Treatment of Nicotine Dependence Ron Alexander

The Public Health Field has led the fight for tobacco control Health hazards associated with using tobacco products Cessation efforts Clean indoor air

The Addiction field has lagged behind, almost protecting the use of nicotine, as the lesser of 2 evils.

Cooperation between tobacco control and addiction treatment is coming

Marathon County – 5 years of collaboration Health Department and Premiere Recovery Services (NCHC) “Quit Smoking Now” Program Support Group “Thinking About Quitting” Clean Indoor Efforts (Marathon County Tobacco Free Coalition)

Why should Wisconsin AODA Treatment Providers be concerned about Nicotine Dependence Treatment?

78% of the drinking and drugging population is dependent on Nicotine compared to less than 25% in the general population

Recovering alcoholics and addicts continuing to use nicotine are dying from smoking related causes years sooner than those nicotine free

Tobacco related disease is the leading cause of death in the recovering and actively addicted community

Research shows that recovering addicts who also quit nicotine are not at risk to relapse to their other substance at a higher rate, in fact there is some evidence that shows there is less relapse.

70% of tobacco users have a desire to quit, for those who also have an alcohol addiction 50% indicated they would like to prioritize alcohol first and then take on cigarettes

70% of tobacco users have a desire to quit, for those who also have an alcohol addiction 50% indicated they would like to prioritize alcohol first and then take on cigarettes but 20% were interested in dealing with both

70% of tobacco users have a desire to quit, for those who also have an alcohol addiction 50% indicated they would like to prioritize alcohol first and then take on cigarettes but 20% were interested in dealing with both this is a significant number and cannot be ignored.

There is a treatment protocol Medicine – primarily Zyban NRT – patch, gum, inhaler, spray, lozenge Group therapy - responds well Individual therapy – responds equally well Cognitive therapy Behavioral therapy

Barriers to Treating Nicotine Addiction Concurrently can’t quit everything at once (myth) the anxiety produced will cause relapse to other substance clients will resist will detract from serious addictions lesser of 2 evils. don’t know how to treat (cop out) no funding any how some counselors and administrators continue to smoke

Mainstream Addiction treatment will include nicotine dependence

The national association of addiction counselors (NAADC) 12,000 members, recently endorsed a policy to include nicotine dependence on the same priority as other drugs

New Jersey – all addiction treatment programs must include nicotine dependence treatment in order to be licensed

Certification as a specialist in Nicotine dependence available at the University of Florida and at Mayo Clinic

Mayo Clinic, Hazelden, the University of Minnesota Public Health Department and in Wisconsin (CTRI) are offering nicotine dependence education and training for best clinical practices.

A task force has been formed in the Department of Health and Family Services Tobacco Control Program on treating tobacco addiction. Maybe a directive or policy change is forth coming???

Addiction Journal Coverage January 2005 Article - National Institute on Drug Abuse (NIDA) awards $2.1 million contract to learn more about genetic influences on nicotine addiction and treatment responses July 2005 Advertisment for Hazelden Cessation Residential Program “WE HEARD YOU WANTED SOME HELP QUITTING SMOKING ”

Premiere Recovery Services North Central Health Care Day Treatment Program AODA Education Group Genesis Treatment Program Individual Counseling

Day Treatment Program 3 week duration Most intensive primary treatment program Nicotine dependence gets 15 minutes per week of attention (up from 10 minutes) Focus is on readiness Based on experiences at the Henley Hazelden Center in West Palm Beach, FL “Smoke” break is still valued in our program – Some clients even start to smoke when they enter AODA treatment

AODA Education Group 10 week program 1 hour each cycle devoted to Nicotine dependence/cessation

Genesis Treatment Program 14 sessions 7 weeks 1 hour presentation on nicotine dependence/cessation

Individual Counseling Attention given is minimal and inconsistent and often depends upon the counselor.

Research shows that 20% of all clients who present with addiction to multiple substances including nicotine are ready for a concurrent quit attempt.

It is common in addiction treatment for a person to be at different readiness state for each substance – but at least priorities can be addressed in the treatment plan.

Funding and Payment for Cessation and Treatment Tobacco settlement monies were re- allocated Major setback but efforts did not stop There is passion in this field volunteerism

Funding and Payment for Cessation and Treatment Separate funding for nicotine treatment done concurrently with other drugs is not an issue. Funding available for both group or individual counseling

Funding and Payment for Cessation and Treatment Separate nicotine dependence treatment is currently funded by Medicare, Medicaid with a master’s level clinician. Some health insurance or HMO coverage for replacement medication and counselor. Recent CTRI report 32% increase between

Quit Smoking Now Educational focus Preparation to quit NRT/stress management/nutrition Joint venture between Health Department and Premiere Recovery Since 2001 Currently being revised 4 times a year 8 sessions to 6 sessions - weekly Better coordination with support group

Why a Smoking Cessation Support Group? We know that nicotine dependence is a chronic disorder

Why a Smoking Cessation Support Group? We know that nicotine dependence is a chronic disorder Requires ongoing rather than acute care

Why a Smoking Cessation Support Group? We know that nicotine dependence is a chronic disorder Requires ongoing rather than acute care Staying involved in a support group for 1 year increases chances of staying quit

Smoking Cessation Support Group Began at Premiere Recovery in June 2001 following the 1 st Quit Smoking Now class. Meets every Wednesday 6-7 pm For all community members

Readiness You can create movement towards a quit attempt. You do not have to tell them to come back when they are really ready

Readiness levels Just finished Quit Smoking Now

Readiness levels Just finished Quit Smoking Now Seeking information – provide packet of information

Readiness levels Just finished Quit Smoking Now Seeking information – provide packet of information Ready for a quit attempt

Readiness levels Just finished Quit Smoking Now Seeking information – provide packet of information Ready for a quit attempt Just relapsed

Relapse Remember relapse is a component of the chronic nature of nicotine dependence - not an indication of personal failure by clients or clinician

During group interactions avoid argument and confrontation - focus on the positive benefits, not negative labels

For new group members use the 5 A’s Ask about tobacco use

For new group members use the 5 A’s Ask about tobacco use Advise them to quit

For new group members use the 5 A’s Ask about tobacco use Advise them to quit Assess willingness to quit

For new group members use the 5 A’s Ask about tobacco use Advise them to quit Assess willingness to quit Assist describe best clinical practices

For new group members use the 5 A’s Ask about tobacco use Advise them to quit Assess willingness to quit Assist describe best clinical practices Arrange for follow-up

The 5 R’s Relevance – tailor advice to each person

The 5 R’s Relevance – tailor advice to each patient Risks – of continual smoking

The 5 R’s Relevance – tailor advice to each patient Risks – of continual smoking Rewards – benefits of quitting

The 5 R’s Relevance – tailor advice to each patient Risks – of continual smoking Rewards – benefits of quitting Roadblocks – individual barriers

The 5 R’s Relevance – tailor advice to each patient Risks – of continual smoking Rewards – benefits of quitting Roadblocks – individual barriers Repetition – the “heart” of the support group

Quit attempt’s 4 D’s Delay

Quit attempt’s 4 D’s Delay Distract

Quit attempt’s 4 D’s Delay Distract Drink Water

Quit attempt’s 4 D’s Delay Distract Drink Water Deep Breathing

Address all areas in the process of recovery

Cessation Support Group for community support program (NCHC) Meets weekly For persons with dual diagnosis Very difficult population