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Quick Facts Mental Illnesses
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1. Pharmacological Treatments for Smoking Cessation
Allen Y. Masry, MD
Assistant Professor Addiction Psychiatrist
Department of Psychiatry
UMass Memorial Medical Center/ UMass Medical School
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2. Quick FactsMental Illnesses & Tobacco 7.1% of the U.S. population has a psychiatric
illness; however, this population consumes over 34.2% of all cigarettes. (Grant et al., 2004)
In the U.S., persons with mental illnesses
represent an estimated 44.3% of the tobacco
market and are dependent at rates 2-3 xs the
general population. (Grant et al., 2004)
Smoking quit rates for individuals with
psychiatric illness are NOT significantly lower than the general population. (el-Guebaly et al., 2002) 2
3. Session goals: Some info on smoking and psychotropics
Review of available medications for Smoking Cessation, both nicotine and non- nicotine.
Role of medications in smoking cessation and maintenance of smoking.
Review Smoking and SMI
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5. Ranking of nicotine in relation to other drugs in terms of addiction 5
6. Tobacco Effects on Psychiatric Medication Blood Levels Smoking induces the P450s 1A2 isoenzyme secondary to the polynuclear aromatic hydrocarbons
Smoking increases the metabolism of some medications
Haldol, Prolixin, Olanzapine, Clozapine, Mellaril, Thorazine, etc
Caffeine is metabolized through 1A2
CHECK for medication SE or relapse to mental illness with changes in smoking status
Nicotine does not change medication blood levels (2D6)
NRT doesnt affect medication blood levels
Nicotine may modulate cognition, psychiatric symptoms, and medication side effects 6
7. Nicotine Replacement Therapy (NRT)
-Patch (OTC)
-Gum (OTC)
-Lozenge (OTC)
-Oral Inhaler (Rx)
-Nasal Spray (Rx)
Non-Nicotine Medications
-Varenicline (Chantix, Rx)
-Bupropion Hydrochloride (Rx)
First-Line Medications 7 Medications used in tobacco dependence treatment are classified as first-line and second-line medications depending on how safe and effective they are. Except for sustained release Bupropion all medications classified as first-line replace the mode of nicotine delivery, so they are called nicotine replacement therapy.Medications used in tobacco dependence treatment are classified as first-line and second-line medications depending on how safe and effective they are. Except for sustained release Bupropion all medications classified as first-line replace the mode of nicotine delivery, so they are called nicotine replacement therapy.
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9. Reasons for Using NRT It works: roughly doubling success rates.
It helps the person feel more comfortable (treats nicotine withdrawal syndrome).
It is very safe: the person is getting clean nicotine instead of dirty nicotine with 4000 plus chemicals.
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10. Nicotine withdrawal Withdrawal syndrome is a collection of signs and symptoms caused by abstinence
Nicotine or cigarette withdrawal?
Nicotine replacement reduces severity of withdrawal symptoms
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11. Sign of Nicotine Toxicity Extremely RARE IN SMOKERS & thus even more rare in NRT use.
Nausea and/or vomiting
Sweating
Vertigo and/or Light-headedness
Tremors
Confusion
Weakness
Racing heart
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12. Nicotine Patch Dosing:
< 10 cigs/day: 14 mg patch
= 10 cigs/day: 21 mg patch
Length of Treatment:
Up to 12 weeks (PDR)
Use:
Apply to clean skin area
(upper trunk/ arms)
24 or 16 hour dosing, try
24 to dec. morning craving
Watch for nightmares
Given with or without taper
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13. Nicotine Gum Dosing:
2mg < 25 cigarettes/day
4mg > 25 cigarettes/day
Length of Treatment:
8-10 weeks (PDR)
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15. Nicotine Lozenge Use: Allow to dissolve (Dont Chew but Suck like a hard candy.)
Pros: Flexible dosing (Up to 20 lozenges/ day)
More discreet than gum; Keep mouth busy; OTC;
Cons: Need to use correctly (dont chew, suck)
May cause insomnia, some nausea,
hiccups, heartburn, coughing
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16. Nicotine Nasal Spray Dosing:
1-2 doses per hour
1 does = 2 spays (1 spray/nostril)
Use enough to control withdrawal symptoms
Length of Treatment:
3-6 months weeks (PDR)
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17. Nicotine Nasal Spray Use: Spray (dont sniff, swallow, or inhale)
PRN or fixed-schedule (1-2 doses/hour)
Pros: Rapid delivery though nasal mucosa
Flexible dosing (up to 40 doses)
Cons: Nasal irritation, rhinitis, coughing, &
watering eyes.
Some dependence liability
Rx needed
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18. Nicotine Medications Use high enough dose
Scheduled better than PRN
Use long enough time period
Can be combined with Bupropion
Dont combine with Varenicline
Can be combined with eachother
Have very few contraindications
Have no drug-drug interactions 18
19. Efficacy of NRT medications 19
20. 20
21. Some strategies Recommended doses of nicotine replacement therapy are inadequate for many smokers
In heavy smokers, under dosing may limit the effectiveness of patch
Patch plus Gum
Improves abstinence rates (Kornitzer 1995, Puska 1995)
Decreased withdrawal (Fagerstrom 1993)
Well tolerated
UMass uses up to 42mg patch or patch plus GUM
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23. Smoking with NRT Relatively safe
Harm Reduction
Less reinforcing effects
Not a distraction from quit attempts
(Benowitz 1997, Hartman 1991, Slade 1995)
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24. Concern about this is not supported by data.
Joseph took a high risk cardiac group and put them on patch or placebo.
49% with active angina
40% with history of heart attack
35% with history of cardiac bypass
No increase in cardiac events for the patient group
21% of the patients were not smoking at the end vs 9% of the placebo group.
Jiminez-Ruiz put severe COPD patients on nicotine gum
Most patients continued to smoke, though less.
No adverse events attributed to nicotine.
COPD (chronic obstructive pulmonary disease) got better
(Joseph AM. NEJM 335:1792-8, 1996 & Jiminez-Ruiz. Respiration 69:452-6, 2002)
Slide copied from OASAS. Smoking and NRT: IS THAT SAFE? 24
25. Conclusions Nicotine Replacement Therapy is being provided to assist tobacco users to become tobacco free.
NRT is not a treatment in itself, but is intended to complement the other assessments and treatments provided.
NRT works by reducing craving and withdrawal severity, enabling the patient to feel comfortable and able to concentrate on other psychosocial treatments. 25
26. Non-Nicotine Pharmacotherapy First-line non-nicotine medications
-Bupropion (Zyban/Wellbutrin)**
-Varenicline (Chantix)**
Others (nortriptyline, clonidine)
**FDA Approved for smoking cessation 26
27. Bupropion Hydrochloride Dopamine and norepinephrine (noradrenaline) effects
Reduces cravings, withdrawal
Improved abstinence rates in trials
Less weight gain while using (Need to gain 100 pounds to diminish health benefit)
Start 7-10 days prior to quit date
Continue 7-12 weeks or longer
( > 6 months)
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28. Bupropion Precautions Contraindicated: seizure disorder, eating disorders, electrolyte abnormalities, MAO use
OK with SSRIs
NOT dangerous to smoke while taking
Monitor blood pressure
Side effects:
Insomnia (40%)
2nd dose early evening helps
Dry mouth
Headaches
Rash 28
29. Bupropion Efficacy 29
30. Varenicline (Chantix) Action at ?4?2 nicotine receptor
Partial agonist/antagonist
Releases lower amounts of dopamine into brain than smoke
Reduces withdrawal
Not as addictive as smoke
Blocks nicotine from binding to receptor
Prevents reward of smoking
31. Varenicline (Chantix) Action at ?4?2 nicotine receptor
Partial agonist/antagonist
Releases lower amounts of dopamine into brain than smoke
Reduces withdrawal
Not as addictive as smoke
Blocks nicotine from binding to receptor
Prevents reward of smoking 31
32. Dosing Titrate dose from 0.5 mg daily to twice daily to 1 mg twice daily over 1 week
Abstinence rates better vs. placebo and Bupropion at 1 year
Optimal duration 12-24 weeks
Most common side effect is nausea
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33. Abstinence by medication use 33
34. Serious Mental Illness Reduced Cessation
-Schizophrenia/Schizoaffective disorder
-Bipolar disorder
-PTSD
-Alcohol use disorder 34
35. Smoking and Schizophrenia High prevalence of smoking (about 90%, OR = 5.9)
Highly nicotine dependent (FTND = 7 or higher)
Nicotine produces cognitive or other benefit
Smoking ameliorates medication side effects (e.g., lower rates of neuroleptic-induced Parkinsonism) 35
36. Smoking and Schizophrenia (Continued) Smokers with schizophrenia take in more nicotine per cigarette than smokers without this disorder
Higher levels of positive symptoms and decreased negative symptoms
Ad libitum smoking increases after initiation of haloperidol
SCZ tend to smoke less on clozapine 36
37. Neurobiology of Smoking and Schizophrenia Decreased low affinity and high affinity nAChRs
Abnormal P50 responses are normalized
Improved Spontaneous Pursuit Eye Movement and decreased Saccades with nicotine
Improved cognition and attention 37
38. Smoking & Bipolar Disorder High prevalence of smoking: 61-80%
Findings are inconsistent regarding the prevalence of smoking between bipolar disorder with and without psychotic features
Bupropion is contraindicated
Quit rates are comparable to general population and durable
Quit rates enhanced with CBT
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39. Smoking and Depression The prevalence of smoking: 37-60%
Leads to more severe nicotine withdrawal symptoms
- High risk for relapse in first week
- Female > Male
30% risk of relapse to MDE after quitting if past history present
Depressed smokers have higher suicide rates than depressed nonsmokers
(Bruce, 1994; Lohr, 1992; Yassa, 1987)
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40. Link Between MDD and Smoking 40
41. Smoking and Depression (Continued) NRT alone insufficient treatment for smokers with current and/or past MDD
Combining NRT with non-NRT pharmacotherapy appear to be promising for smokers with depression (Ait-Daoud et al., 2006)
CBT that emphasizes group cohesion and social support appears to be particularly effective for depressed smokers with or without alcohol dependence
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42. Smoking and Anxiety D/O The prevalence of smoking: About 35-50%
Smokers have greater anxiety and panic symptoms than non-smokers
Heavy smoking in adolescent is associated with higher risk of developing Agoraphobia, GAD, and Panic Disorder
PTSD:
Increased risk for relapse in first two weeks of quit attempt
Increased the risk of smoking and nicotine dependence
lower rates for quitting smoking & remission from nicotine dependence
Stopping smoking not associated with worsening of PTSD
Bupropion tolerated and effective treatment
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43. SSRIs and Smokers with Anxiety Disorder No benefit for smoking cessation
Can reduce likelihood of emergent anxiety and panic during quit attempt
Bupropion is not appropriate as only medication
Can be combined with NRT/Bupuropion
Can be combined with varnicline 43
44. Smoking and Alcohol Dependence High prevalence of smoking: 80-95%
Two studies reporting similar outcomes of NRT in alcoholics compared with non-alcoholics (e.g., Grant et al., Alcohol, 2007)
Tobacco dependence treatment does not cause abstinent alcoholics to relapse (Hughes & Callas, 2003)
Smoking cessation reduces the risk of alcohol relapse (Sobell et al., 1995)
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45. Smoking and Alcohol Dependence (Continued) Bupropion added to nicotine patch did not improve smoking outcomes
Topiramate group was significantly more likely to become abstinent (OR = 4.46) compared with placebo group (Johnson et al., 2003)
Topiramate group reported more weight loss compared with placebo group (44% vs. 18%) 45
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47. Benefits of Treating Tobacco Dependence in Mental Healthcare Settings Emerging evidence shows that morbidity is reduced
May enhance abstinence from other substances
Reduced financial burden
Increased self-confidence 47
48. Conclusions Pharmacotherapy works and is relatively safe
Many options now available
Patients should be given accurate expectations (no magic bullet) 48