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

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


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

  • Add Trainer Names
  • Hours of Training
  • Breaks
  • Restrooms
  • Tobacco Use Policy
  • Cell Phones
  • Active Participation
  • Complete Pre-test/Post-test
  • Complete Training Evaluation
training modules
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

module 2 agenda
Module 2 Agenda
  • Assessment and Screening
  • Stages of Change and Readiness to Change
  • Diagnosing Tobacco Dependence
  • Pharmacotherapy and Medical Issues
  • Case Studies
module 2 objectives
Module 2 Objectives

Please refer to the list of objectives in your participant manual

screen and assess for tobacco use
Screen and Assess for Tobacco Use

Initial Assessment


Assessment is revisited many times during treatment

the five a s
The Five A’s
  • Ask
  • Advise
  • Assess
  • Assist
  • Arrange

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


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

assessment domains
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
sample of screening tools
Sample of Screening Tools

Fagerström TestforNicotineDependence

Heaviness ofSmokingIndex(HSI – Questions1 and 4 of theFagerström)


(Hooked onNicotineChecklist)

tobacco screening tool review
Tobacco Screening Tool Review
  • Small Group Discussion
    • Review how the tool is used
    • Pros & Cons of each tool
  • Large Group Discussion

PM 16 - 20

co monitor
CO Monitor

Immediate feedback

Immediate measure of success

Additional assessment tool





stages of change vary by problem
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
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 30 - 32

evidence based practices
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
the patch arrgh the basics
The Patch: (arrgh!) The Basics
  • Over-the-counter (OTC) or prescription
  • Different dosages available
  • Nicotine has no drug-to- drug interactions
nicotine gum the basics
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!

nicotine lozenges the basics
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

nicotine nasal spray the basics
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
nicotine inhaler the basics and dosing
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
prescription non nicotine drugs bupropion sr
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
more about bupropion
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
still more about bupropion dosing
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
prescription non nicotine drugs varenicline
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
varenicline cont d
Varenicline, cont’d

Considerations Psychiatric history

Side effects: nausea, insomnia

Precautions History of kidney disease

Pregnancy Category C

Note: Varenicline is 93% excreted unchanged from the kidneys and has no drug-to-drug interactions

varenicline cont d1
Varenicline, cont’d

Dosage 0.5mg 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

Availability Prescription only

Note: FDA now requires black box warning for adverse effects

second line medications
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
combination medications
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)

combination medications cont d
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)

considerations and contraindications
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
case study questions
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?


The Tobacco Recovery Resource Exchange

E-Learning and Online Resources


Email: [email protected]



Email: [email protected]

BeBetter Networks NRT