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Addressing Nicotine Dependence in Drug Treatment

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  1. Addressing Nicotine Dependence in Drug Treatment Kimber Paschall Richter, PhD, MPH Robert M. McCool, MS University of Kansas School of Medicine, Kansas City

  2. Thanks to: • KC Area Methadone Clinics • KU Methadone Clinic • Paseo Clinic • KCTC • DRD-KC • Bridgeway Recovery • Rodgers South • NIDA • Robert Wood Johnson Foundation • CSAT OPAT

  3. Active Drug Users CAN Quit Smoking • 16,661 participants, NHSDA • 1,465 used and illicit drug past month • Most were occasional marijuana users • Most (71%) current users smoke • 1 IN 5 (21%) current users were FORMER smokers • Quit rate of 23%(% of “ever” smokers that have quit) • Compared to about 50% quit rate in general population

  4. People in Treatment CAN Quit, Too • 550 participants, KC Metro Methadone Survey • 84% patients participated • Most (77%) smoke cigarettes • 11% were FORMER smokers, 11% NEVER smokers • Quit rate of 12%

  5. Why Quit? I see my grandparents, my relatives that have all got emphysema. …They can’t go to the mall. They can’t go to dinner. … And I think why should I keep doing this shit to me. [Noah] I don’t want to get hurt and I don’t want to hurt anyone else. … I have three babies. …I am falling asleep with cigarettes in my hand and that is the reality that I need to stop smoking. [KCTC, unidentified]

  6. Patients That Smoke Pay the Price Addictions patients that continue to smoke die from tobacco related illnesses • 11-year longitudinal study of 845 addictions patients: 51% of deaths were related to tobacco • 24-year follow-up of 405 patients from ‘60s: death rate of smokers 4X that of non-smokers

  7. Can We Help MORE Quit? (Sussman 2002) • 24 studies • 9 inpatient, 5 newly “sober”, 5 sober several years, 3 teen inpatients, 2 opioid/cocaine outpatient • Generally small sample sizes, descriptive • Outcomes • Inpatient no higher than 12% abstinent, 6 months • Outpatient as high as 25%, 1 year • Sober several years – up to 46% abstinent, 1 year • 2003 study: Past alcohol problems do not predict worse smoking cessation outcomes (Hughes et al.)

  8. Helping Methadone Patients Quit • Shoptaw et al., 2002 • 2X2 design, 175 patients • 12 weeks of treatment • all got patches, were assigned to a mix of relapse prevention and contingency management • up to 36% quit during treatment, most relapsed afterwards • tobacco free=drug free • Ongoing studies • Clinical Trials Network patch study (Malcolm Reid, PI) • Rhode Island Patch Study (Michael Stein, PI)

  9. Breathe Easy (Ongoing pilot study, Richter et al.) • 28 patients from 5 local clinics • Dual pharmacotherapy, counseling • Bupropion – 7 weeks • Nicotine gum – 12 weeks • 20% were quit at 6 months • Excellent attendance – 85% of all appointments were made, 2 lost to follow up

  10. Who Treats Patients, Why & Why Not? • Which clinics provide services, what services do they provide? • What clinics do/don’t provide services • Understand barriers, benefits for clinics • Understand covert/overt pro-smoking forces • How well clinics adhere to guidelines for treating nicotine dependence (5 A’s) • Help policymakers support clinics

  11. Services Provided, Past 30 Days % Providing service to at least 1 patient NRT Zyban Groups Brief Advice Counseling Referral Brochure Acupunct.

  12. Staff not trained Patients not interested Other drug treatment more important Not enough staff Clinic does not receive reimbursement Staff are too busy Staff smoke cigarettes Smoking treatment is ineffective Other Most Important Barrier to Providing Smoking Cessation Services

  13. Name 3 Clinic Benefits From Providing Smoking Cessation Services • Improve health of all • Permit more comprehensive services • Improve drug treatment • Monetary/financial benefits for clinic/patient • Cleanliness, Aesthetics • Improved education for clinic or patient • No benefit or unclear benefit Total comments = 593

  14. Lessons Learned • People in recovery CAN quit smoking • Methadone clinics DO help with quitting • But not routinely • There ARE barriers to offering services • There are also BENEFITS to offering services

  15. Recommendations • Need culture change to create more support & encouragement for quitting • Regulatory agencies could require/encourage clinics to >in some way< address nicotine addiction among stable patients • Methadone clinics need CEUs – offer Nicotine Dependence Treatment Training! • Could find clinics that are already doing it, empower them to disseminate programs