Transcript Alcohol and Tobacco Interventions 101: for Primary Care Physicians

Tobacco Cessation
Interventions
Lunch and Learn Seminar Series
for Physicians, Family Health
Teams, and other Health/Allied
Health Practitioners
Session 6:
Pharmacotherapies (2):
The art and science of
pharmacotherapy with
complex patients
Faculty: Dr. Bernard Le Foll,
MD, PhD
Housekeeping
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Please sign-in
Please ensure you have completed Learning Assessment 1
http://www.surveymonkey.com/s/fhtsept2011la1
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A link to Learning Assessment 2 will be sent by e-mail
Both Learning Assessments are required for the Letter of
Completion
If you haven’t already, please dial-in via audioconference
Conference #: 1-800-669-6180
Participant Code: 925619
The Adobe Connect webinar will remain ON until 1:00 pm
Dr. Bernard Le Foll, MD, PhD
[email protected]
(416) 535-8501 ext. 4772
Dr Bernard Le Foll, MD PhD is a clinician-scientist specialized in drug addiction.
He is Head of the Translational Addiction Research Laboratory at the Centre for
Addiction and Mental Health and Associate Professor at University of Toronto in
the Departments of Family and Community Medicine, Psychiatry, Pharmacology
and Institute of Medical Sciences. Its clinical activity is centered on tobacco
dependence at the Nicotine Dependence Clinic at CAMH and on alcohol addiction
at the Alcohol Dependence Clinic that he recently set up at the CAMH. He received
specialized training in drug addiction and behavioral and cognitive therapy at Paris
University in France. He has written the French smoking cessation guideline and
has been coordinator of clinical trials for treatment of tobacco dependence in
France and in Canada. He obtained a PhD in Pharmacology at INSERM and has
performed a Fogarty Visiting Fellowship at the National Institutes of Health. His
research evaluates novel therapeutic approaches using a combination of
preclinical, clinical, genetic and brain imaging approaches. He has received
scientific prizes and awards from the French Academy of Medicine, the American
College for Neuropsychopharmacology, the College on Problems on Drug
Dependence, the National Institutes of Health, the Society for Research on
Nicotine and Tobacco, Pfizer, OPGRC, the Heart and Stroke Foundation, Ontario
Lung Association, the Canadian Institutes for Health Research and NARSAD.
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Disclosures
Dr. Bernard Le Foll
BLF is supported by CAMH
Dr Le Foll’s research support:
CAMH
Ontario Ministry of Innovation
Canadian Fondation for Innovation,
Canadian Tobacco Control Research Initiative
Pfizer GRAND Award 2008, 2009, 2010
Pfizer Cardio-vascular Research Award
CIHR training program
OPGRC
Ontario Lung Association
Heart and Stroke Foundation
CIHR Operating Grant_Catalyst Grant
NIH-NIDA
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The recipient of the funding is in
compliance with the CMA and the
CPA guidelines / recommendations
for interaction with the
pharmaceutical industry.
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Disclaimer
These materials (and any other materials provided in
connection with this presentation) as well as the
verbal presentation and any discussions, set
out only general principles and approaches to
assessment and treatment pertaining to tobacco
cessation interventions, but do not constitute
clinical or other advice as to any particular
situations and do not replace the need for
individualized clinical assessment and treatment
plans by health care professionals with knowledge
of the specific circumstances.
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Disclaimer: TEACH Curriculum Development
The TEACH Curriculum and slides were developed and compiled with funding
from the Government of Ontario, Ministry of Health Promotion. Content of
slides are primarily based on evidence based guidelines including:
US Guidelines Treating Tobacco Use and Dependence: clinical Practice
Guideline 2008 Update. US Department of Health and Human Services,
Public Health Service
Rethinking Stop-Smoking Medications: Treatment Myths and Medical
Realities OMA Position Paper, January 2008.
The development or delivery of the TEACH curriculum was not influenced or
funded in any part by tobacco industry. TEACH has not received funding
from the tobacco industry. The development of the TEACH curriculum has
not been influenced by pharmaceutical industry. TEACH project did receive a
$10 000 unrestricted grant from Pfizer, to develop video vignettes that are
used in our training. Information presented on pharmacotherapy refers to
generic products only, and recommendations are based on existing
research, including the US guidelines. An algorithm is provided to help
practitioners determine if and which pharmacotherapy is appropriate for a
smoker.
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Session 6: Learning Objectives
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2.
3.
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Identify medication issues and concerns for
patients with complex issues.
Develop and monitor treatment plans for
these patients.
Access additional consultation/resources.
The Highly Complex Client
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The Highly Complex Patient:
Lessons Learned
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Traditional Health Care Model
Heart
Disease
Diabetes
COPD
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Osteoporosis
Depression
Integrated Health Promotion
MODIFIABLE
BEHAVIOURAL RISK
FACTORS
Smoking
Physical activity
Alcohol and other
substances
Nutrition
Stress Tolerance
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INTERMEDIATE
PHYSICAL /
PHYSIOLOGICAL RISK
FACTORS
SELECTED
CHRONIC
DISEASES
High blood pressure
CVD
Cholesterol /
lipids
Diabetes
Glucose intolerance
Cancer
Overweight /
obesity
Mental health
Traditional Model:
Patient & HCP Roles
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The Patient-HCP Partnership
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Patient Self-Management Approach
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Support Patients to Become Positive Self
Managers
Building Self Efficacy
The Chronic Disease Self-Management Program Leaders Manual,
Canadian Edition (2006)
Patient Self-Management:
Goal Setting
S.M.A.R.T. Goals
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•
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Specific
Measurable
Attainable
Realistic
Time Framed
Action Plans
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Complex Patients - Case Studies
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For the next section we will work through three
unique case studies
Following each case description is a series of
questions to reflect on
I will go through the case and provide feedback
on how to work with the complex patient
Please feel free to offer your suggestions in the
chat box
Q&A will follow each case
Case Study: Carolyn
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Case Study: Carolyn
Age: 48 years old
Gender: Female
Occupation: Unemployed
Relationship Status: Single
Carolyn is a 48-year-old female with schizophrenia who reports regular smoking since age 14. She
is on clozapine, which she takes regularly as prescribed, and was referred to the tobacco clinic by
her community support worker.
Her support worker noticed that even though Carolyn smokes contraband cigarettes, the financial
impact of her smoking affects her overall quality of life and ability to “make ends meet” between
receiving government disability cheques.
Carolyn states that she smokes approximately 76 cigarettes per day, and says that she has been
wanting to quit for a long time. Her CO levels are 25 ppm. In her assessment, Carolyn states, “I
heard you people can make quitting easy – that’s what I need. This is it! I am walking out of here a
non-smoker.”
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Case Study: Carolyn
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4.
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In addition to the financial impact and # of cigarettes per day,
what other areas would you want to assess (and address)
with respect to Carolyn’s tobacco use?
What do you think of Carolyn’s decision to quit immediately?
How would you respond?
If you were recommending a nicotine patch, what level would
you recommend she start with?
What psychosocial intervention(s) might be helpful in this
case?
Case Study: Paul
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Case Study: Paul
Age: 35 years old
Gender: Male
Occupation: Food Service Industry
Relationship Status: Divorced
A 35 y.o. divorced Caucasian male with a history of schizophrenia d/o, paranoid type is currently
being treated as an outpatient at a local mental health center. He is prescribed Zyprexa 15 mg for
psychosis and Lisinopril 40 mg for high blood pressure. He has diabetes, which is currently nonmedicated and maintained through his diet. He presents to the smoking cessation program
requesting help to quit smoking.
This is the fourth or fifth time the patient has presented to the clinic requesting help to quit smoking.
In his past admissions, he has been able to quit twice for periods up to 2 months, once using patch
and the other time using Bupropion. In the past, when he’s been unsuccessful in quitting, he has
gotten frustrated and dropped out of smoking cessation treatment. Now, the patient states that he
would like to quit for health reasons, but he worries about gaining weight when quitting. The patient
is already 60 lbs overweight, which he attributes to his Zyprexa use.
Upon evaluation, he reports smoking an average of 30 cig/day. He reports smoking since the age of
13. The patient states that he believes one of the reasons he smokes is to help reduce anxiety.
When questioned further, it is learned that most of his smoking relapses occurred as a result of
either a psychiatric exacerbation or trying to cope with a stressful situation.
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Case Study: Paul
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What are the medication issues/concerns with this
case?
What other issues or concerns should we pay
attention to?
How would you proceed?
Case Study: Jack
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Case Study: Jack
Age: 68 years old
Gender: Male
Occupation: Retired Construction Worker
Relationship Status: Widowed
Jack began abusing substances at a very early age. He grew up in a mining town in Northern
Ontario with his father who was an abusive man with severe alcohol dependence and his
mother who suffered from anxiety. His father had difficulty staying employed which meant that
the family often had trouble making ends meet. Jack began smoking at age 7 and started
drinking at age 10. Eventually dropping out of school, he moved to Sudbury to find work at 15.
Jack began a long career using cocaine in his mid-20s, in addition to other substances but over
the last 8 years he has stopped using. Jack still drinks and smokes tobacco and has suffered
from severe chronic depression for over 40 years. He also has a myriad of health problems
due to his prolonged use of substances, poor nutrition and sedentary lifestyle, including
osteoporosis, COPD, and hyperlipidemia.
Jack has recently tried to reconnect with his 28 year old son and is interested in getting healthy,
but finds it difficult to stay motivated as he continues to have feelings of worthlessness, poor
appetite, poor concentration, loss of interest in things/activities, feeling irritable, feeling sad. He
denies suicidal ideation.
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Case Study: Jack
1.
2.
3.
4.
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What are the potential medication issues/concerns
with this case?
What other issues or concerns should we pay
attention to?
What kind of smoking cessation medication would
you recommend in this case?
What would Jack’s treatment plan look like?
Q&A
and
Troubleshooting
Tell us about your
complex patients…
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Resources
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
Algorithm for Tailoring Pharmacotherapy for Smoking Cessation1,2
Advise: As your physician, I am concerned about your tobacco use,
and advise you to quit. Would you like my help?
Motivational
Interviewing
Assess the 5 R’s:
Relevance
Rewards
Risk
Roadblocks
Repetition
No
Cold
Turkey
No response
Has bupropion/NRT failed? N
Is weight gain a concern? N
Want to quit within 7 days? Y
= NRT
(Gum, Patch, Lozenge or Inhaler)
No
Yes
Low importance or confidence (≤ 5)
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High importance or confidence (>5)
Assist in Quit Attempt: Would you like to quit abruptly?
Have you tried quitting cold turkey?
Yes
No
Yes: Pharmacotherapy
options
Has NRT failed?
Y/N
Is weight gain a concern? Y
…History of seizures? N
...History of mental illness? N
…Eating disorder?
N
...Allergic to bupropion?
N
...Previous non-responder? N
Want to quit within 7 days? N
= Bupropion SR
Has bupropion/NRT failed? Y
Is weight gain a concern? N
...History of seizures?
N
…History of mental illness?
N
…Eating disorder?
N
...Allergic to varenicline? N
...Previous non-responder? N
Want to quit within 7 days? N
= Varenicline
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.*
@ 4 weeks
Partial response
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
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?
Developed by Peter Selby, MBBS, CCFP. This algorithm 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.
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)
*N.B. for 2nd line medications (clonidine and nortriptyline), see
guidelines.
tobaccocontrol.bmj.com
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Remember …
A link to the Online Course Evaluation will be
sent by e-mail.
 A link to Learning Assessment 2 will also be
sent by e-mail. This must be completed by
September 28th in order to receive your Letter
of Completion
 Next session: October 19th, 2011:
Pharmacotherapies (3): Prescription Medications
**Applications will open on Monday Sept. 26**
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Thank
you!
Copyright
Copying or distribution of these materials is
permitted providing the following is noted on
all electronic or print versions:
© CAMH/TEACH
No modification of these materials can be
made without prior written permission of
CAMH/TEACH.
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