussion What is the frequency of patients having a co-occurring mental health disorder and substance use disorder?

27. National and NYS Data National Data: • 50 - 75% of SUD patients have MHD • 25 - 50% of MHD patients have SUD (Center for Substance Abuse Treatment, 2005) NYS Chemical Dependence Programs: • 23% - 46% of SUD patients have MHD, rates varies by modality (Office of Alcoholism and Substance Abuse Services, 2008) PM 20

28. Activity #3 Tobacco and Co-occurring Disorders Knowledge Activity PM 21 - 23

29. 1. Average Rate of Tobacco Smoking About 70% of people with a mental health disorder (MHD) and/or a substance use disorder (SUD), also smoke tobacco. Studies vary as to each disorder and people with some disorders have smoking rates up to 80 - 90%. 70% PM 24

30. 2. Percentage of Cigarettes Consumed About half of all cigarettes consumed in the US are by people with MHD and/or SUD. 44-46% Results in significant illness, death, and health disparity for two vulnerable populations. PM 24

31. 3. Average Reduced Life Span Primary cause of death is cardiovascular disease (CVD) and diabetes. #1 cause of CVD is tobacco smoke and tobacco is a key factor in onset of diabetes. 25 years! The average lifespan in US is 77.8 years. For smokers with MHD or SUD, this life span is reduced by 32%. 32% PM 24

32. 4. Average percent of monthly income spent on tobacco Average percentage of monthly income spent on tobacco 27% Averages about $142 per month based upon 2000 - 2002 costs. PM 25

33. 5. Daily smoking can predict suicidal thinking and attempts Facts ! Increased suicide thinking and attempts even considering a prior history of depression, substance use disorder, and prior suicide attempts. Increased risk of suicide for people with bipolar illness and schizophrenia. PM 25

34. 6. Heavy smoking can be a predictor of suicide risk and completion Facts ! Increased suicide completion rates for tobacco using adolescents and greater number of attempts, especially for females Heavy tobacco smoking is highly associated with increased suicide completion PM 26

35. 7. Nicotine causes cancer and CVD Facts ! Nicotine is not a carcinogen and is not a major risk factor of cardiovascular disease (CVD). Tobacco smoke is the disease-causing agent. PM 26

36. 8. Nicotine can affect metabolism of psychiatric medications Facts ! Nicotine does not affect the metabolism of medications. Tobacco smoke induces the liver to increase the metabolism rate of some psychiatric and some non-psychiatric medications. PM 26

37. 9. Stopping smoking requires an increase in psychiatric medications Facts ! Many people can stop without changes in medication levels. Some may require lower doses to avoid medication toxicity (i.e., clozapine, olanzepine) or to avoid increased side effects (i.e., amitriptyline, nortriptyline, and imipramine). See Table 1 - Common Drugs Affected by Tobacco Smoke PM 27

38. 10. Use of tobacco increases anxiety Facts! Increased feelings of general anxiety from using tobacco. Patients often confuse nicotine withdrawal symptoms with primary anxiety symptoms of MHD or SUD. Many mistakenly assume using tobacco causes their general anxiety symptoms to stop. PM 28

39. 11. Stopping tobacco leads to panic attacks, and smoking reduces panic attacks and panic disorder Facts ! Tobacco use is a significant risk factor for panic disorder, agoraphobia, and generalized anxiety disorder (GAD). Also refer back to answer in Statement 10. PM 28

40. 12. Most people with MHD or SUD are not interested in stopping tobacco use Facts ! 70% expressed an interest in stopping in the past year. People with MHDs and/or SUDs express an interest in stopping tobacco use as often as smokers in the general population. PM 28

41. 13. Most people with MHD or SUD cannot stop using tobacco Facts ! Many can stop and need more frequent treatment, more intense treatment, and more engagement. No increased problems after stopping and recent research shows MH symptoms decrease after tobacco abstinence. PM 29

42. 14. Chantix reduces the effects of some psychiatric medications Facts ! About 92% of Chantix is eliminated unchanged from body by kidneys. Chantix has no drug-to-drug interactions. PM 29

43. 15. Smoking increases MHD/SUD risk Facts! Tobacco is a common “gateway drug” for AOD use Smoking increases risk for mental illness and doubles the risk for major depression when used in adolescence. Adolescent tobacco use associated with increased adult risk for panic disorder, anxiety disorder, agoraphobia, depression, suicidal behavior, SUD, and schizophrenia. PM 30

44. 15. Smoking increases MHD/SUD risk, cont’d Facts ! Active psychiatric disorders are associated with daily smoking and progression to dependence. Risk of major depression in women who smoke is increased 93%. PM 30

45. Knowledge Summary How many of these answers did you already know? Were there any surprises from what you just learned?

46. Biopsychosocial Approach to Substance Dependence Tobacco dependence is a biopsychosocial disease PM 31

47. Neurobiological Factors and Neuro-chemical Effects of Tobacco/Nicotine • Various genes are involved for first tobacco use, risk of dependence, withdrawal severity, and inability to stop using. • Different neurotransmitters are affected by nicotine and likely by other chemicals in tobacco smoke. • Nicotine provides some short-term benefits, but tobacco use aggravates MHDs and SUDs. PM 32 - 33

48. Other Factors Affecting Tobacco Use • Psychological • Behavioral • Social • Treatment / Recovery • Large System (Tobacco Industry, Media, etc). PM 34 - 35

49. Interaction between Tobacco Dependence and Other Substance Use Disorder Tobacco Dependence Other Substance Use Disorder PM 36

50. Interaction between Substance Use Disorder and Mental Health Disorder Substance Use Disorder Mental Health Disorder PM 37