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Module 5 - Co-Occurring Disorders:
Integrating Tobacco Use Interventions into Chemical Dependence Services
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Welcome
Add Trainer Name(s)
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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
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Housekeeping
Hours of Training Breaks Restrooms Tobacco Use Policy Cell Phones Active Participation Complete Training Evaluation Form
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Introductions
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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
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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 StudiesPM 10
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Module 5 Objectives
Please review page 10 in your manual
PM 10
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Unit 1Attitudes and Beliefs, Challenges
and Barriers
PM 11
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Review
Learning points from prior modules
New knowledge or skills integrated into practice
PM 12
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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
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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
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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
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Activity #1 Confidence, Attitudes, and Beliefs
Assess your current confidence, attitudes, and beliefs about tobacco use among people with MHD and SUD
PM 15
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Debriefing Activity #1
Examining how attitudes and beliefs about tobacco, affect staff and patient behavior to examine and address tobacco use.
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Activity #2 Video - Smoke Alarm
Produced by Clubhouse of Suffolk Ronkonkoma, NY
www.clubhouseofsuffolk.com
PM 16
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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
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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
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Summary
PM 17
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
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Unit 2 Prevalence and
Co-morbidity Factors
PM 19
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Discussion
What is the frequency of patients having a co-occurring mental health disorder and substance use disorder?
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National and NYS Data
PM 20
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)
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Activity #3
PM 21 - 23
Tobacco and Co-occurring Disorders
Knowledge Activity
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1. Average Rate of Tobacco Smoking
Studies vary as to each disorder and people with some disorders have smoking rates up to 80 - 90%.
70%
About 70% of people with a mental health disorder (MHD) and/or a substance use disorder (SUD), also smoke tobacco.
PM 24
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2. Percentage of Cigarettes Consumed
About half of allcigarettes consumed in the US are bypeople with MHDand/or SUD.
Results in significant illness, death, and health disparity for two vulnerable populations.
44-46%
PM 24
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Knowledge Summary
How many of these answers did you already know?
Were there any surprises from what you just
learned?
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Biopsychosocial Approach to Substance Dependence
Tobacco dependence is a biopsychosocial disease
PM 31
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Neurobiological Factors and Neuro-chemical Effects of Tobacco/Nicotine
PM 32 - 33
• 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.
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Other Factors Affecting Tobacco Use
PM 34 - 35
• Psychological
• Behavioral
• Social
• Treatment / Recovery
• Large System (Tobacco Industry, Media, etc).
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Interaction between Tobacco Dependence and Other Substance Use Disorder
PM 36
Other Substance Use DisorderTobacco Dependence
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Interaction between Substance Use Disorder and Mental Health Disorder
Substance Use Disorder Mental Health Disorder
PM 37
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Interaction between Tobacco Dependence Mental Health Disorder and
Mental Health Disorder Tobacco Dependence
PM 38
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Interaction between Tobacco Dependence, Mental Health Disorder, and Substance Use Disorder
Mental Health Disorder
Substance Use DisorderTobacco Dependence
PM 39
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Discussion
What are the common factors between tobacco dependence, substance use disorders, and mental health disorders?
PM 40 - 41
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Summary
All have common chemical pathways affecting the brain
All are chronic, biopsychosocial diseases
The disorders negatively interact and result in co-morbid conditions
Treatment using medication, behavioral, psychoeducation, and supportive therapies
Recovery is possible and requires lifestyle changes
PM 42
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Unit 3Treatment Strategy Review and Case
Studies
PM 43
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Tobacco Treatment Review
• First Line Tobacco Medications – OTC (patch, gum, lozenge)– Prescription (inhaler and nasal spray) – Chantix – Bupropion
• Second Line Tobacco Medications – Nortriptyline – Clonidine
PM 44
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Tobacco Treatment Review, cont’d
• Nicotine medications are well-tested and have high margin of safety.
• Tobacco medications often used incorrectly, not often enough, or doses used are too low. – As a result when people have withdrawal symptoms, they
think the medications don’t work and/or stop using them.
• Some people need higher doses of nicotine medications and/or long-term medication.
PM 45 - 47
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Tobacco Treatment Review, cont’d
PM 48
• Combinations of two or more medications works work better than a single medication.
• MI, CBT, and RPT are effective first line methods.
• Medication plus counseling is more effective, than either alone.
• Peer counseling and peer support may be helpful.
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Important Reminders
• Tobacco dependence is a biopsychosocial disease that aggravates and complicates SUDs and MHDs
• People with COD often need more engagement, andlonger and more frequent treatment
• Not addressing tobacco use for all patients sends an unhealthy and wrong message
PM 49
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Case Studies
• Three cases studies
• Read the assigned case
• Answer the questions related to that case
PM 50
61 PM 51 - 52
Case Studies
PM 53 - 54
PM 55 - 56
Smoking/Drug Chart PM 57
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Discussion of Case Study Questions
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Summary
Tobacco dependence treatment for people with MHD or COD is not different from other populations
Often requires higher intensity and frequency of treatment episodes, and often more engagement
Tobacco treatment medications are important to use along with counseling, psychoeducation, and supportive
therapies
Anticipate possible need to modify medication dosage PM 58
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Revisit Confidence, Attitudes and Beliefs
Revisit your confidence, attitudes, and beliefs from the questions posed earlier
PM 59
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Resources
The Tobacco Recovery Resource Exchange http://www.tobaccorecovery.org
E-Learning and Online Resources
OASAS http://www.oasas.state.ny.us/tobacco/index.cfm
Email: [email protected]
PM 61-62
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Workshop Evaluation
