Module 2 - Assessment, Diagnosis, and Pharmacotherapy: Integrating Tobacco Use Interventions into Chemical Dependence Services

2 This training was developed by the Professional Development Program, under a contract with the NYS Department of Health, Tobacco Control Program. PDP developed five classroom-based curricula and seven online modules, which are available at

3 Welcome  Add Trainer Names

4 Housekeeping  Hours of Training  Breaks  Restrooms  Tobacco Use Policy  Cell Phones  Active Participation  Complete Pre-test/Post-test  Complete Training Evaluation

Introductions 5

6 PM 6 Training Modules Module 1 – Foundations Module 2 – Assessment, Diagnosis, Pharmacotherapy Module 3 – Behavioral Interventions Module 4 – Treatment Planning Module 5 – Co-occurring Disorders E-Learning – All Modules

7 PM 7 Module 2 Agenda  Assessment and Screening  Stages of Change and Readiness to Change  Diagnosing Tobacco Dependence  Pharmacotherapy and Medical Issues  Case Studies

8 PM 7 Module 2 Objectives Please refer to the list of objectives in your participant manual

Unit 1 Assessment and Diagnosis 9 PM 11

10 PM 12 Initial Assessment (Intake) Screen and Assess for Tobacco Use Assessment is revisited many times during treatment

11 PM 13 The Five A’s  Ask  Advise  Assess  Assist  Arrange

12 PM 13 Reframing Language Public Health TermsRecovery Terms smokingtobacco use, dose smokertobacco user quit dateabstinence date, recovery start date cessationtreatment, recovery

13 Discussion How do you currently assess or evaluate patients regarding their alcohol, drug, and tobacco use?

14 Discussion What are some issues/domains that you assess with your clients through the intake assessment process?

15 PM 14 Assessment Domains  Presenting problem  Family/living environment/social functioning  Educational  Employment  Medical/medications  Mental health status and symptoms  Alcohol, tobacco, and other drug use  Stage of change for each problem area  Supports & strengths

16 PM 15 Sample of Screening Tools Fagerström Test for Nicotine Dependence HONC (Hooked on Nicotine Checklist ) Heaviness of Smoking Index (HSI – Questions 1 and 4 of the Fagerström)

17 Tobacco Screening Tool Review  Small Group Discussion  Review how the tool is used  Pros & Cons of each tool  Large Group Discussion PM

18 PM CO Monitor Immediate feedback Immediate measure of success Additional assessment tool

19 PM % 20%

20 PM 27

21 PM 28 Stages of Change Vary By Problem Stage of change vary for each problem and substance used. Patients may be willing/unwilling to:  Become abstinent from tobacco  Attempt to reduce tobacco use  Take tobacco medications to mange withdrawal  Make major lifestyle changes to avoid relapse

22 PM 29 Assessing Readiness, Willingness, and Ability to Change Tobacco Use Uses tobacco and is willing to stop Uses tobacco but is not willing to stop Willing and ready to stop, but not able Willing, ready, and able to stop Previously used tobacco, not using currently Never used tobacco

23 DSM-IV-TR Criteria for Substance Dependence Criteria for Nicotine Dependence (305.1) a.k.a. Tobacco Dependence Criteria for Nicotine Withdrawal (292.0) PM

Unit 2 Tobacco Treatment Medications 24 PM 35

25 PM Evidence-Based Practices Clinical Practice Guideline 2008 Update:  Nicotine-based medications are effective  Non-nicotine medications are effective  Supportive counseling is effective  Counseling and medication is more effective than either method alone  Advise all patients to use medication, unless contra- indicated or lack of evidence of effectiveness

26 PM 38 The Patch: (arrgh!) The Basics  Over-the-counter (OTC) or prescription  Different dosages available  Nicotine has no drug-to- drug interactions

27 PM 38 Nicotine Patch ConsiderationsPrimary side effects: local skin reaction, insomnia PrecautionsPregnancy Category D Dosage and Duration 21mg/24 hours for 4 weeks; then 14mg/24 hours for 2 weeks; then 7mg/24 hours for 2 weeks AvailabilityOver the counter (OTC) and Prescription

28 PM 39 Nicotine Gum: The Basics  OTC availability  “Chew and park”- use on a fixed schedule  Absorbed through mucosa in cheek  Tailor dosage and duration to patient  No food/drink 15 minutes before and after use How not to use nicotine gum !

29 PM 39 Nicotine Gum ConsiderationsPrimary side effects: mouth soreness, dyspepsia. Patients often do not use enough and/or use incorrectly. PrecautionsPregnancy Category D Dosage & Duration 2mg and 4mg Up to 24 pieces/day Up to 12 weeks AvailabilityOTC

30 PM 40 Nicotine Lozenges: The Basics  Over-the-counter (OTC)  Placed under tongue or in cheek pouch (not swallowed) so that nicotine is absorbed through mucosa  Avoid food/drink 15 minutes before and after An old nicotine lozenge attempt

31 PM 40 Nicotine Lozenge ConsiderationsPrimary side effects: nausea, insomnia. Patients often do not use enough and/or use incorrectly. Provide scheduled dosing. PrecautionsPregnancy Category D Dosage & Duration 2mg and 4mg Up to 20 per day Up to 12 weeks AvailabilityOTC

32 PM 41 Nicotine Nasal Spray: The Basics  Prescription only  Provides highest level of nicotine by medication and gives fastest relief of cravings  May cause nasal irritation  Carries some dependence potential

33 PM 41 Nicotine Nasal Spray ConsiderationsPrimary side effects: nasal Irritation; some dependence potential PrecautionsSevere reactive airway disease. Pregnancy Category D Dosage and Duration 8 – 40 doses/day 3 – 6 months AvailabilityPrescription only

34 PM 42 Nicotine Inhaler: The Basics and Dosing  Actually is an oral puffer, it is not inhaled  By prescription only  Some patients report preference for inhaler due to the simulation of smoking

35 PM 42 Nicotine Inhaler (Oral Puffer) ConsiderationsPrimary side effects: local irritation of mouth and throat; coughing, rhinitis. The best effects are achieved with frequent puffing. PrecautionsPregnancy Category D Dosage & Duration 6 – 16 cartridges/day Up to 6 months; taper dosage in final 3 months AvailabilityPrescription only

36 PM 43 Prescription non-nicotine drugs: Bupropion SR  Trade names Zyban and Wellbutrin; FDA approved  Failed success with NRT alone? Depression after stopping tobacco?  Side effects: insomnia, dry mouth, and weight loss  Not for pregnant women, people with seizures, recent sedative withdrawal, or eating disorder

37 PM 43 More about Bupropion  Doubles abstinence rates when compared to placebo  Effective for smoking even when patient’s depression remains unchanged  No worsening of psychotic symptoms reported  FDA requires black box warning for adverse effects

38 PM 43 Still MORE about Bupropion: dosing  150 mg every morning x 3 days; then 150 mg x 2 (300 mg) per day  7-12 weeks, up to 6 months

39 PM 44 Prescription non-nicotine drugs: Varenicline  Non-nicotine medication approved by FDA in July 2006 (trade name Chantix)  Mechanism of action: partial agonist and antagonist of specific receptors – result is less DA release / blocks nicotine activation of receptors  Reduces nicotine craving and withdrawal

40 PM 44 Varenicline, cont’d ConsiderationsPsychiatric history Side effects: nausea, insomnia PrecautionsHistory of kidney disease Pregnancy Category C Note: Varenicline is 93% excreted unchanged from the kidneys and has no drug-to-drug interactions

41 PM 44 Varenicline, cont’d Dosage0.5mg 1x/day for 3 days & Duration 0.5mg 2x/day for 4 days 1.0mg 2x/day for 3 months Stop tobacco use on day 8 Use up to 6 months AvailabilityPrescription only Note: FDA now requires black box warning for adverse effects

42 PM 45 Second-Line Medications  Nortriptyline and Clonidine  Some evidence of effectiveness in tobacco dependence treatment, but not FDA approved for tobacco treatment  Used as off-label medications  Greater concern with potential side effects

43 PM 46 Combination Medications Combinations of medication works better Clinicians should consider the use of certain combination of tobacco medications that have been identified as effective. (Fiore, Jaen, Baker, et al., 2008 Clinical Practice Guideline, 2008 Update)

44 PM 46 Combination Medications, cont’d  Long-term (>14 weeks) nicotine patch plus other NRT (gum, lozenge, and/or nasal spray)  Nicotine patch plus nicotine inhaler or nasal spray  Nicotine patch plus bupropion SR  Nicotine gum or lozenge plus bupropion SR (Fiore, Jaen, Baker, et al., 2008)  Bupropion SR and varenicline (Ebbert, et al., 2009)

45 PM Considerations and Contraindications  Stopping use may affect other medications  Due to adverse effects of smoking, practitioners sometimes choose to use medications on a case- by-case even if effectiveness not proven  Contraindications for NRT

Unit 3 Case Studies 46 PM 53

47 PM 54

48 PM 54 Case Study Questions 1. Can a Fagerström score be determined? 2. Is DSM-IV-TR criteria evident for tobacco dependence and nicotine withdrawal? 3. Patient stage for tobacco use? Stage for other AOD use? 4. Key patient issues needing immediate attention? 5. Recommended treatment medications?

49 PM Bill J.

50 PM Barbara G.

51 PM Jorge G.

52 PM Alvin C.

53 PM Maryann P.

54 PM Resources The Tobacco Recovery Resource Exchange E-Learning and Online Resources OASAS

55 PM Resources OASAS BeBetter Networks NRT

Post-Test and Workshop Evaluations 56