Module 5 - Co-Occurring Disorders: Integrating Tobacco Use Interventions into Chemical Dependence Services

2 Welcome  Add Trainer Name(s)

3 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

4 Housekeeping  Hours of Training  Breaks  Restrooms  Tobacco Use Policy  Cell Phones  Active Participation  Complete Training Evaluation Form

5 Introductions

6 Training Modules Module 1 - Foundations Module 2 - Assessment, Diagnosis, and Pharmacotherapy Module 3 - Behavioral Interventions Module 4 - Treatment Planning Module 5 - Co-occurring Disorders E-Learning - All Modules PM 9

7 Module 5 Agenda  Review of prior modules  Personal attitudes and beliefs  Prevalence and co-morbidity  Basic neurobiology of tobacco dependence  Review of tobacco treatment strategies  Case Studies PM 10

8 Module 5 Objectives Please review page 10 in your manual PM 10

9 Unit 1 Attitudes and Beliefs, Challenges and Barriers PM 11

10 Review Learning points from prior modules New knowledge or skills integrated into practice PM 12

11 Defining Co-occurring Disorders How do you define co-occurring disorders? Co-occurring disorders - when a person has a substance use disorder and mental health disorder at the same time. PM 13

12 Defining Co-morbidity How do you define co-morbidity? Co-morbidity - two or more disorders are present at the same time and they interact in ways that affect the course and/or prognosis of each disorder. PM 13

13 Setting the Context Currently very little research on co-occurring disorders (COD)and tobacco dependence. Tobacco treatment is effective for wide range of people, including those with mental health (MHD) and substance use disorders (SUD). What is known about tobacco users with a MHD or SUD, may be applicable for COD PM 14

14 Activity #1 Confidence, Attitudes, and Beliefs Assess your current confidence, attitudes, and beliefs about tobacco use among people with MHD and SUD PM 15

15 Debriefing Activity #1 Examining how attitudes and beliefs about tobacco, affect staff and patient behavior to examine and address tobacco use.

16 Activity #2 Video - Smoke Alarm Produced by Clubhouse of Suffolk Ronkonkoma, NY PM 16

17 Video - Vignettes 1 to 3 What is the relationship of tobacco to people’s mental health disorder? What are common fears about stopping tobacco use? PM 16

18 Vignette #1

19 Vignette #2

20 Vignette #3

21 Video - Vignettes 4 and 5 What are the barriers and challenges mentioned about stopping tobacco use? How might treatment for people with COD need to be modified or enhanced? PM 16

22 Vignette #4

23 Vignette #5

24 Summary PM 17 Definition of co-occurring disorders and co- morbidity Confidence, attitudes, and beliefs Patient perspectives on tobacco use/dependence Challenges and barriers to addressing tobacco use by people with SUDs and MHDs

25 Unit 2 Prevalence and Co-morbidity Factors PM 19

26 Discussion What is the frequency of patients having a co- occurring mental health disorder and substance use disorder?

27 National and NYS Data PM 20 National Data: % of SUD patients have MHD % of MHD patients have SUD (Center for Substance Abuse Treatment, 2005) NYS Chemical Dependence Programs: 23% - 46% of SUD patients have MHD, rates varies by modality (Office of Alcoholism and Substance Abuse Services, 2008)

28 Activity #3 PM Tobacco and Co-occurring Disorders Knowledge Activity

29 1.Average Rate of Tobacco Smoking Studies vary as to each disorder and people with some disorders have smoking rates up to %. 70% About 70% of people with a mental health disorder (MHD) and/or a substance use disorder (SUD), also smoke tobacco. PM 24

30 2.Percentage of Cigarettes Consumed About half of all cigarettes consumed in the US are by people with MHD and/or SUD. Results in significant illness, death, and health disparity for two vulnerable populations % PM 24

31 3.Average Reduced Life Span Primary cause of death is cardiovascular disease (CVD) and diabetes. #1 cause of CVD is tobacco smoke and tobacco is a key factor in onset of diabetes. 25 years! The average lifespan in US is 77.8 years. For smokers with MHD or SUD, this life span is reduced by 32%. 32% PM 24

32 4.Average percent of monthly income spent on tobacco Average percentage of monthly income spent on tobacco 27% Averages about $142 per month based upon costs. PM 25

33 5.Daily smoking can predict suicidal thinking and attempts Facts ! Increased s uicide thinking and attempts even considering a prior history of depression, substance use disorder, and prior suicide attempts. Increased risk of suicide for people with bipolar illness and schizophrenia. PM 25

34 6.Heavy smoking can be a predictor of suicide risk and completion Facts ! Increased s uicide completion rates for tobacco using adolescents and greater number of attempts, especially for females Heavy tobacco smoking is highly associated with increased suicide completion PM 26

35 7.Nicotine causes cancer and CVD Facts ! Nicotine is not a carcinogen and is not a major risk factor of cardiovascular disease (CVD). Tobacco smoke is the disease-causing agent. PM 26

36 8.Nicotine can affect metabolism of psychiatric medications Facts ! Nicotine does not affect the metabolism of medications. Tobacco smoke induces the liver to increase the metabolism rate of some psychiatric and some non- psychiatric medications. PM 26

37 9.Stopping smoking requires an increase in psychiatric medications Facts ! Many people can stop without changes in medication levels. Some may require lower doses to avoid medication toxicity (i.e., clozapine, olanzepine) or to avoid increased side effects (i.e., amitriptyline, nortriptyline, and imipramine). See Table 1 - Common Drugs Affected by Tobacco Smoke PM 27

38 10.Use of tobacco increases anxiety Facts! Increased feelings of general anxiety from using tobacco. Patients often confuse nicotine withdrawal symptoms with primary anxiety symptoms of MHD or SUD. Many mistakenly assume using tobacco causes their general anxiety symptoms to stop. PM 28

39 11.Stopping tobacco leads to panic attacks, and smoking reduces panic attacks and panic disorder Facts ! Tobacco use is a significant risk factor for panic disorder, agoraphobia, and generalized anxiety disorder (GAD). Also refer back to answer in Statement 10. PM 28

40 12.Most people with MHD or SUD are not interested in stopping tobacco use Facts ! 70% expressed an interest in stopping in the past year. People with MHDs and/or SUDs express an interest in stopping tobacco use as often as smokers in the general population. PM 28

41 13.Most people with MHD or SUD cannot stop using tobacco Facts ! Many can stop and need more frequent treatment, more intense treatment, and more engagement. No increased problems after stopping and recent research shows MH symptoms decrease after tobacco abstinence. PM 29

42 14.Chantix reduces the effects of some psychiatric medications Facts ! About 92% of Chantix is eliminated unchanged from body by kidneys. Chantix has no drug-to-drug interactions. PM 29

Smoking increases MHD/SUD risk Facts ! Tobacco is a common “gateway drug” for AOD use Smoking increases risk for mental illness and doubles the risk for major depression when used in adolescence. Adolescent tobacco use associated with increased adult risk for panic disorder, anxiety disorder, agoraphobia, depression, suicidal behavior, SUD, and schizophrenia. PM 30

44 15.Smoking increases MHD/SUD risk, cont’d Facts ! Active psychiatric disorders are associated with daily smoking and progression to dependence. Risk of major depression in women who smoke is increased 93%. PM 30

45 Knowledge Summary How many of these answers did you already know? Were there any surprises from what you just learned?

46 Biopsychosocial Approach to Substance Dependence Tobacco dependence is a biopsychosocial disease PM 31

47 Neurobiological Factors and Neuro- chemical Effects of Tobacco/Nicotine PM Various genes are involved for first tobacco use, risk of dependence, withdrawal severity, and inability to stop using. Different neurotransmitters are affected by nicotine and likely by other chemicals in tobacco smoke. Nicotine provides some short-term benefits, but tobacco use aggravates MHDs and SUDs.

48 Other Factors Affecting Tobacco Use PM Psychological Behavioral Social Treatment / Recovery Large System (Tobacco Industry, Media, etc).

49 Interaction between Tobacco Dependence and Other Substance Use Disorder PM 36 Other Substance Use DisorderTobacco Dependence

50 Interaction between Substance Use Disorder and Mental Health Disorder Substance Use DisorderMental Health Disorder PM 37

51 Interaction between Tobacco Dependence Mental Health Disorder and Mental Health DisorderTobacco Dependence PM 38

52 Interaction between Tobacco Dependence, Mental Health Disorder, and Substance Use Disorder Mental Health Disorder Substance Use DisorderTobacco Dependence PM 39

53 Discussion What are the common factors between tobacco dependence, substance use disorders, and mental health disorders? PM

54 Summary All have common chemical pathways affecting the brain All are chronic, biopsychosocial diseases The disorders negatively interact and result in co-morbid conditions Treatment using medication, behavioral, psychoeducation, and supportive therapies Recovery is possible and requires lifestyle changes PM 42

55 Unit 3 Treatment Strategy Review and Case Studies PM 43

56 Tobacco Treatment Review First Line Tobacco Medications –OTC (patch, gum, lozenge) –Prescription (inhaler and nasal spray) –Chantix –Bupropion Second Line Tobacco Medications –Nortriptyline –Clonidine PM 44

57 Tobacco Treatment Review, cont’d Nicotine medications are well-tested and have high margin of safety. Tobacco medications often used incorrectly, not often enough, or doses used are too low. –As a result when people have withdrawal symptoms, they think the medications don’t work and/or stop using them. Some people need higher doses of nicotine medications and/or long-term medication. PM

58 Tobacco Treatment Review, cont’d PM 48 Combinations of two or more medications works work better than a single medication. MI, CBT, and RPT are effective first line methods. Medication plus counseling is more effective, than either alone. Peer counseling and peer support may be helpful.

59 Important Reminders Tobacco dependence is a biopsychosocial disease that aggravates and complicates SUDs and MHDs People with COD often need more engagement, and longer and more frequent treatment Not addressing tobacco use for all patients sends an unhealthy and wrong message PM 49

60 Case Studies Three cases studies Read the assigned case Answer the questions related to that case PM 50

61 PM Case Studies PM PM Smoking/Drug Chart PM 57

62 Discussion of Case Study Questions

63 Summary T obacco dependence treatment for people with MHD or COD is not different from other populations Often requires higher intensity and frequency of treatment episodes, and often more engagement Tobacco treatment medications are important to use along with counseling, psychoeducation, and supportive therapies Anticipate possible need to modify medication dosage PM 58

64 Revisit Confidence, Attitudes and Beliefs Revisit your confidence, attitudes, and beliefs from the questions posed earlier PM 59

65 Resources The Tobacco Recovery Resource Exchange E-Learning and Online Resources OASAS PM 61-62

66 Workshop Evaluation