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Treating Tobacco Dependence in Patients with Other Addictions

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areddick
57 diapositives · 602 Views · Jan 04, 2020

This article explores the co-occurrence of tobacco dependence and other addictions, highlighting the high risk of premature mortality in this population. It also discusses the benefits of treating tobacco dependence simultaneously with other addictions.

#treating tobacco dependence in patients with other addictions #treating tobacco dependence in patients with other addictions ppt #powerpoint #presentation
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  1. Treating Tobacco Dependence in Patients with Other Addictions Richard D. Hurt, M.D. Professor of Medicine, Mayo Clinic College of MedicineDirector, Nicotine Dependence Centerhttp://ndc.mayo.edu

  2. Smoking and Mental Illness • 22% of people who have never been diagnosed with a mental illness currently smoke. • 34.8% of people who have had been diagnosed with a mental illness sometime in their life currently smoke. • 41% of people who have been diagnosed with a mental illness In the past month currently smoke • 44% of all cigarettes smoked are by people with a ‘past-month’ mental health diagnosis. Lasser et. Al. 2000

  3. Nicotine Dependence and Psychiatric DisordersU.S. Adults • National Epidemiologic Survey on Alcohol and Related Conditions • Face-to-face interviews (N=43,093) to determine co-occurrence of DSM-IV nicotine dependence and Axis I & II psychiatric disorders • NIAAA Alcohol Use Disorder and Associated Disabilities Interview Schedule – DSM-IV • Current cigarette use = any use in past year. Characterized on days smoked and cigarettes usually smoked Grant BF. Arch Gen Psychiatry 61:1107, 2004

  4. Nicotine Dependence and Psychiatric DisordersU.S. Adults Grant BF. Arch Gen Psychiatry 61:1107, 2004

  5. Prevalence of Psychiatric Disorders Among Respondents with Nicotine Dependence Grant BF. Arch Gen Psychiatry 61:1107, 2004

  6. Prevalence of Nicotine Dependence Among Psychiatric Disorders Grant BF. Arch Gen Psychiatry 61:1107, 2004

  7. Alcoholism and SmokingBackground • Regular smoking usually precedes development of alcoholism • 2-3x  in prevalence of smoking among substance abusers • 10x  in prevalence of alcoholism among heavy smokers vs. nonsmokers • Smoking alcoholics constitute 26% of all smokers

  8. Alcoholism and Tobacco DependenceBill Wilson, AA Co-founder “A heavy, sloppy smoker all his life, he developed emphysema in the 1960s. It killed him. He gave his last speech to the International AA Convention in Miami in 1970, lifted to the platform in a wheelchair, gasping for breath and sucking oxygen from the tank that was always with him.” Robertson: Inside Alcoholics Anonymous

  9. Mortality Following Inpatient Addictions TreatmentStudy Design • Olmsted County patients admitted for inpatient addictions treatment 1972-1983 • Follow-up through 1994 – Rochester Epidemiology Project • Vital status and death certificates • CDC classification of alcohol or tobacco-related cause of death Hurt RD, et al. JAMA 275:1097, 1996

  10. Mortality Following Inpatient Addictions TreatmentPatient Demographics • n=845 (65% men, 35% women) • Mean age at admission – 41.4 years • 78% alcohol only, 18% alcohol and other drugs • 75% current and 8% former smokers • Length of follow-up/patient – 10.55.6 years (8913 pt/yrs) Hurt RD, et al. JAMA 275:1097, 1996

  11. Hurt RD, et al. JAMA 275:1097, 1996

  12. Mortality Following Inpatient Addictions TreatmentTobacco or Alcohol Cause of Death Hurt RD, et al. JAMA 275:1097, 1996

  13. Mortality Following Inpatient Addictions TreatmentConclusions • High risk for premature mortality • Tobacco-related diseases leading cause of death • Treating tobacco dependence is imperative in this high risk group Hurt RD, et al. JAMA 275:1097, 1996

  14. Treating Alcohol and Tobacco Dependence SimultaneouslyDesign • Prospective nonrandomized controlled trial with 1 year abstinence outcomes • Inpatient addictions treatment unit • Control group (n=50) – usual care • Intervention group (n=51) • Consultation • Group sessions (5) • Education sessions (5) • Telephone follow-up Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994

  15. Treating Alcohol and Tobacco Dependence SimultaneouslySubstance Use History Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994

  16. Treating Alcohol and Tobacco Dependence SimultaneouslyAbstinence Outcomes Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994

  17. Treating Alcohol and Tobacco Dependence SimultaneouslyConclusions • 11.8% tobacco abstinence rate acceptable but can be improved • Study run in less than optimal environment • Perception that it is hard is real • No apparent negative effect on abstinence from alcohol or other drugs • Unit became tobacco-free after study Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994

  18. Nicotine Patch Therapy in Recovering Alcoholic SmokersBaseline Characteristics Hurt RD, et al. Addiction 90:1541, 1995

  19. Nicotine Patch Therapy in Recovering Alcoholic SmokersConclusions • More nicotine dependent than nonalcoholics • Can achieve short-term tobacco abstinence with nicotine patch therapy • May require more intensive intervention: • Dose matching • Longer treatment •  behavioral intervention •  relapse prevention Hurt RD, et al. Addiction 90:1541, 1995

  20. Nicotine Patch Therapy in Alcoholic SmokersDemographics Hays JT, et al. Ann Behav Med 21:244, 1999

  21. Nicotine Patch Therapy in Alcoholic SmokersTobacco Abstinence Rates Hays JT, et al. Ann Behav Med 21:244, 1999

  22. High Dose Nicotine Patch Therapy in Heavy SmokersMethods • Post hoc analysis of 1039 heavy smokers (30 cpd) • Screened for current alcohol problem with short alcohol dependence data questionnaire • Smokers with alcohol problems in past year were excluded • Nicotine patch dose – placebo, 21 mg, 35 mg, or 42 mg • Higher nicotine patch doses were “slightly more efficacious” Hughes, JR, et al. Drug Alcohol Depend 71:269, 2003

  23. High Dose Nicotine Patch Therapy in Heavy Smokers Hughes, JR, et al. Drug Alcohol Depend 71:269, 2003

  24. High Dose Nicotine Patch Therapy in Heavy SmokersConclusions • In heavy smokers with or without past history of alcohol problems, no difference in: • time to lapse • prolonged tobacco abstinence • Thus, past history of alcohol problems does not predict a worse outcome Hughes, JR, et al. Drug Alcohol Depend 71:269, 2003

  25. Bupropion for Smokers with past History of Alcoholism or DepressionResults • Neither PHMDD nor alcoholism associated with abstinence at EOT (p=0.93) or 1 year (p=0.23) • Dose response effect for bupropion at EOT (p<0.001) and 1 year (p=0.02) Hayford KE, et al. Br J Psychiatry 174:173, 1999

  26. Weeks 1-8Open label tailored nicotine patch therapy (n=195) Week 52 Bupropion 300 mg/d (n=56) Week 76 Follow-up Placebo (n=54) Pharmacologic Relapse Prevention for Recovering Alcoholic Smokers R01 AA-11219

  27. Nicotine Patch Dose Based on Serum Cotinine Hurt RD, et al. J Stud Alcohol 66:506-516, 2005.

  28. Tailored Nicotine Patch Therapy for Recovering Alcoholic SmokersSerum Cotinine

  29. Tailored Nicotine Patch Therapy for Recovering Alcoholic SmokersSmoking Abstinence Rates 100/195 96/195 94/195 94/195 95/195 93/195 94/195 75/195 Hurt RD, et al. J Stud Alcohol 66:506-516, 2005.

  30. 7-day point prevalence Continuous Abstinent (%) Visit number CP1120196B-1 Tailored Nicotine Patch Therapy forRecovering Alcoholic SmokersSmoking Abstinence Hurt RD, et al. J Stud on Alcohol, 66:506, 2005

  31. Tailored Nicotine Patch Therapy for Recovering Alcoholic SmokersConclusions • Excellent 8 week smoking abstinence rate (51%) with tailored nicotine patch therapy • Dosing algorithm works • No evidence of nicotine toxicity • Very low rate of relapse to drinking Hurt RD, et al. J Stud Alcohol 66:506-516, 2005.

  32. Nicotine Patch Therapy in Alcoholics • Efficacy of 21 or 42 mg x 4 wk (then taper) nicotine patch doses in heavy smokers (N=130) with PH alcoholism • FTND score 7.7, mean smoking rate 31.5 cpd • Median alcohol abstinence 4 months (69% receiving alcoholism treatment at the time of enrollment) • Longer alcohol abstinence predicted better smoking abstinence outcome Kalman D, et al. Psychol Addict Behav 18:78-82, 2004

  33. Nicotine Patch Therapy in Alcoholics Kalman D, et al. Psychol Addict Behav 18:78-82, 2004

  34. Treating Alcohol and Tobacco DependenceRationale to Initiate Treatment During Treatment of other Dependencies • Serious cause of morbidity/mortality • Closely related behaviors • Eliminates a cue to drink • Common message • Apply same treatment philosophy • Protected milieu to initiate an attempt • Many patients in CD programs express interest in stopping tobacco (46-70%)

  35. Treating Tobacco Dependence in Alcoholics in Treatment or Recovery • Meta-analysis of 19 randomized controlled trials • Post-treatment intervention effects (but not long-term) were significant and comparable for patients in addictions treatment or recovery • Tobacco dependence interventions provided during addictions treatment  (25%) long-term alcohol and/or drug abstinence Prochaska JJ, et al. J Consult Clin Psychol 72:1144-1156, 2004

  36. Timing of Alcohol and Smoking Cessation (TASC) • Smokers in treatment for alcohol dependence willing to consider stopping smoking • Randomized to concurrent treatment or delayed treatment 6 months after alcohol dependence treatment • N=499, mean age 39.2, mean CPD 25.5, FTND 6.0, 47% previously used NRT or bupropion Joseph AM. J Addict Dis 22:87-107, 2003