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Module 5 - Co-Occurring Disorders: Integrating Tobacco Use Interventions into Chemical Dependence Services. Welcome. Add Trainer Name(s). This training was developed by the Professional Development Program, under a contract with the NYS Department of Health, Tobacco Control Program.

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


Welcome l.jpg
Welcome

  • Add Trainer Name(s)


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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 www.tobaccorecovery.org


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Housekeeping Program, under a contract with the NYS Department of Health, Tobacco Control Program.

  • Hours of Training

  • Breaks

  • Restrooms

  • Tobacco Use Policy

  • Cell Phones

  • Active Participation

  • Complete Training Evaluation Form


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Introductions Program, under a contract with the NYS Department of Health, Tobacco Control Program.


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Training Modules Program, under a contract with the NYS Department of Health, Tobacco Control Program.

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


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Module 5 Agenda Program, under a contract with the NYS Department of Health, Tobacco Control Program.

  • 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


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Module 5 Objectives Program, under a contract with the NYS Department of Health, Tobacco Control Program.

Please review page 10 in your manual

PM 10


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Unit 1 Program, under a contract with the NYS Department of Health, Tobacco Control Program.Attitudes and Beliefs, Challenges and Barriers

PM 11


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Review Program, under a contract with the NYS Department of Health, Tobacco Control Program.

Learning points from prior modules

New knowledge or skills integrated into practice

PM 12


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Defining Co-occurring Disorders Program, under a contract with the NYS Department of Health, Tobacco Control Program.

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


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Defining Co-morbidity Program, under a contract with the NYS Department of Health, Tobacco Control Program.

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


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Setting the Context Program, under a contract with the NYS Department of Health, Tobacco Control Program.

  • 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


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Activity #1 Program, under a contract with the NYS Department of Health, Tobacco Control Program.Confidence, Attitudes, and Beliefs

Assess your current confidence, attitudes, and beliefs about tobacco use among people with MHD and SUD

PM 15


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Debriefing Activity #1 Program, under a contract with the NYS Department of Health, Tobacco Control Program.

Examining how attitudes and beliefs about tobacco, affect staff and patient behavior to examine and address tobacco use.


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Activity #2 Program, under a contract with the NYS Department of Health, Tobacco Control Program.Video - Smoke Alarm

Produced by Clubhouse of Suffolk Ronkonkoma, NY

www.clubhouseofsuffolk.com

PM 16


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Video - Vignettes 1 to 3 Program, under a contract with the NYS Department of Health, Tobacco Control Program.

  • What is the relationship of tobacco to people’s mental health disorder?

  • What are common fears about stopping tobacco use?

PM 16


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Vignette #1 Program, under a contract with the NYS Department of Health, Tobacco Control Program.


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Vignette #2 Program, under a contract with the NYS Department of Health, Tobacco Control Program.


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Vignette #3 Program, under a contract with the NYS Department of Health, Tobacco Control Program.


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Video - Vignettes 4 and 5 Program, under a contract with the NYS Department of Health, Tobacco Control Program.

  • 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


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Vignette #4 Program, under a contract with the NYS Department of Health, Tobacco Control Program.


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Vignette #5 Program, under a contract with the NYS Department of Health, Tobacco Control Program.


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Summary Program, under a contract with the NYS Department of Health, Tobacco Control Program.

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

PM 17


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Unit 2 Program, under a contract with the NYS Department of Health, Tobacco Control Program.Prevalence and Co-morbidity Factors

PM 19


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Discussion Program, under a contract with the NYS Department of Health, Tobacco Control Program.

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


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National and NYS Data Program, under a contract with the NYS Department of Health, Tobacco Control Program.

National Data:

  • 50 - 75% of SUD patients have MHD

  • 25 - 50% 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)

PM 20


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Activity #3 Program, under a contract with the NYS Department of Health, Tobacco Control Program.

Tobacco and Co-occurring Disorders

Knowledge Activity

PM 21 - 23


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1. Average Rate of Tobacco Smoking Program, under a contract with the NYS Department of Health, Tobacco Control Program.

About 70% of people with a mental health disorder (MHD) and/or a substance use disorder (SUD), also smoke tobacco.

Studies vary as to each disorder and people with some disorders have smoking rates up to 80 - 90%.

70%

PM 24


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2. Percentage of Cigarettes Consumed Program, under a contract with the NYS Department of Health, Tobacco Control Program.

About half of all

cigarettes consumed

in the US are by

people with MHD

and/or SUD.

44-46%

Results in significant illness, death, and health disparity for two vulnerable populations.

PM 24


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3. Average Reduced Life Span Program, under a contract with the NYS Department of Health, Tobacco Control Program.

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


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4. Average percent of monthly income spent on tobacco Program, under a contract with the NYS Department of Health, Tobacco Control Program.

Average percentage of monthly income spent on tobacco

27%

Averages about $142 per month based upon 2000 - 2002 costs.

PM 25


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5. Daily smoking can Program, under a contract with the NYS Department of Health, Tobacco Control Program.predict suicidal thinking and attempts

Facts !

Increased suicide 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


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6. Heavy smoking can be a Program, under a contract with the NYS Department of Health, Tobacco Control Program.predictor of suicide risk and completion

Facts !

Increased suicide 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


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7. Nicotine causes cancer and CVD Program, under a contract with the NYS Department of Health, Tobacco Control Program.

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


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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


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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


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10. Use of tobacco increases anxiety medications

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


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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


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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


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13. Most people with MHD or SUD cannot stop using tobacco stopping tobacco use

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


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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


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15. Smoking increases MHD/SUD risk medications

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


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15. Smoking increases MHD/SUD risk, medicationscont’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


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Knowledge Summary medications

How many of these answers did you already know?

Were there any surprises from what you just learned?


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Biopsychosocial Approach to Substance Dependence medications

Tobacco dependence is a biopsychosocial disease

PM 31


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Neurobiological Factors and Neuro-chemical Effects of Tobacco/Nicotine

  • 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.

PM 32 - 33


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Other Factors Affecting Tobacco Use Tobacco/Nicotine

  • Psychological

  • Behavioral

  • Social

  • Treatment / Recovery

  • Large System (Tobacco Industry, Media, etc).

PM 34 - 35


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Interaction between Tobacco Dependence and Other Substance Use Disorder

Tobacco Dependence

Other Substance Use Disorder

PM 36


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Interaction between Substance Use Disorder and Mental Health Disorder

Substance Use Disorder

Mental Health Disorder

PM 37


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Interaction between Tobacco Dependence Mental Health Disorder and

Tobacco Dependence

Mental Health Disorder

PM 38


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Interaction between Tobacco Dependence, Mental Health Disorder, and Substance Use Disorder

Tobacco Dependence

Substance Use Disorder

PM 39

Mental Health Disorder


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Discussion Disorder, and Substance Use Disorder

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

PM 40 - 41


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Summary Disorder, and Substance Use Disorder

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


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Unit 3 Disorder, and Substance Use DisorderTreatment Strategy Review and Case Studies

PM 43


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Tobacco Treatment Review Disorder, and Substance Use Disorder

  • First Line Tobacco Medications

    • OTC (patch, gum, lozenge)

    • Prescription (inhaler and nasal spray)

    • Chantix

    • Bupropion

  • Second Line Tobacco Medications

    • Nortriptyline

    • Clonidine

PM 44


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Tobacco Treatment Review, Disorder, and Substance Use Disordercont’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 45 - 47


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Tobacco Treatment Review, Disorder, and Substance Use Disordercont’d

  • 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.

PM 48


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Important Reminders Disorder, and Substance Use Disorder

  • 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


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Case Studies Disorder, and Substance Use Disorder

  • Three cases studies

  • Read the assigned case

  • Answer the questions related to that case

PM 50


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Case Studies Disorder, and Substance Use Disorder

PM 53 - 54

PM 55 - 56

Smoking/Drug Chart PM 57

PM 51 - 52


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Discussion of Case Study Questions Disorder, and Substance Use Disorder


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Summary Disorder, and Substance Use Disorder

Tobacco 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


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Revisit Confidence, Attitudes and Beliefs Disorder, and Substance Use Disorder

Revisit your confidence, attitudes, and beliefs from the questions posed earlier

PM 59


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Resources Disorder, and Substance Use Disorder

The Tobacco Recovery Resource Exchange http://www.tobaccorecovery.org

E-Learning and Online Resources

OASAS http://www.oasas.state.ny.us/tobacco/index.cfm

Email: [email protected]

BeBetter Networks (NRT)

http://www.nrtdistribution.com/Welcome.aspx

PM 61-62


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Workshop Evaluation Disorder, and Substance Use Disorder


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