Pharmacotherapy CAN-ADAPTT Guideline Webinar Series March 1, 2011

1. PharmacotherapyCAN-ADAPTT Guideline Webinar SeriesMarch 1, 2011 Lead: Peter Selby, MBBS, CCFP, MHSc, FASAM

2. Bio and Disclosures • Peter Selby is Clinical Director, Addictions Program and Head of the Nicotine Dependence Clinic at the Centre for Addiction and Mental Health (CAMH). He is an Associate Professor in the Departments of Family and Community Medicine, Psychiatry and Public Health Sciences at the University of Toronto. • Previous funds from Schering Canada to provide buprenorphine training (2000) • Paid consultant and advisory board member- Pfizer consumer health care Canada, Pfizer Inc, Canada, Sanofi-Synthelabo, Canada, GSK, Canada. Genpharm and Prempharm, Canada, CTI. • Grants: Health Canada, SFO, CIHR • NO TOBACCO INDUSTRY FUNDS

3. Guideline Development Group Peter Selby, MBBS, CCFP, MHSc, FASAM; Gerry Brosky, MD, MSc, CCFP; Charl Els, MBChB, FCPsych, MMed Psych (cum laude), Cert. ASAM, MRO; Rosa Dragonetti, MSc; Sheila Cote-Meek, BScN, MBA, PhD; Jennifer O’Loughlin, PhD; Paul McDonald, PhD, FRSPH; Alice Ordean, MD, CCFP, MHSc; Robert Reid, PhD, MBA

4. CAN-ADAPTT • Guideline development, dissemination and engagement project • Integrates practice, policy and research in a collaborative smoking cessation network • Goal: To inform the development of a Pan-Canadian clinical practice guideline (CPG) for smoking cessation Funded by the Drugs and Tobacco Initiative, Health Canada

5. Practice-informed Research Agenda National Network RESEARCH PRACTICE Clinical Practice Guideline Dissemination & Engagement Knowledge Translation

6. 5 Guidelines Included Version 1.0 February 2009 Initial LITERATURE REVIEWfor existing Clinical Practice Guidelines COMPREHENSIVE LITERATURE SEARCH 87 Guidelines Found Appraisal: AGREE 4 independent reviewers (practicing physicians) All formally trained on AGREE instrument Highest scoring CPG’s included 6 Guidelines Included Appraisal: AGREE Plus 8 Additional questions developed by CAN-ADAPTT to understand the applicability of the recommendations in the Canadian context The CAN-ADAPTT program engaged the Guidelines Advisory Committee HIGH QUALITY CLINICAL PRACTICE GUIDELINES U.S. Department of Health and Human Services Public Health Service: Treating Tobacco Use and Dependence (2008 Update), New Zealand Smoking Cessation Guidelines (August 2007), Registered Nurses Association of Ontario: Integrating Smoking Cessation into Daily Nursing Practice (March 2007), Registered Nurses Association of Ontario: Integrating Smoking Cessation into Daily Nursing Practice (October 2003), Institute for Clinical Systems Improvement. Tobacco use prevention and cessation for infants, children and adolescents (June 2004), Institute for Clinical Systems Improvement Tobacco use prevention and cessation for adults and mature adolescents (June 2004).

7. HIGH QUALITY CLINICAL PRACTICE GUIDELINES • Clinical Approaches • 7 clinical sections discussed • Workshop held: November 1, 2009 • 100 CAN-ADAPTT members attended and provided feedback • The Guideline Development Group (GDG) reviewed the section notes and determined revisions to the summary statements. Population Level approaches Sections: Population level approaches to tobacco cessation in Canada Workshop/AGM: Oct 1st, 2010 • Levels of Evidence • Attributed levels of evidence and grades of recommendation to each summary statement based on GRADE principles Input from CAN-ADAPTT Network Spring – Summer 2010 Network Input Network input Version2.0 Currently Posted Version 3.0 Release Date January 2011

8. Guideline Development Applied principles of ADAPTE… Review existingCPGs Highest-scoring CPGs included Ongoing input from CAN-ADAPTT network GRADE framework used Grade of Recommendation High Low Strong Level of Evidence Weak

9. Pregnant and Breastfeeding Women/ Femmes enceintes et qui allaitent Youth (Children and Adolescents)/ Jeunes (enfants et adolescents) Mental Health and/or Other Addictions/ Santé mentale et/ou autres dépendances Aboriginal Peoples/ Autochtones Hospital-based populations/ Populations des hôpitaux

10. Ask about tobacco use: How much do you smoke? 0 - ___ cigarettes per day (cpd)? (one large pack = 25 cpd, one small pack = 20 cpd) Yes Advise: As your physician, I am concerned about your tobacco use, and advise you to quit. Would you like my help? Assess Readiness: Given everything going on in your life, on a scale of 0-10, where 0 is lowest… How important is it for you to quit smoking? How confident are you that you can quit smoking? • Motivational Interviewing • Assess the 5 R’s: • Relevance • Rewards • Risk • Roadblocks • Repetition No Yes Low importance or confidence (≤ 5) Assist in Quit Attempt: Would you like to quit abruptly? High importance or confidence (>5) No Have you tried quitting cold turkey? Cold Turkey Yes No Reduce to Quit (RTQ) Step 1: (0-6 weeks) - Smoker sets a target for no. of cigarettes per day to cut down and a date to achieve it by (at least 50% recommended) - Smoker uses gum to manage cravings Step 2: (6 weeks up to 6 months) - Smoker continues to cut down cigarettes using gum - Goal should be complete stop by 6 months - Smoker should seek advice from HCP if smoking has not stopped within 9 months Step 3: (within 9 months) - Smoker stops all cigarettes and continues to use gum to relieve cravings Step 4: (within 12 months) - Smoker cuts down the amount of gum used, then stops gum use completely (within 3 months of stopping smoking) Yes No response Pharmacotherapy Algorithm for Tailoring Pharmacotherapy in Primary Care Settings

11. Has NRT failed? Y/N Is weight gain a concern? Y …History of seizures? N ...History of unstable mental illness? N …Eating disorder? N ...Allergic to bupropion? N ...Previous non-responder? N …Want to quit in 7 days? N = Bupropion SR Has bupropion/NRT failed? Y Is weight gain a concern? N …History of unstable mental illness? N ...Allergic to Varenicline? N ...Previous non-responder? N Want to quit within 7 days? N = Varenicline Has bupropion/NRT failed? N Is weight gain a concern? N Want to quit within 7 days? Y = NRT (Gum, Patch, Lozenge or Inhaler) @ 4 weeks Partial response Choose the following combinations: 1. Two or more forms of NRT a. patch (15mg) + gum (2mg) b. patch + inhaler c. patch + lozenge 2. Bupropion + form of NRT a. Bupropion + patch b. Bupropion + gum No Varenicline with NRT Arrange Follow Up 1. Monitor carefully 2. Consider contraindications 3. Consider comorbidities and specific pharmacotherapy 4. Consider dual purpose medications 5. If after 4 weeks no response, consider alternative 1st line medications.* Developed by Peter Selby, MBS, CCFP. This algortihm is based on: Bader, McDonald, Selby, Tobacco Control, 2009; 18:34-42. Fiore MC et al., Clinical Practice Guideline: Treating Tobacco Use and Dependence, May 2008. Gray, Therapeutic Choices: 5th Ed., 2007, Chapter 10: 147-157. Version 2, revised December 8, 2010. *N.B. for 2nd line medications (clonidine and nortriptyline), see guidelines. Consider combination pharmacotherapy, based on: 1. failed attempt with monotherapy 2. breakthrough cravings 3. level of dependence 4. multiple failed attempts 5. experiencing nicotine withdrawal

12. Have additional feedback? • Join the network • Review the current version of the guideline • Provide your feedback online • Clinical considerations; tools/resources

13. For more information CAN-ADAPTT Centre for Addiction and Mental Health 175 College St. Toronto, ON M5T 1P7 T: 416-535-8501 ext. 7427 www.can-adaptt.net Note:These presentation slides may be used or reproduced for educational purposes only. Please acknowledge authorship of this content to CAN-ADAPTT and CAMH.