Tobacco Use in Special Populations: Young Adults with Psychiatric and Substance Use Disorders

1. Tobacco Use in Special Populations: Young Adults with Psychiatric and Substance Use Disorders Eric Heiligenstein, M.D. Clinical Director, Psychiatry Service University Health Services Associate, CTRI University of Wisconsin-Madison

2. Objectives Identify disproportionate smoking rates among young adults experiencing Psychiatric/Substance Use (PD/SUD) disorders Understand the additive morbidity and mortality to smokers with PD/SUD Discuss the barriers to identification and cessation efforts in mental health/substance abuse practices Understand the concurrent treatment needs of young adults with PD/SUD when they are treated for nicotine dependence

3. Smoking Prevalence in the U.S.

4. Tobacco Use Disparities Ethnic minorities Low SES/educational level Pregnant women Youth/Young adults

5. During 1983--2003, a sustained decline in cigarette smoking occurred in all age groups except persons aged 18--24 years

6. College Students and Smoking 45.7% of students use a tobacco product in past year 20% of occasional smokers become daily smokers 14% are daily smokers

7. �Occasional Smokers� Experience more emotional or physical abuse Utilization of mental health and ER services Higher-risk alcohol use Greater depression

8. Tobacco Use Disparities Ethnic minorities Low SES/educational level Pregnant women Youth/Young adults Coexisting PD/SUD

10. 22% of Adults have a Psychiatric Disorder: Consume 45% of cigarettes smoked in U.S

11. Smoking Rates Compared to the Number of Lifetime Psychiatric Diagnoses

12. Complications of Smoking and PD/SUD Additive mortality risks Heart disease is 7X higher than peers and more than 7x the suicide rate. Smoking is severity of illness multiplier Average loss of life is 24 years

13. How Has the Field Responded? Nicotine dependence treatment is neglected Received cessation counseling 38% of visits with primary care 12% visits with psychiatrists Psychiatric inpatients 1% assessed for smoking status Not included in treatment plan Fifty five% college health services offer smoking-cessation programs

14. Fundamental Barriers and Challenges Neurobiological factors reinforce use of nicotine Feel excluded from mainstream cessation programs Lower rate of quit attempts Higher tobacco relapse rates

15. Broad Barriers and Challenges Self medication hypotheses as explanation Results in insufficient attention to other plausible explanations Discourages efforts in mental health treatment settings to promote tobacco cessation Individual rights to smoke Limitations to absolute freedom Addiction is not a real choice

16. Specific Barriers and Challenges Patients We are again �managing their lives� Providers Nicotine dependence treatment is seen as �one more thing� Systems Programs are nicotine dependent

17. Patient/ClientBarriers and Challenges Belief that nicotine dependence treatment will interfere with treatment of PD/SUD and jeopardize progress Lack of confidence in ability to quit successfully Poor access to nicotine dependence treatments

18. Patient/ClientBarriers and Challenges The cost of nicotine dependence treatments Beliefs by patients/clients� families/support people that mirror the broad barrier/challenges

19. Provider Barriers and Challenges Failure to define nicotine dependence treatment as part of their role Beliefs that nicotine dependence treatment will interfere with treatment and jeopardize patient/client progress Receive little or no training on nicotine dependence treatment

20. Provider Barriers and Challenges Beliefs that smokers with PD/SUD don�t want to quit A relatively high prevalence of smoking among providers themselves

21. System Barriers and Challenges Lack of resources Lack of reimbursement if nicotine dependence treatment services provided Little regulatory oversight that would promote best practices in nicotine dependence treatment Few incentives to promote best practices in nicotine dependence treatment

22. Rationale for Tobacco Treatment Demonstrated interest in quitting across populations Smoking cessation does not jeopardize stability of primary disorder or recovery Emerging evidence that morbidity is reduced May enhance abstinence from substances

23. We must expand the definition of �mental health treatment� to include the treatment of comorbid nicotine dependence that often accompanies psychiatric and substance use disorders

24. Clinical and Program Solutions

25. Intake Assessment Recommendations for Cessation Programs Past/current history of PD treatment and SUD recovery Current health history including medications Current life situation Social supports Tobacco use history Determine current interest in quitting If interested; determine readiness to quit

26. Intake Assessment Recommendations for PD/SUD Programs Use some form of the classic 5 A�s The 5 A�s (Ask, Advise, Assess, Assist, Arrange) Ask and Act (AAFP) ABC (Ask, Brief intervention, Cessation treatment) Formalize identification and action in health record

27. Treatment Principles for Nicotine Dependence Treatment in PD Motivation �Interested� is sufficient Don�t rule out initiating some type of intervention if not motivated to quit now Stability Need to be psychiatrically stable-do not need to be in full remission No major medication changes No major life changes No active intoxication/withdrawal; consumer/client in recovery process

28. Treatment Principles for Nicotine Dependence Treatment in PD Best delivered in context of ongoing therapeutic relationship May be more effective treatment Not brief episodic care Treatment may need to be repeated and protracted

29. Treating Nicotine Dependence in PD/SUD Traditional cessation treatments may be inadequate Flexibility in setting quit date Reduced smoking to reach abstinence Combination treatments (behavioral & medical)

30. Treatment Principles for Nicotine Dependence Treatment in PD All smokers trying to quit should receive pharmacotherapy (PHS Clinical Practice Guideline) Dose level and duration of drug treatment individualized Many will need Higher doses of medication Longer duration of treatment Combination treatments

31. Treating Nicotine Dependence in PD/SUD SRI antidepressants have no benefit for nicotine dependence Bupropion (BUP) effective in smokers with PD/SUD but relapse high when treatment discontinued Varenicline anecdotally effective

32. Pharmacotherapy for Nicotine Dependence in PD/SUD Nicotine replacement therapy (NRT) NRT rarely sufficient treatment Many smokers may require higher dose (42 mg) Many smokers may require more than one type of NRT (gum and patch) NRT/CBT has promising results for smokers with PD/SUD

33. Pharmacotherapy for Nicotine Dependence in PD/SUD Bupropion (BUP) Effective in wide number of PD Contraindicated in seizure and eating disorders Not recommended Alcohol abuse/dependence Bipolar disorder Extended sleep deprivation Past head trauma

34. Pharmacotherapy for Nicotine Dependence in PD/SUD Varenicline Anecdotal reports of effectiveness for PD/SUD One study in UK; positive results Gap in the varenicline evidence base Post marketing adverse behavior and mood changes Have been reported in all samples Causal links have not yet been established Providers need to closely monitor mental status of anyone quitting smoking on varenicline

35. Pharmacotherapy Principles Managing psychotropic medications Cessation may produce rapid, significant increase in blood levels Need to monitor for increased side effects

36. Michael is a 26-year old graduate student He has a past history of major depression, once when he was in high school, another time in college, and most recently following a relationship breakup. He presently smokes about a pack of cigarettes a day but stopped on his own 2 weeks ago using a nicotine patch. Shortly thereafter he developed intense thoughts of suicide. He was seen for an urgent consultation the next day.

37. Jake is a 20 year old male presenting with daily panic attacks and depression. Four weeks ago his physician started him on Sertraline 25 mg/day for anxiety. He had an adverse reaction (hallucination, increased anxiety, poor sleep) and stopped the medication after 2 days. His panic attacks have returned leading to an urgent Psychiatry referral. He also reported prominent symptoms of depression. He is a current smoker with no interest in quitting. He smokes 3-4 cigarettes/day and 1 year ago became a daily smoker. His first cigarette is within 30 minutes of awakening. He has no previous quit attempts.

38. Amber is a 23 year old female with a childhood diagnosis of ADHD. She returns for medication follow up as she stopped her Adderall XR 40 mg/day last month. She wishes to discuss alternative medication. She smokes 1 pack/day and notes that her intake dramatically increases when she takes Adderall (smoking 2-3 cigarettes at a time and over 1 1/2 pack/day). Last QA was this summer and lasted 2 weeks. It was unaided and she relapsed due to concnerns. Her first cigarette is upon awakening.

39. Closing the Deal Mental health providers ideal persons to deliver smoking cessation treatment Have therapeutic alliance with patients Patients will return for care (repeated QA encouraged) Cost effective (planned visits)

40. Public Health Best Practices Reduce exposure to environmental tobacco smoke Smoking bans and restrictions Decrease tobacco use initiation Increase unit price of tobacco products Mass media education campaigns featuring long-term, high intensity counter-marketing

41. Conclusions Most important barrier to overcome The internalized belief that our patients/clients cannot or will not quit, rather than looking at how we can help them do so

42. Conclusions Most important component is a sincere belief in the right of this population To receive the same level of health care assessment and treatment in regard to the use of nicotine that is the expectation for the general population

44. Question Authority: Ask Me Anything!

45. Contact Information Eric Heiligenstein, M.D. elheilig@wisc.edu 608-262-9199