Module 2 - Assessment, Diagnosis, and Pharmacotherapy: Integrating Tobacco Use Interventions into Chemical Dependence Se

1. Module 2 - Assessment, Diagnosis, and Pharmacotherapy:Integrating Tobacco Use Interventions into Chemical Dependence Services

2. 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

3. Welcome • Add Trainer Names

4. Housekeeping • Hours of Training • Breaks • Restrooms • Tobacco Use Policy • Cell Phones • Active Participation • Complete Pre-test/Post-test • Complete Training Evaluation

5. Introductions

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

7. Module 2 Agenda • Assessment and Screening • Stages of Change and Readiness to Change • Diagnosing Tobacco Dependence • Pharmacotherapy and Medical Issues • Case Studies

8. Module 2 Objectives Please refer to the list of objectives in your participant manual

9. Unit 1Assessment and Diagnosis

10. Screen and Assess for Tobacco Use Initial Assessment (Intake) Assessment is revisited many times during treatment

11. The Five A’s • Ask • Advise • Assess • Assist • Arrange

12. Reframing Language

13. Discussion How do you currently assess or evaluate patients regarding their alcohol, drug, and tobacco use?

14. Discussion What are some issues/domains that you assess with your clients through the intake assessment process?

15. Assessment Domains • Presenting problem • Family/living environment/social functioning • Educational • Employment • Medical/medications • Mental health status and symptoms • Alcohol, tobacco, and other drug use • Stage of change for each problem area • Supports & strengths

16. Sample of Screening Tools Fagerström TestforNicotineDependence Heaviness ofSmokingIndex(HSI – Questions1 and 4 of theFagerström) HONC (Hooked onNicotineChecklist)

17. Tobacco Screening Tool Review • Small Group Discussion • Review how the tool is used • Pros & Cons of each tool • Large Group Discussion PM 16 - 20

18. CO Monitor Immediate feedback Immediate measure of success Additional assessment tool

19. 40% 40% 20%

21. Stages of Change Vary By Problem Stage of change vary for each problem and substance used. Patients may be willing/unwilling to: • Become abstinent from tobacco • Attempt to reduce tobacco use • Take tobacco medications to mange withdrawal • Make major lifestyle changes to avoid relapse

22. Assessing Readiness, Willingness, and Ability to Change Tobacco Use

23. DSM-IV-TR • Criteria for Substance Dependence • Criteria for Nicotine Dependence (305.1) a.k.a. Tobacco Dependence • Criteria for Nicotine Withdrawal (292.0) PM 30 - 32

24. Unit 2Tobacco Treatment Medications

25. Evidence-Based Practices Clinical Practice Guideline 2008 Update: • Nicotine-based medications are effective • Non-nicotine medications are effective • Supportive counseling is effective • Counseling and medication is more effective than either method alone • Advise all patients to use medication, unless contra-indicated or lack of evidence of effectiveness

26. The Patch: (arrgh!) The Basics • Over-the-counter (OTC) or prescription • Different dosages available • Nicotine has no drug-to- drug interactions

27. Nicotine Patch

28. Nicotine Gum: The Basics • OTC availability • “Chew and park”- use on a fixed schedule • Absorbed through mucosa in cheek • Tailor dosage and duration to patient • No food/drink 15 minutes before and after use How not to use nicotine gum!

29. Nicotine Gum

30. Nicotine Lozenges: The Basics • Over-the-counter (OTC) • Placed under tongue or in cheek pouch (not swallowed) so that nicotine is absorbed through mucosa • Avoid food/drink 15 minutes before and after An old nicotine lozenge attempt

31. Nicotine Lozenge

32. Nicotine Nasal Spray: The Basics • Prescription only • Provides highest level of nicotine by medication and gives fastest relief of cravings • May cause nasal irritation • Carries some dependence potential

33. Nicotine Nasal Spray

34. Nicotine Inhaler: The Basics and Dosing • Actually is an oral puffer, it is not inhaled • By prescription only • Some patients report preference for inhaler due to the simulation of smoking

35. Nicotine Inhaler (Oral Puffer)

36. Prescription non-nicotine drugs: Bupropion SR • Trade names Zyban and Wellbutrin; FDA approved • Failed success with NRT alone? Depression after stopping tobacco? • Side effects: insomnia, dry mouth, and weight loss • Not for pregnant women, people with seizures, recent sedative withdrawal, or eating disorder

37. More about Bupropion • Doubles abstinence rates when compared to placebo • Effective for smoking even when patient’s depression remains unchanged • No worsening of psychotic symptoms reported • FDA requires black box warning for adverse effects

38. Still MORE about Bupropion: dosing • 150 mg every morning x 3 days; then 150 mg x 2 (300 mg) per day • 7-12 weeks, up to 6 months

39. Prescription non-nicotine drugs:Varenicline • Non-nicotine medication approved by FDA in July 2006 (trade name Chantix) • Mechanism of action: partial agonist and antagonist of specific receptors – result is less DA release / blocks nicotine activation of receptors • Reduces nicotine craving and withdrawal

40. Varenicline, cont’d Considerations Psychiatric history Side effects: nausea, insomnia Precautions History of kidney disease Pregnancy Category C Note: Varenicline is 93% excreted unchanged from the kidneys and has no drug-to-drug interactions

41. Varenicline, cont’d Dosage 0.5mg 1x/day for 3 days & Duration 0.5mg 2x/day for 4 days 1.0mg 2x/day for 3 months Stop tobacco use on day 8 Use up to 6 months Availability Prescription only Note: FDA now requires black box warning for adverse effects

42. Second-Line Medications • Nortriptyline and Clonidine • Some evidence of effectiveness in tobacco dependence treatment, but not FDA approved for tobacco treatment • Used as off-label medications • Greater concern with potential side effects

43. Combination Medications Combinations of medication works better Clinicians should consider the use of certain combination of tobacco medications that have been identified as effective. (Fiore, Jaen, Baker, et al., 2008 Clinical Practice Guideline, 2008 Update)

44. Combination Medications, cont’d • Long-term (>14 weeks) nicotine patch plus other NRT (gum, lozenge, and/or nasal spray) • Nicotine patch plus nicotine inhaler or nasal spray • Nicotine patch plus bupropion SR • Nicotine gum or lozenge plus bupropion SR (Fiore, Jaen, Baker, et al., 2008) • Bupropion SR and varenicline (Ebbert, et al., 2009)

45. Considerations and Contraindications • Stopping use may affect other medications • Due to adverse effects of smoking, practitioners sometimes choose to use medications on a case-by-case even if effectiveness not proven • Contraindications for NRT

46. Unit 3Case Studies

48. Case Study Questions 1. Can a Fagerström score be determined? 2. Is DSM-IV-TR criteria evident for tobacco dependence and nicotine withdrawal? 3. Patient stage for tobacco use? Stage for other AOD use? 4. Key patient issues needing immediate attention? 5. Recommended treatment medications?

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