Addressing Nicotine Addressing Nicotine Dependence in Drug Dependence in Drug

TreatmentTreatment

Kimber Paschall Richter, PhD, MPHKimber Paschall Richter, PhD, MPH

Robert M. McCool, MSRobert M. McCool, MS

University of Kansas School of Medicine, Kansas CityUniversity of Kansas School of Medicine, Kansas City

Thanks to:Thanks to:

KC Area Methadone ClinicsKC Area Methadone Clinics KU Methadone ClinicKU Methadone Clinic Paseo ClinicPaseo Clinic KCTCKCTC DRD-KCDRD-KC Bridgeway RecoveryBridgeway Recovery Rodgers SouthRodgers South

NIDANIDA Robert Wood Johnson FoundationRobert Wood Johnson Foundation CSAT OPATCSAT OPAT

Active Drug Users CAN Quit Active Drug Users CAN Quit SmokingSmoking

16,661 participants, NHSDA16,661 participants, NHSDA 1,465 used and illicit drug past month1,465 used and illicit drug past month

Most were occasional marijuana usersMost were occasional marijuana users Most Most (71%)(71%) current users smoke current users smoke 1 IN 5 1 IN 5 (21%)(21%) current users were FORMER current users were FORMER

smokerssmokers Quit rate of 23%Quit rate of 23% (% of “ever” smokers that have quit)(% of “ever” smokers that have quit)

Compared to about 50% quit rate in general Compared to about 50% quit rate in general populationpopulation

People in Treatment CAN People in Treatment CAN Quit, TooQuit, Too

550 participants, KC Metro Methadone 550 participants, KC Metro Methadone SurveySurvey

84% patients participated84% patients participated Most (77%) smoke cigarettesMost (77%) smoke cigarettes 11% were FORMER smokers, 11% 11% were FORMER smokers, 11%

NEVER smokersNEVER smokers Quit rate of 12%Quit rate of 12%

Why Quit? Why Quit?

I see my grandparents, my relatives that have all got emphysema. …They can’t go to the mall. They can’t go to dinner. … And I think why should I keep doing this shit to me. [Noah]

I don’t want to get hurt and I don’t want to hurt anyone else. … I have three babies. …I am falling asleep with cigarettes in my hand and that is the reality that I need to stop smoking. [KCTC, unidentified]

Patients That Smoke Pay the Patients That Smoke Pay the PricePrice

Addictions patients that continue to smoke Addictions patients that continue to smoke die from die from tobacco related illnessestobacco related illnesses

11-year longitudinal study of 845 addictions 11-year longitudinal study of 845 addictions patients: 51% of deaths were related to patients: 51% of deaths were related to tobaccotobacco

24-year follow-up of 405 patients from ‘60s: 24-year follow-up of 405 patients from ‘60s: death rate of smokers 4X that of non-smokersdeath rate of smokers 4X that of non-smokers

Can We Help MORE Quit? Can We Help MORE Quit? (Sussman 2002)(Sussman 2002)

24 studies24 studies 9 inpatient, 5 newly “sober”, 5 sober several 9 inpatient, 5 newly “sober”, 5 sober several

years, 3 teen inpatients, 2 opioid/cocaine years, 3 teen inpatients, 2 opioid/cocaine outpatient outpatient

Generally small sample sizes, descriptiveGenerally small sample sizes, descriptive OutcomesOutcomes

Inpatient no higher than 12% abstinent, 6 monthsInpatient no higher than 12% abstinent, 6 months Outpatient as high as 25%, 1 yearOutpatient as high as 25%, 1 year Sober several years – up to 46% abstinent, 1 yearSober several years – up to 46% abstinent, 1 year

2003 study: Past alcohol problems do not predict 2003 study: Past alcohol problems do not predict worse smoking cessation outcomes (Hughes et al.)worse smoking cessation outcomes (Hughes et al.)

Helping Methadone Patients Helping Methadone Patients Quit Quit

Shoptaw et al., 2002Shoptaw et al., 2002 2X2 design, 175 patients2X2 design, 175 patients 12 weeks of treatment12 weeks of treatment all got patches, were assigned to a mix of relapse all got patches, were assigned to a mix of relapse

prevention and contingency management prevention and contingency management up to 36% quit during treatment, most relapsed up to 36% quit during treatment, most relapsed

afterwardsafterwards tobacco free=drug freetobacco free=drug free

Ongoing studiesOngoing studies Clinical Trials Network patch study (Malcolm Reid, PI)Clinical Trials Network patch study (Malcolm Reid, PI) Rhode Island Patch Study (Michael Stein, PI)Rhode Island Patch Study (Michael Stein, PI)

Breathe Easy Breathe Easy (Ongoing pilot study, Richter et (Ongoing pilot study, Richter et

al.)al.)

28 patients from 5 local clinics28 patients from 5 local clinics Dual pharmacotherapy, counseling Dual pharmacotherapy, counseling

Bupropion – 7 weeksBupropion – 7 weeks Nicotine gum – 12 weeksNicotine gum – 12 weeks

20% were quit at 6 months20% were quit at 6 months Excellent attendance – 85% of all Excellent attendance – 85% of all

appointments were made, 2 lost to appointments were made, 2 lost to follow upfollow up

Who Treats Patients, Why & Who Treats Patients, Why & Why Not? Why Not?

Which clinics provide services, what Which clinics provide services, what services do they provide?services do they provide? What clinics do/don’t provide servicesWhat clinics do/don’t provide services Understand barriers, benefits for clinicsUnderstand barriers, benefits for clinics Understand covert/overt pro-smoking forcesUnderstand covert/overt pro-smoking forces How well clinics adhere to guidelines for How well clinics adhere to guidelines for

treating nicotine dependence (5 A’s)treating nicotine dependence (5 A’s) Help policymakers support clinicsHelp policymakers support clinics

Services Provided, Past 30 Services Provided, Past 30 DaysDays

0

10

20

30

40

50

60

70

% P

rov i

ding

ser

vice

to a

t lea

st 1

pat

i ent

Brief A

dvice

Counseling

GroupsNRT

Zyban

Referra

l

Brochure

Acupunct.

Most Important Barrier to Most Important Barrier to Providing Smoking Cessation Providing Smoking Cessation

ServicesServices

Staff not trained Staff not trained Patients not Patients not

interested interested Other drug treatment Other drug treatment

more importantmore important Not enough staffNot enough staff Clinic does not receive Clinic does not receive

reimbursementreimbursement

Staff are too busy Staff are too busy Staff smoke Staff smoke

cigarettes cigarettes Smoking treatment Smoking treatment

is ineffectiveis ineffective OtherOther

Name 3 Clinic Benefits From Name 3 Clinic Benefits From Providing Smoking Cessation Providing Smoking Cessation

ServicesServices Improve health of all Improve health of all Permit more comprehensive servicesPermit more comprehensive services Improve drug treatment Improve drug treatment Monetary/financial benefits for clinic/patient Monetary/financial benefits for clinic/patient Cleanliness, Aesthetics Cleanliness, Aesthetics Improved education for clinic or patient Improved education for clinic or patient No benefit or unclear benefit No benefit or unclear benefit

Total comments = 593Total comments = 593

Lessons LearnedLessons Learned

People in recovery CAN quit smokingPeople in recovery CAN quit smoking Methadone clinics DO help with quittingMethadone clinics DO help with quitting

But not routinelyBut not routinely There ARE barriers to offering servicesThere ARE barriers to offering services There are also BENEFITS to offering There are also BENEFITS to offering

servicesservices

RecommendationsRecommendations

Need culture change to create more Need culture change to create more support & encouragement for quitting support & encouragement for quitting

Regulatory agencies could Regulatory agencies could require/encourage clinics to >in some require/encourage clinics to >in some way< address nicotine addiction among way< address nicotine addiction among stable patientsstable patients

Methadone clinics need CEUs – offer Methadone clinics need CEUs – offer Nicotine Dependence Treatment Training!Nicotine Dependence Treatment Training!

Could find clinics that are already doing it, Could find clinics that are already doing it, empower them to disseminate programsempower them to disseminate programs