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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

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Module 2 assessment diagnosis and pharmacotherapy integrating tobacco use interventions into chemical dependence s

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


Module 2 assessment diagnosis and pharmacotherapy integrating tobacco use interventions into chemical dependence s

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


Welcome

Welcome

  • Add Trainer Names


Housekeeping

Housekeeping

  • Hours of Training

  • Breaks

  • Restrooms

  • Tobacco Use Policy

  • Cell Phones

  • Active Participation

  • Complete Pre-test/Post-test

  • Complete Training Evaluation


Introductions

Introductions


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


Unit 1 assessment and diagnosis

Unit 1Assessment and Diagnosis


Screen and assess for tobacco use

Screen and Assess for Tobacco Use

Initial Assessment

(Intake)

Assessment is revisited many times during treatment


The five a s

The Five A’s

  • Ask

  • Advise

  • Assess

  • Assist

  • Arrange


Reframing language

Reframing Language


Discussion

Discussion

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


Discussion1

Discussion

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)

HONC

(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


Module 2 assessment diagnosis and pharmacotherapy integrating tobacco use interventions into chemical dependence s

40%

40%

20%


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


Assessing readiness willingness and ability to change tobacco use

Assessing Readiness, Willingness, and Ability to Change Tobacco Use


Dsm iv tr

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


Unit 2 tobacco treatment medications

Unit 2Tobacco Treatment Medications


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 patch

Nicotine Patch


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 gum

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 lozenge

Nicotine Lozenge


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 nasal spray

Nicotine Nasal Spray


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


Nicotine inhaler oral puffer

Nicotine Inhaler (Oral Puffer)


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

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


Varenicline cont d1

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


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


Unit 3 case studies

Unit 3Case Studies


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?


Module 2 assessment diagnosis and pharmacotherapy integrating tobacco use interventions into chemical dependence s

Bill J.


Module 2 assessment diagnosis and pharmacotherapy integrating tobacco use interventions into chemical dependence s

Barbara G.


Module 2 assessment diagnosis and pharmacotherapy integrating tobacco use interventions into chemical dependence s

Jorge G.


Module 2 assessment diagnosis and pharmacotherapy integrating tobacco use interventions into chemical dependence s

Alvin C.


Module 2 assessment diagnosis and pharmacotherapy integrating tobacco use interventions into chemical dependence s

Maryann P.


Resources

Resources

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]


Resources1

Resources

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

Email: [email protected]

BeBetter Networks NRT

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


Post test and workshop evaluations

Post-Test and Workshop Evaluations


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