Transcript by Treatment - 2005 National Conference on Tobacco or Health

Treating Nicotine Dependence in
Smokers with Mental Illness and
Chemical Dependencies
Lirio S. Covey, Ph.D.
David Kalman, Ph.D.
Taru Kinnunen, Ph.D.
Kimber Richter, Ph.D.
Jill M. Williams, M.D.
Nancy Kaufman, M.A.
Today’s Goals
• The nature of nicotine dependence
• Nicotine dependence and psychiatric comorbidity
• Smoking cessation and psychiatric disorders
• Treatments
Today’s Goals
• The nature of nicotine dependence
• Nicotine dependence and psychiatric
comorbidity
• Smoking cessation and psychiatric disorders
• Treatments
The long-standing view:
Tobacco Use Is a Health Risk Factor




Cardiovascular disease
Cancer of multiple organ sites
Pulmonary Disorders
Fetal/infant/childhood morbidity &
mortality through second-hand smoke
Evolved view:
Tobacco Use Is a More than a Risk Factor
Tobacco use, in particular, chronic use
of tobacco, is a disorder in itself.
Nicotine Is a drug that affects
functioning and structure of the brain.
Nicotine Is a Drug: Neurochemical
Effects of Nicotine
DOPAMINE
Pleasure, Appetite Suppression
NOREPINEPHRINE
Arousal, Appetite Suppression
ACETYLCHOLINE
Arousal, Cognitive Enhancement
NICOTINE
Mood Appetite suppression
SEROTONIN
VASOPRESIN
Memory Improvement
BETA-ENDORPHIN
Reduction of Anxiety, Tension
A substance dependence disorder
Nicotine
Tolerance
Heroin
Cocaine
Alcohol
+
+
+
+
+
+
+
+
+
+
+
+
Difficulty quitting or
cutting down
+
+
+
+
Much time spent to
obtain the substance
+
+
+
+
Important activities given
up
+
+
+
+
Continued use despite
harmful consequences
+
+
+
+
Withdrawal
Taken in larger amounts
or longer than intended
Today’s Goals
• The nature of nicotine dependence
• Nicotine dependence and psychiatric
disorders
• Smoking cessation and psychiatric disorders
• Treatments – what works?
 Higher prevalence of tobacco use
among persons with mental illness.
 Multiple mental disorders are involved:
Alcohol and drug dependence
Depression
Anxiety disorders (GAD, phobias, PTSD)
Schizophrenia
Antisocial personality disorder
Conduct disorder and ADHD
Smoking and Mental Illness,
Lasser K et al, JAMA, 2000
 In the U.S., 20% have a lifetime history
of a medical condition
 44% of all cigarette smoking done by
persons with lifetime history of mental
illness.
Current Smokers by Mental Illness
History, Lasser et al, JAMA, 2000
45
40
%
35
30
25
20
15
10
22.5
34.8
41.0
5
0
None
Ever Ill
Past Month
Quit Rates by Mental Illness History
Lasser et al, JAMA, 2000
45
40
35
30
25
42.5
37.1
20
30.5
15
10
5
0
None
Ever Ill
.
Past month
Prevalence of Current Smoking
Lasser, JAMA, 2000
50
45
40
35
%30
25
20
15
10
5
0
Major
Depression
Alcohol
Drug
Dependence Dependence
Psychosis
No Mental
Illness
16.9
21.5
11.4
0.6
50.7
Per cent prevalence of the condition in US population
Prevalence of Current Smoking
Lasser, JAMA, 2000
50
45
40
35
%30
25
20
15
10
5
0
GAD
PTSD
Simple
Phobia
Panic
Attacks
No Mental
Illness
4.8
6.4
11.0
6.5
50.7
Percent prevalence of the condition in the US population
Major Depression
Alcohol Dependence
Drug Dependence
Schizophrenia
Major Depression
• More smokers among depressed persons
• More depression among smokers
• Higher nicotine dependence level
– Often smoke more cigarettes
– Harder time quitting
– More intense withdrawal symptoms
• Treatments
Eversmoking by MDD hx and gender
St. Louis ECA (n=3213)
80
p<.001
p<.001
70
%
60
50
No MDD
MDD
40
30
20
10
0
Men
Glassman, et al, JAMA, 1990
Women
Odds ratios for psychiatric diagnoses by nicotine
dependence ,1200 adults, 21-30 yrs
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Mild
Moderate
MDD
Anxiety
Breslau et al, 1992
Substance
Dep
Major Depression
• More smokers among depressed persons
• More depression among smokers
• Higher nicotine dependence level
– Often smoke more cigarettes
– Harder time quitting
– More intense withdrawal symptoms
• Treatments
Influence of Depression History on
One Year Cessation (Week 52) by Treatment
35
30
25
20
Bupropion
No Bup
15
10
5
0
No MDD
MDD Hx
Smith, Nicotine & Tobacco
Research 2003
Incidence of major depressive episodes in
3-month follow-up of 126 abstinent smokers
30
25
20
15
10
5
0
No MDD
Single MDE
p=<.001,
Covey et al, Am J Psychiatry, 1997
Recurrent MDE
Nicotine withdrawal symptoms:
intensity at week 1 after quit day
4
3.5
MDD
No MDD
3
2.5
p<.05
2
p<.0
1
1.5
1
0.5
0
cravin
anxiou restles
g
irritable
s
s
Covey et al, Comp Psychiatry,1991
appetit
e
concentr
depresse
d
Major Depression
• More smokers among depressed persons
• More depression among smokers
• Higher nicotine dependence level
– Often smoke more cigarettes
– Harder time quitting
– More intense withdrawal symptoms
• Treatments
Treatments that work for smokers
with Major Depression
•
•
•
•
Bupropion (Zyban)
Nortriptyline
Nicotine replacement
Mood-oriented Cognitive Behavioral
Therapy
Long-term quit rates among smokers
with past MDD
35
33%
30
25
29%
20
15
15%
10
5
8%
Active
Placebo
15%
6%
0
Bupropion
Smith et al, 2003
Nortriptyline
Hall et al, 1998
NRT
Kinnunen et al, 2003
Recommendations
 Smokers with past major depression can
quit.
 They will need more intensive and,
possibly, longer treatments.
 More information is needed for smokers
who are currently depressed.
Alcohol Dependence
• Higher rates of current smoking
• In clinical settings, 85% to 90% are smokers
• Many want to quit (up to 100% in one clinical
study)
– Quit rates in recovering groups same as
nonalcoholics
– Quit rates in active drinkers lower than in
nonalcoholics
• No evidence of relapse to drinking upon
tobacco abstinence
Alcohol Dependence
• Higher rates of current smoking
• In clinical settings, 85% to 90% are smokers
• Many want to quit (up to 100% in one clinical
study)
– Quit rates in recovering groups same as
nonalcoholics
– Quit rates in active drinkers lower than in
nonalcoholics
• No evidence of relapse to drinking upon
tobacco abstinence
Alcohol Dependence
• Higher rates of current smoking
• In clinical settings, 85% to 90% are smokers
• Many want to quit (up to 100% in one clinical
study)
• Quit rates in recovering groups same as
nonalcoholics
• Quit rates in active drinkers lower than
in nonalcoholics
• No evidence of relapse to drinking upon
tobacco abstinence
What treatments work for
Alcohol Dependent smokers?
• Bupropion (Zyban) same results as for
nonalcoholic smokers
• Nicotine replacement agents
• Cognitive behavioral treatment for mood
management helps alcoholic smokers
with history of major depression
• 12-step program enhanced effect of
standard counseling treatment
How effective is smoking cessation treatment
for smokers in recovery?
• Over 25 studies to date
• Most studies focused on either smokers in early
recovery (< 3 months) or later recovery (> 1 year)
• Treatment included behavioral counseling and
medication (nicotine replacement, bupropion)
• Rates of successful quitting
– about 10% for smokers in early recovery
– about 25% for smokers in later recovery
How effective is smoking cessation
treatment for smokers in recovery?
25
20
15
10
5
0
Early Recovery < 3 months
Later Recovery > 1year
Effect of Trying to Quit Smoking on Sobriety,
Joseph et al, 2003
• 499 smokers in alcohol dependence
treatment
• Smoking treatment (counseling + NRT)
• Concurrent or delayed (6 months)
• Outcomes - smoking and drinking status
Outcomes at 12 months from concurrent
smoking and alcohol treatment,
Joseph et al, 2003
80
70
60
50
Concurrent
Delayed
40
30
20
10
0
Quit Smoking
Quit drinking
Smoking Abstinence (7-day Point
Prevalence) by Nicotine Patch Dose
(N=130), Kalman, 2002
35
30
25
Percent 20
Abstinent 15
21-mg
42-mg
10
5
0
1 week
12 weeks
Follow up
24 weeks
7-day point prevalence quit rates by length of
abstinence from alcohol (N=130), Kalman, 2002
50
45
40
35
30
Percent
25
Abstinent
20
15
10
5
0
2 to 4 months
3 to 5 months
6 to 11 months
12 or more months
1 week
12 weeks
Follow up
24 weeks
Future Research
•
•Factors affecting smoking cessation outcomes for
alcoholics in early recovery
– Saturated social network of smokers?
– Combination pharmacotherapies (e.g., bupropion plus
naltrexone)
– More frequent smoking cessation counseling.
Drug Dependence
• High rates of current smoking
–
–
–
–
70% in cannabis dependent
75% in cocaine dependent
85%-98% in methadone-maintained
Extremely high levels of nicotine dependence
• Claim that quitting smoking is hardest
• Strong levels of interest in quitting
Drug Dependence
• High rates of current smoking
–
–
–
–
70% in cannabis dependent
75% in cocaine dependent
85%-98% in methadone-maintained
Extremely high levels of nicotine dependence
• Claim that quitting smoking is hardest
• Strong levels of interest in quitting
Drug Dependence
• High rates of current smoking
–
–
–
–
70% in cannabis dependent
75% in cocaine dependent
85%-98% in methadone-maintained
Extremely high levels of nicotine dependence
• Claim that quitting smoking is hardest
• Strong levels of interest in quitting
Drug Dependence
• High rates of current smoking
–
–
–
–
70% in cannabis dependent
75% in cocaine dependent
85%-98% in methadone-maintained
Extremely high levels of nicotine dependence
• Claim that quitting smoking is hardest
• Strong levels of interest in quitting
Limited knowledge base on smoking
cessation treatments for smokers with
drug dependence.

 Specially needed are studies that will
clarify the bidirectional dynamic between
tobacco dependence and drug
dependence.
Review paper, Sullivan and Covey, Current Psychiatry
Reports, 2002
Methadone – Great Place to Start
Richter, 2003
• Medically oriented, not anti-pharmacotherapy
• Patients get stable, can think long-term
• Many patients are over 30 - many start having
tobacco-related illnesses, so do friends
• Patients stay in treatment for long periods, visit
clinics regularly, develop relationships with staff
• Methadone has consistent treatment guidelines
and a strong national network (good for
dissemination)
How to Start?
•
•
•
•
•
•
•
What are the best treatments?
When to treat?
What do patients want/have tried?
How to prevent relapse to other drugs?
What are providers doing now?
What do they find works best?
Etc.
Percent service provided to at
least 1 patient in the Past 30 Days
70
60
50
40
30
20
10
0
Most Important Barrier to Providing
Smoking Cessation Services,
Richter, 2003
• Staff not trained (118)
• Patients not interested
(111)
• Other drug treatment
more important (78)
• Not enough staff (58)
• Clinic does not receive
reimbursement (49)
• Staff are too busy (36)
• Staff smoke cigarettes (20)
• Smoking treatment is
ineffective (7)
• Other (33)
Lessons Learned
• There ARE barriers to offering services
– #1 is lack of staff training
– #2 is perception that patients aren’t interested
• There are also BENEFITS to offering services
– Improve health, outcomes, cleanliness
• Few clinicians actively discourage/delay quitting
• Perceptions that some patients appear to benefit
from smoking (may explain why cessation
treatment is not always offered?)
Recommendations
• Regulatory agencies could require/encourage
clinics to in some way address nicotine addiction
among stable patients
• Methadone clinics need to offer Nicotine
Dependence Treatment Training!
• Find clinics that are already doing it, empower
them to disseminate programs
• Address benefits of tobacco use and alternate
treatments for mood disorders
Schizophrenia
• High prevalence of smoking – 80-95%
• Very low rates of complete abstinence
• Smoking ameliorates symptoms
• Smoking ameliorates medication side
effects
• Responsive and tolerant to NRT and
bupropion
Schizophrenia
• High prevalence of smoking – 80-95%
• Very low rates of complete abstinence
• Smoking ameliorates symptoms
• Smoking ameliorates medication side
effects
• Responsive and tolerant to NRT and
bupropion
Schizophrenia
• High prevalence of smoking – 80-95%
• Very low rates of complete abstinence
• Smoking ameliorates negative symptoms
– E.g., cognitive dysfunction
• Smoking ameliorates medication side effects
• Responsive and tolerant to NRT and bupropion
Schizophrenia
• High prevalence of smoking – 80-95%
• Very low rates of complete abstinence
• Smoking ameliorates symptoms
• Smoking ameliorates medication side
effects
• Responsive and tolerant to NRT and
bupropion
Schizophrenia
•
•
•
•
High prevalence of smoking – 80-95%
Very low rates of complete abstinence
Smoking ameliorates symptoms
Smoking ameliorates medication side
effects
• Responsive and tolerant to NRT and
bupropion
Clinical Trial (Ziedonis et al, 1997)
•
•
•
•
•
24 Patients
Received NRT, behavioral counseling
Patients interested in participating
No worsening of psychiatric disorder
50% completed 10 week program
13% abstinent for 24 weeks
Clinical Trial, Addington, 1997,
50 Subjects, 7 weeks group counseling
10 weeks of NRT (patch)
- 42% abstinent at 7 weeks
- 16 % abstinent at 12 weeks
- 12% at 24 weeks
No change in symptoms of schizophrenia
No great difficulty in having schizophrenics use the patch
Percent abstinent in clinical Trial with Nicotine
Patch and Group Counseling, Addington, 1997,
45
40
35
42%
30
25
Smokers with
Schizophrenia (50)
20
15
16%
10
12%
5
0
Week 7
Week 10
Week 24
Bupropion and CBT, Evins et al,
• 12 weeks Bupropion/placebo and weekly
group counseling (n=19 subjects)
• Abstinence verified by CO<9 ppm
• Smoking reduction:
66% in bupropion vs. 11% in placebo
• 1 patient on Bupropion quit smoking
• No difference in positive symptoms
Conclusions
• It is possible for individuals with
schizophrenia to stop smoking.
• Nicotine replacement treatment
and bupropion are helpful
cessation aids for patients with
schizophrenia.
Future directions: Overcoming
traditional barriers to smoking cessation
for smokers with mental illness
• Presumption of low interest in quitting.
• Fear that tobacco withdrawal may
exacerbate current symptoms or provoke
new episodes.
• Need for evidence-based treatment
approaches particularly for currently ill.