Transcript The Anxiety Disorders Some Practical Questions & Answers

Tobacco
Use Disorder
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process1
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
September 21, 2012
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This presentation is designed as a problem-based learning module.
Why is this important?
• Scioto County has the highest
smoking rate in the United
States! (36%!)
• Tobacco kills more people each
year than anything else.
• Secondhand smoke causes 10%
of the tobacco-related deaths.
• Nonsmokers live more than a
dozen years longer than
smokers.
• Nicotine is highly addictive.
• About 20% of us smoke.
• Many more are affected by that
smoke.
• Our progress in decreasing
smoking has stalled.1
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• After listening to this
presentation, you will be able
to answer the following
questions:
– Why is this important?
– What are the diagnostic criteria?
– How many people does smoking
kill each year?
– What are some of the
demographics of tobacco use
disorder?
– What counseling techniques are
helpful?
– What medications are helpful?
– What excuses do we physicians
make for not engaging these
patients more?
Young people often start smoking because they still view smoking as cool.
What current diagnoses are included
in this category?
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Nicotine Dependence
Nicotine Withdrawal
Nicotine-Related Disorder NOS
In DSM-5, these will likely be replaced
with Tobacco Use Disorder and
included in the Substance Use
Disorders category.
What are the diagnostic criteria?1
• Problematic pattern of tobacco use causing significant
impairment or distress
– Tobacco used longer than intended
– Unsuccessful efforts to cut down usage
– A great deal of time consumed by tobacco-related activities
and complications
– A tobacco-related failure to fulfill obligations at school,
work or home
– Continued tobacco use in spite of the problems it causes
– Tobacco use negatively impacts social, occupational or
recreational activities
– Recurrent use when physically hazardous
– Continued use in spite of tobacco-related complications
– Tolerance
– Withdrawal
– Craving
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These are the proposed DSM-5 criteria.
How many people does smoking kill
each year?1
Other Cancers 35,300
Stroke 15,900
Other Diseases
44,000
Lung Cancer 128,900
COPD 92,900
Heart Disease
126,000
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Adapted from Rakel and Rakel, Textbook of Family Medicine and the CDC, Average Annual Number of Deaths, 2000-2004.
What are some of the key
demographics of tobacco use?1
• Few people start smoking after age 18.
• About 4000 children smoke for the first time
every day; 2/3 will become addicted.
• 70% of smokers would like to stop.
• 50% try to stop.
• Less than 5% will succeed.
• College graduates are more likely to succeed.
• Only about 6% of people with graduate
degrees smoke.
• People with mental illness smoke 70% of the
cigarettes in the United States.
• Smoking is a pestilence mostly embraced by
the poor, uneducated and mentally ill.1
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Rakel and Rakel, Textbook of Family Medicine
What about filtered cigarettes?1
• These varieties, 97% of those sold
here, are not safer.
• Those who smoke “low nicotine,
low tar” cigarettes just smoke more
of them to get the same nicotine hit.
• Likewise, “natural” and “organic”
cigarettes are just marketing ploys.
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Rakel and Rakel, Textbook of Family Medicine
What about cigars?1
• These carry the same risks as
cigarettes.
• The risk varies with the number
smoked and the degree on inhalation.
• More than 9% of men and 2% of
women smoke cigars.
• The higher pH of cigar smoke permits
nicotine absorption across the oral
mucosa.
• Cigar smokers do tend to inhale less.
• The use of alcohol multiplies the risks.
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Rakel and Rakel, Textbook of Family Medicine
What about electronic cigarettes?1
• These were developed in China in 2003.
• They contain a battery, atomizer and
cartridge with liquid nicotine, and
propylene glycol (used in antifreeze and
cosmetics)
• Flavors such as chocolate and bubblegum
are included to entice children.
• The FDA regulates them, but testing has
not yet been completed.
• Internet sales are growing.
• The price is dropping.
• These may become “harm reduction” tools
and play some helpful role.
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Rakel and Rakel, Textbook of Family Medicine
What about smokeless tobacco?1
• Snuff greatly increases the odds of cancer of
the gums and cheeks.
• About 9% of high school students use
smokeless tobacco products; it is more
popular with boys than girls
• Spitting tobacco is popular in organized
sports.
• Carcinogens are more concentrated in
smokeless tobacco than in cigarette smoke.
• Nitrosamine levels are 10,000 times greater
than in bacon and beer.
• Tobacco companies are marketing snus as an
alternative to spitting and smoking.
• Smokeless tobacco users are less successful at
quitting.
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Rakel and Rakel, Textbook of Family Medicine
What about secondhand smoke?1
• 1/3 of lung cancers are caused by living
with a smoker.
• Passive smoking is the third most
common preventable cause of death–after
smoking and drinking.
• Passive smoking increases SIDS,
respiratory infections, ear infections,
asthma and slows lung growth.
• There is no risk-free level of exposure.
• Only eliminating smoking indoors
completely protects nonsmokers.
• Cleaning rooms after smokers pollute
them is not entirely possible.
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Rakel and Rakel, Textbook of Family Medicine
What about third hand smoke?1
• Tobacco smoke reacts with nitrous acid
to produce tobacco-specific
nitrosamines—a carcinogen that
becomes more potent over time.
• It is concentrated in dust and carpeting
and is thus more harmful to children.
• Worse still, this stuff is essentially
impossible to remove.
• This danger is regularly overlooked by
parents who mistakenly think not
smoking indoors when kids are present
is safe.
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Rakel and Rakel, Textbook of Family Medicine
What counseling techniques are
helpful?1
• Assess the patient’s readiness for change and
respond accordingly:
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Pre-contemplation (not interested)
Contemplation (thinking about quitting)
Preparation (planning to quit in next 30 days)
Action (in process of quitting)
Maintenance (tobacco free for 3 months or more)
• Use motivational interviewing to build patient’s
self motivation.
• Brief counseling (<3 minutes) = 13% quit rate.
• Intensive counseling = 22% quit rate
• Prenatal care, non fatal MIs and hospitalizations
for tobacco-use complications are the best
teachable moments. Seize them!
• Study Treating Tobacco Use and Dependence:
2008 Update, a critical clinical practice guideline.
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Rakel and Rakel, Textbook of Family Medicine
What medications are helpful?1
• Nicotine Patch (Nicoderm,
Habitrol, Nicotrol, ProStep)
– Start 2 weeks before the
patient plans to quit.
– This first-line treatment is
often combined with
counseling and other
medications.
– Avoid insomnia by removing
the patch before going to
bed.
– Adding gum, the lozenge or
nasal spay for
“breakthrough” symptoms
increases the odds of success.
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Rakel and Rakel, Textbook of Family Medicine
• Nicotine Gum (Nicorette)
– Chew slowly, intermittently
and park between the gum
and cheek for a half hour.
– Avoid eating or drinking
anything but water for 5
minutes and during
administration.
– Use enough!
– Use the 4 mg strength for
those who smoke more than
1 pack per day.
– Continue the trial for at least
6 weeks.
What medications are helpful?1
• Nicotine Lozenge
(Commit)
– The effect lasts 20-30
minutes
– Do not eat or drink 15
minutes before or during
use.
– Use up to 20/day for up
to 12 weeks.
– The side effects are
similar to those with
nicotine gum (sore teeth,
throat, gums,
indigestion)
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Rakel and Rakel, Textbook of Family Medicine
• Nicotine Inhaler
(Nicotrol Inhaler)
– Use up to 16
cartridges/day for 12
weeks, then taper and
discontinue over the next
12 weeks.
– Each cartridge is
equivalent to 2
cigarettes.
– Nicotine delivery
declines in cold
temperatures.
What medications are helpful?1
• Nicotine Nasal Spray
(Nicotrol NS)
– Do not use if you have
severe restrictive airway
disease.
– Do not sniff, inhale or
swallow when you spray.
– Tilt your head slightly
back when spraying.
– Spray once in each
nostril up to 40
times/day for 12 weeks.
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Rakel and Rakel, Textbook of Family Medicine
• Bupropion SR
– Start 2 weeks before
quitting.
– Take 150 mg every
morning for 3 days, then
BID for 12 weeks.
– Do not use if you have a
history of head trauma,
seizures or if you have
used a MAOI in the past
14 days.
– Side effects include
nausea, bad dreams,
insomnia, headache and
flatulence.
What medications are helpful?1
• Varenicline(Chantix)
– Start 1 week before you
plan to quit.
– Take 0.5 mg daily for 3
days, then BID for 4 days,
then 1.0 mg daily for
total of 12 weeks.
– The side effects are
similar to bupropion SR.
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Rakel and Rakel, Textbook of Family Medicine
• Combination Therapy
– This may be the best
approach.
– Think of bupropion SR or
the patch as maintenance
and short-acting NRT
agents breakthrough
drugs.
– Triple therapy (patch,
bupropion SR and the
inhaler) for up to 6
months has produced the
best documented results.
What public health interventions
actually work?1
• Enforce tobacco advertising bans.
• Raise the price of tobacco products.
• Provide smokers who want to quit with the
help they need.
• Prevent unwanted exposure to secondhand
smoke.
• Publicize the health hazards of tobacco use.
• Decrease the impact of the marketers of
death.
• Increase the influence of anti-smoking forces.
• Use attention-getting warning labels.
• Read more about this problem here.
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Rakel and Rakel, Textbook of Family Medicine
What excuses do physicians make?1
• “My patients are not motivated.”
• “My patients don’t have the necessary
insurance coverage.”
• “I am not reimbursed enough for my
time when treating these people.”
• “I don’t have enough time to do this.”
• “There are not enough resources to
refer my patients to.”
• “Nothing works anyway.”
• “I’m not trained to do this; this is not
my specialty.”
• “I don’t like this kind of work.”
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Rakel and Rakel, Textbook of Family Medicine
What should you do?1
• You must be the change you want to see in
the world. Mahatma Gandhi
• Become a wellness champion and continue
that lifestyle as long as you live.
• If you smoke or use any tobacco product,
stop now.
• Support prevention efforts for kids.
• Ask every new patient about tobacco use.
• If they use, ask them to please stop.
• Inquire whether patients who are using
tobacco are ready to stop—at every visit.
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Rakel and Rakel, Textbook of Family Medicine
What else should you do?1
• Seize every teachable moment to urge
quitting.
• Make sure your users know 1-800QUITNOW (1-800-784-8669)
• Remember, the first two weeks are critical;
arrange daily phone or text follow up
contacts.
• View this as a chronic disease.
• Focus on what you can do instead of fretting
about what you can’t do.
• Never, never, ever give up.
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Rakel and Rakel, Textbook of Family Medicine
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment
plan while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition,
2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry,
2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second
Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth
Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January
2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work
and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000
Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Justin Greenlee, DO
Thomas Carter, DO
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