Transcript Evidence based cessation medication treatment for

Evidence-based medication treatment of
tobacco use disorder in people with
mental health and addictions
[email protected]
2016
THE PRESCRIBER ROLE: THE 5 AS
Ask about tobacco use. Identify and document tobacco use status for
every patient at every visit.
Advise to quit. In a clear, strong and personalized manner urge every
tobacco user to quit.
Assess willingness to make a quit attempt. Is the tobacco user willing
to make a quit attempt at this time?
Assist in quit attempt. For the patient willing to make a quit attempt,
offer medication and provide or refer for counseling or additional
treatment to help the patient quit. For patients unwilling to quit at the
time, provide interventions designed to increase future quit attempts.
Arrange follow-up. For the patient willing to make a quit attempt,
2
arrange for follow-up contacts, beginning within the first week after
the quit date. For patients unwilling to make a quit attempt at the
time, address tobacco dependence and willingness to quit at next
clinic visit.
Dixon et al 2009
FIRST LINE CESSATION
MEDS
• Bupropion, nicotine replacement, varenicline
• Using medication doubles or triples chance of quitting
• All have been shown effective in people with behavioral health
conditions
• Cessation medications reduce craving while quitting – studies
show impact for use up to a year
• Nicotine replacement and varenicline reduce nicotine withdrawal
symptoms (look at withdrawal slides or video)
• Much more effective if used in combination
• NRT most effective in combination: daily patch plus prn gum
• NRT with other medications may be more effective then either alone
• Individual counseling or group/class teach quit skills
• Counseling + combination pharmacotherapy = quit
success
ASSESS TOBACCO USE
• Assessment enables tailored prescribing and effective
coaching on how to use medication treatments
• Type of tobacco used
• Amount tobacco used
• When tobacco used
• Triggers and high risk situations
• Previous quit attempts – what worked, what didn’t work,
how meds and other treatments helps/hurt
ASSESS MENTAL HEALTH AND
SUBSTANCE USE DISORDERS
• Ensure patient is engaged in treatment
• Tobacco cessation treatment can be integrated with
mental health and addiction treatment at same time
• Best if outpatients are stable
• Inpatients benefit from full dose treatment to reduce
withdrawal, because withdrawal symptoms can be
confused with mental illness symptoms or withdrawal
from other substances
NICOTINE REPLACEMENT THERAPY (NRT)
• Available in: patch, gum, lozenge, spray
• Patch Dosing: Apply patch to alternating arm every day:
• 21 mg/D X 6 wks, then 14 mg/D X 2 wks, 7 mg/d X 2 wks (total 10
weeks, OK to use up to 1 year)
• Adjust dose based on how much people smoke: If smokes ≤1/2
pack/day then start with 14 mg/d patch plus prn gum or lozenge
• Lozenge/gum dosing: 2 mg or 4 mg prn craving hourly 8Xday if
used with patch, up to 24Xday without patch – adjust based on level of
smoking
• Combination daily NRT patch with prn NRT
gum/lozenge is most effective
• Start on quit date – OK to start a month earlier
• Using prn gum or lozenge to cut down by skipping cigarettes
increases self efficacy and can lead to cessation
USE NRT GUM IN ADVANCE OF HIGH
RISK SITUATIONS
Nicotine blood levels
• NRT gum blood levels are lower and increase slower
than cigarette = less addictive but requires planning.
Use 15 minutes before high risk situations
INSTRUCTIONS FOR USING NRT
• Gum: Chew until taste flavor, then ‘park’ between
teeth/gum and lining of cheek. Repeat, parking at
different spot, for up to 30 minutes
• Lozenge: Good for those with dentures. Suck until
taste flavor, then ‘park’ between teeth/gum and lining of
check. Repeat, parking at different spot, for up to 30 m.
• The nicotine will be absorbed through oral mucosa,
NOT swallowed. Nicotine takes 15 min to achieve peak
• Avoid coffee/orange just before use; reduces absorption
• People need to anticipate situations with urges; use in advance
• If people develop nausea - they are swallowing the nicotine
rather than allowing mucosal absorption
• If people develop mucosal irritation - they are not moving the
gum/lozenge around enough or need lower dose
INSTRUCTIONS FOR USING NRT
• Patch: Apply 1 to upper arm 1st thing in the morning
• Leave on for 24 hours, then remove and place new
patch on adjacent area or other arm to avoid irritating
skin.
• If patient usually smokes within 30 minutes upon awakening, use
gum or lozenge immediately as well as placing patch upon
awakening
• Use prn gum or lozenge to deal with cue-induced craving
• Patch gives steady level of nicotine that suppresses withdrawal,
but does not reduce cue-induced craving.
• Is person a night smoker? If so, keep patch on at night and use
nighttime NRT. If not, may need to remove patch to avoid dreams
NRT SAFETY AND SIDE EFFECTS
CAN PEOPLE USE NRT WHILE SMOKING?
• Yes, higher doses and smoking on patch is safe
(Benowitz 1998; Zevin 1998)
• Use in patients with cardiac and surgical disease is safe
after stabilization (Silva 2016; Nolan 2015)
• Nicotine slightly increases blood pressure and heart rate in lab but
not in clinical use
• Nicotine does not interact with behavioral health
medications
• Nicotine side effects
• Headache, stomach upset, diarrhea, dizzy, insomnia, dream, local
irritation at site of use
• If side effects occur,
• Remove NRT or stop smoking.
• Adjust strategy (move location, reduce dose, change timing)
What to do if person says they tried it before
and it didn’t work
• Find out how it was used before: most people do not use
high enough dose and/or use incorrectly
• Address efficacy - adjust dose based on amount
smoking – usually need higher dose or combination
patch +gum or lozenge
• Show them how to use it correctly – See Brunette video
or other Youtube video demonstrations
• Address side effects by teaching correct use and
adjusting timing of use
BUPROPION (ZYBAN)
•
•
•
•
NE and DA reuptake inhibitor
Also commonly used as antidepressant
Dose: 300 mg/day (150 BID) – up to a year
Interactions: Inhibits hepatic enzyme 2D6, metabolized by 2B6,
reduces seizure threshold
• Consider reduce dose of these concomitant meds
•
aripiprazole, risperidone, iloperidone
• Caution with all meds that may reduce seizure threshold
• Potential interactions with many antidepressants
• Safety/side effects
• Insomnia, stomach upset, constipation, diarrhea, HTN
• Most effective when used with Nicotine Replacement therapy patch
plus lozenge or gum
• Start 2 weeks before quit date
VARENICLINE (CHANTIX)
• Alpha4beta2 nicotine acetylcholine agonist
• Titrate up from 0.5 mg/day to 1.0 BID over 1
week. 0.5-1.0 mg BID 3-6 months
• Monitor weekly for a period of time
• Interactions - no significant – excreted in urine
• Safety/side effects: Nausea, diarrhea,
headache, agitation, suicidal or homicidal
thoughts
• Lower dose to address side effects
COMPARATIVE SUMMARY OF
NEUROPSYCHIATRIC SIDE EFFECTS
(REMEMBER WITHDRAWAL ALSO HAS EFFECTS)
Nicotine
Patch
Buproprion
Varenicline
Placebo*
Abnormal
Dreams
41%
43%
39%
35%
Anxiety
9%
10%
8%
6%
Agitation
4%
6%
5%
4%
Depressed
Mood
5%
5%
5%
5%
Anthenelli et al, The Lancet, 2016
COMPARATIVE SUMMARY OF
SIDE EFFECTS
(REMEMBER WITHDRAWAL ALSO HAS EFFECTS)
Nicotine
Patch
Patch + Bupropion Bup +
lozenge
lozenge
Varenicline
Placebo*
Nausea
4.3
7.9
3.8-16*
5.0
52*
16-19*
Local
irritation
Skin
15%
Throat
2-7%
Throat 2%
Throat
2-7%
Smith et al, 2009; *Nides et al 2006
FLOW SHEET FOR USE OF CESSATION
MEDICATION/NRT
• Developed based on
• Evidence of efficacy and safety in general population
• Evidence of efficacy and safety in people with behaivoral health
disorders
• Consider most effective options first: varenicline and
combinations
• Safety and patient choice also guide medication selection
1.
•
•
•
•
•
Get smoker to their baseline for their behavioral health
condition and initiating abstinence from substances.
Then assess whether, in the past year, was this patient:
Suicidal or homicidal
Significantly depressed
Violent
Unwilling to attend regular doctor’s appointments to monitor
medications
Under 18 years old
Yes to any
2. Does patient have a history of:
•
Mania
•
Anxiety disorder
•
Seizure
•
Eating disorder
•
Under 18 years old
Yes to any
4. Does patient:
• Smoke 20 or more cigarettes a day
• Have a history of failure at serious
quit attempt
Yes to any
High dose combination NRT
No to all
A GUIDE FOR CHOOSING SMOKING
CESSATION MEDICATION IN
MENTAL ILLNESS/ADDICTION
TAILORING BASED ON RESEARCH EVIDENCE
(ANTHENELLI 2016; BADER 2009; FIORE 2008; PIPER 2009;
EVINS 2010; HITSMAN 2009)
No to all
VARENICLINE
3. Does patient:
• Smoke 20 or more cigarettes a day
• Have a history of failure at serious quit attempts
• Have nicotine withdrawal when patient stops smoking, or
• Failure on single daily low dose of NRT
Yes to any
No to all
BUPROPION + High dose
combination NRT
BUPROPION +Low dose
combination NRT
• Have nicotine withdrawal when patient stops smoking, or
• Failure on single daily low dose of NRT
No to all
Low dose combination NRT
Combination Nicotine Replacement Therapy (NRT):
High dose NRT: 21mg patch plus immediate release
Low dose NRT: 14mg patch plus immediate release
Immediate release: gum, lozenge, spray or inhaler up to 8 X day at appropriate strength. (Gum and lozenge come in either 2mg or 4 mg strength.)
WHAT ABOUT AFTER PEOPLE QUIT?
• Some behavioral health medications may need to be adjusted with
smoking abstinence
• Chemicals in smoke (polynuclear aromatic hydrocarbons) speed
hepatic metabolism of many medications
• Serum concentrations of medications that are stable in smokers
may rise following abstinence as hepatic metabolism slows
• Affected enzymes are CYP 1A1, 1A2, and 2E1
• Abstinence associated with 30-42% reduction in 1A2 activity over the first
1-3 days of abstinence
• Haldol, Prolixin, Olanzapine, Clozapine, Mellaril, Thorazine,
Asenapine
• Caffeine is also metabolized through 1A2
• Therapeutic drug monitoring and 10% dose reduction for these
meds has been recommended
• Nicotine in NRT does not change metabolism
• Monitor… for adverse effects, relapse to smoking
KEEP TRYING: YOUR PERSISTENCE
WILL HELP PEOPLE QUIT
• Many people take a long time to quit, or quit  relapse
 try to quit again
• Encourage people to keep trying, many people need
several tries
• Adjust (usually increase) dose for increased efficacy or
switch cessation meds to address side effects
• Encourage cessation counseling – people need to learn
skills to resist urges to smoke
• Teach stress management skills – people may relapse
under stress
• Use combinations if hasn’t been tried:
• NRT combination; bupropion + NRT combo; varenicline + NRT
SUMMARY
• NRT and medications double or triple success of quit
attempts
• NRT and medications are not addictive and are safe for
people with behavioral health disorders
• Encourage behavioral intervention if not attending
class/group – people need to learn skills to resist urges
to smoke
• Use combinations of cessation medications
• Tailor treatment based on amount of smoking, timing of
smoking, side effects and preferences
• Be persistent! People may need to use for many months
before they can quit. Meds prevent relapse after quit.
OTHER RESOURCES - WEBSITES
http://smokingcessationleadership.ucsf.edu/MH_Resources.htm
This site has a wide array of resources and links related to smoking
cessation for people with mental illness. Included are lectures from
various leaders in the field.
http://tdi.dartmouth.edu/prcd/cessation/ This site has excellent
lectures by Nancy Rigotti, Professor of Medicine at Harvard. Topics
include motivational interviewing, pharmacotherapy, biology of
nicotine. There are live patients with which you can interact to
practice counseling strategies.
https://www.smokingcessationandpregnancy.org/ This site has
excellent lectures and simulated patients with a focus on smoking
cessation in women and around pregancy. You can earn 4 CME
credits for $25.
VIDEO LINKS FOR BRIEF LECTURES
Nicotine and nicotine withdrawal
https://www.youtube.com/watch?v=FlpSQLalqB8&index=3&list=PLPDZ9rcIfxyP
QzxdEX5f3mFe7brwQefDk
Nicotine replacement therapy
https://www.youtube.com/watch?v=lWvhYUuAV_w&index=2&list=PLPDZ9rcIfx
yPQzxdEX5f3mFe7brwQefDk
Varenicline smoking cessation treatment for people with mental illness
https://www.youtube.com/watch?v=4bxGb5EHZ48&index=3&list=PLPDZ9rcIfxy
PQzxdEX5f3mFe7brwQefDk
Quick facts about e-cigarettes for mental health and addiction clinicians
https://www.youtube.com/watch?v=9Lii9xEaJ7U&list=PLPDZ9rcIfxyPQzxdEX5f3
mFe7brwQefDk&index=4
REFERENCES PAGE 1 OF 2
Anthenelli RM, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine
patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised,
placebo-controlled clinical trial. Lancet. 2016. doi: 10.1016/S0140-6736(16)30272-0. PubMed
PMID: 27116918.
Bader P, McDonald P, Selby P. An algorithm for tailoring pharmacotherapy for smoking cessation:
results from a Delphi panel of international experts. Tob Control 2009;18(1):34-42.
Evins AE, Cather C, Pratt SA, et al. Maintenance treatment with varenicline for smoking cessation
in patients with schizophrenia and bipolar disorder: a randomized clinical trial. JAMA.
2014;311(2):145-54. PMID: 24399553
Fiore et al. Treating tobacco use and dependence Clinical practice guideline 2008 Update
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf
REFERENCES PAGE 2 OF 2
Fiore et al. Treating tobacco use and dependence Clinical practice guideline 2008 Update
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf
Gershon Grand RB et al. Short-term naturalistic treatment outcomes in cigarette smokers with
substance abuse and/or mental illness. J ClinPsych 2007;68(6):892-8.
Hitsman B, Moss TG, Montoya ID, George TP. Treatment of tobacco dependence in mental health
and addictive disorders. Can J Psych - 2009;54(6):368-78
Smith SS et al. A randomized placebo-controlled clinical trial of 5 smoking cessation
pharmacotherapies. Arch Gen Psych 2009;66(11):1253-62.
Thurgood SL, McNeill A, Clark-Carter D, Brose LS. A Systematic Review of Smoking Cessation
Interventions for Adults in Substance Abuse Treatment or Recovery. Nicotine Tob Res. 2015.
Tidey J. and Miller M. Smoking cessation and reduction in people with chronic mental illness BMJ
2015.