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A Look at a Consumer Peer Based Program with Jill Williams, MD

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From the the first Annual National Conference on Tobacco and Behavioral Health, which occurred May 19-20, 2014 in Bethesda, MD and was hosted by the Central East Addiction Technology Transfer Center, a program of The Danya Institute. You can see videos from the conference on our website www.ceattc.org (go to “Tobacco and Behavioral Health Resources” under “Special Topics”).

Having peers who have succeeded in recovering from tobacco dependence talk to smokers with mental illness offers advantages. Advantages of using peer counselors include reduced language and cultural barriers, increased trust and lowered defenses, and low cost. Peer counselors are often rated highly by other consumers and there is an added benefit in the modeling that comes from seeing peers do well and return to work. We have promoted community based advocacy and education through the CHOICES Program (Consumers Helping Others Improve their Condition by Ending Smoking). CHOICES employs mental health peer counselors known as Consumer Tobacco Advocates (CTA) to deliver the vital message to smokers with mental illness that addressing tobacco use is important and to motivate them to seek treatment. The philosophy of CHOICES is to bring information to smokers with mental illness about the harm of tobacco, as well as the benefits of quitting and possibilities of treatment. Additional goals are to enhance advocacy and education about addressing tobacco in mental health treatment settings through strong partnerships with a consumer advocacy organization (Mental Health America) and state government (New Jersey Division of Mental Health Services).
Participants will be able to:
- Understand the benefits of using peer counselors to disseminate health education information and increase demand for tobacco services
- Examine existing community relationships and partnerships that will help promote culture change in mental health systems.
- Understand how materials like newsletters and websites increase the reach of peer counselors
- Become familiar with CHOICES, a peer delivered tobacco dependence education and intervention program in New Jersey

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A Look at a Consumer Peer Based Program with Jill Williams, MD

  1. 1. Smokers with MI or SMI Reduced Quitting over Lifetime Mental Illness (MI) = anxiety, MDE, PTSD, psychoses, bipolar, drug dependence Serious Mental Illness (SMI)= measured by K6 Hagman 2007; McClave 2010; Lasser 2000; Pratt & Brody 2010 FormerSmokers(%) E= N x S Exsmokers =(number trying to quit) x (success of attempts) R West, 2013
  2. 2. Smokers with Depression Less Likely to Quit fewer former smokers
  3. 3. Smoking Cessation in Outpatient SA treatment • Part of CTN, included methadone sites • N=225 smokers  SC adjunct or  treatment‐as‐usual (TAU)  9 weeks group counseling plus NP • No difference in SC vs TAU –on rates of retention in SA tx –abstinence from primary substance –craving for primary substance. Reid et al., 2008
  4. 4. Heaviness of Smoking Index= Measure of Dependence Number of cigarettes per day (cpd) AM Time to first cigarette (TTFC) ≤ 30 minutes = moderate  ≤ 5 minutes = severe  Heatherton 1991
  5. 5. Smokers with Depression Smoke More CPD & Are More Dependent
  6. 6. Greater Nicotine Dependence in Serious Psychological Distress 0 10 20 30 40 50 60 70 NDSS TTFC 5 Mins TTFC 30 Mins SPD no SPD % 2002 National Survey on Drug Use and Health; Hagman et al., 2008 SPD= Estimate of Serious Mental Illness
  7. 7. Smokers in Addiction Treatment Moderately to Severely Addicted to Nicotine N=1882 smokers in NJ addictions treatment, 2001-2002; Williams et al., 2005
  8. 8. Williams et al., NTR 2010 Individuals with Schizophrenia Highly Addicted 4 minute Nicotine Boost (ng/mL) 25.2 vs. 11.1 ; p<0.01 Greater nicotine intake per cigarette
  9. 9. Tobacco Withdrawal Emerge hours after last cigarette Can last for (4) weeks Depressed mood Insomnia Irritability, frustration or anger Anxiety Difficulty concentrating Restlessness Increased appetite or weight gain DSM-5
  10. 10. Reduced Success Quitting in Smokers with Anxiety Disorders panic, social anxiety or GAD More withdrawal symptoms Piper et al., 2010
  11. 11. NRT and Agitation in Smokers w/Schizophrenia: • 40 smokers in psych ER • 21mg patch vs placebo patch • Usual care for psychosis • Agitated Behavior was 33% less at 4  hours and 23% lower at 24 hours for  NRT group • Better response in lower dependence • Same magnitude of response as  antipsychotic studies Allen 2011; Am J Psych
  12. 12. READINESS to QUIT in SPECIAL POPULATIONS * No relationship between psychiatric symptom severity and readiness to quit Smokers with mental illness or addictive disorders are just as ready to quit smoking as the general population of smokers. Slide Courtesy J Prochaska; Acton 2001; Prochaska 2004; Prochaska 2006; Nahvi 2006
  13. 13. Barriers to Addressing Tobacco in Mental Health • Undervalue of tobacco use as an addiction • Consumers/ families minimize the health risks of  tobacco  • Professionals/ MH systems have been slow to  change  in addressing tobacco • Lack the knowledge about effectiveness of  treatment • Lack of advocating for treatment • Lack of adequate reimbursement Williams & Ziedonis, Addictive Behaviors, 2004 Clinicians Belief that patients were not interested in quitting was a major barrier to giving smoking cessation treatment Almost HALF (42% of patients) answered “yes” to question Do you have an interest in quitting on their psychiatric assessment from charts (49/117) reviewed same study 77% 83% 0 20 40 60 80 100 120 Himelhoch Williams Williams et al., in press; Himelhoch et al., 2014
  14. 14. Which Approach to Take Implement current evidence based practices?  Public health model  Primary care  Brief strategies  Limited insurance coverage  Telephone counseling Develop tailored approaches?  Clinical/ co-occurring treatment model  Behavioral health  Face to face  Longer treatment  Expanded Medicaid and Medicare coverage for treatment
  15. 15. Behavioral Health Professionals are  Experts in Psychosocial Treatments • Counseling = First‐line treatment • Effective treatments: Individual or group;  CBT, relapse prevention, social skills • Intensive Treatments – Sessions > 10 minutes – More than 4 sessions – Tobacco treatment specialists – Behavioral health and/or addictions  specialists
  16. 16. Need for Pharmacotherapy in Tobacco Users w/MI and SUD No reason not to use NRT is not a “new drug” First line treatment/ Recommended all  Comfortable detox for temporary abstinence Higher levels of nicotine dependence Psychiatric inpatients not given NRT were >  2X likely to be discharged from the hospital  AMA Fiore 2008; Prochaska 2004
  17. 17. Old NRT Guidelines With caution (talk to doctor) if: Recent MI Smokes < 10 cpd Pregnant/breastfeeding  Adolescents (Not FDA approved) Mild side effects Mostly local Systemic, less common NRT Labeling Updates • No significant safety  concerns associated  with using more than one NRT  • No significant safety concerns  associated with using NRT at the  same time as a cigarette.  • Use longer than 12 weeks is safe APRIL2013 www.fda.gov/ForConsumers/ConsumerUpdates/ucm345087.htm
  18. 18. Varenicline and Suicide  80,660 smokers prescribed  NRT (~63k), varenicline (~11k), and  bupropion (~6k);    UK, primary care  Compared with NRT, the hazard ratio for self harm among  people prescribed varenicline was 1.12 (95% CI 0.67 to 1.88),  and it was 1.17 (0.59 to 2.32) for people prescribed  bupropion.  No clear evidence that varenicline was  associated with an increased risk of fatal (n=2)  or non‐fatal (n=166) self harm  No evidence that varenicline was associated  with an increased risk of depression or suicidal  thoughts Gunnell et al., 2009; BMJ
  19. 19. Review of Studies for Neuropsychiatric Adverse Events • 17 Pfizer‐sponsored studies (N=8027) – 1004 with psychiatric • DOD (N=35,800) VAR vs NRT – No ↑ in hospitaliza ons for AE – Prior to FDA warning;  gen pop sample • Depression, aggression/agitation, suicidal  events and nausea Gibbons et al., AJP, 2013 • VAR not significantly associated with suicidal  thoughts or behavior (OR=0.57) • VAR not significantly associated with  depression (OR=1.01) • VAR not significantly associated with  aggression/ agitation (OR=1.27) • Rates of NPAE   2.28% VAR vs  3.16% for NP
  20. 20. Varenicline‐ Major Depression • 525 past h/o or stable, treated MDE; >10  cpd • MADRS, HAM, C‐SSRS, SBQ • 73% on antidepressants (SSRI or SNRI) • VAR More effective vs placebo • Week 12 CAR: 35.9% vs 15.6%  for placebo   (OR 3.35; p<0.001) • 24 and 52 week outcomes also significant Anthenelli et al., Ann Int Med, 2013
  21. 21. No Worsening of Depression Scores No difference in AEs (abnormal dreams, anxiety, agitation, restlessness, SI) Anthenelli et al., Ann Int Med, 2013
  22. 22. Safety and Efficacy of Varenicline  for Smoking Cessation Schizophrenia/  Schizoaffective Disorder P=0.09 OR: 6.18 95% CI: 0.75, 50.71 P=0.046 OR: 4.74 95% CI: 1.03, 21.78 Participants(%) 10/83 (11.9%) 2/43 (4.7%) 16/83 (19.0%) 1/43 (2.3%) Williams et al., J Clin Psychiatry 2012 At Weeks 12 and 24 Abstinentsubjects(%) Week 24 By week Varenicline Placebo Varenicline Placebo
  23. 23. No Worsening Schizophrenia PANSS by Week Mean Score Mean baseline total score Varenicline: 55.8 Placebo: 54.4 Total score Week No significant changes in PANSS from baseline in any treatment arm in total score or sub-scores Positive symptom score Negative symptom score Anxiety item Depression item Varenicline Placebo Williams et al., J Clin Psychiatry 2012
  24. 24. Maintenance Varenicline Greater abstinence at 1 year 87 smokers with SCZ/ BPD from open label phase Randomized at week 12 to 1mg BID Evins, JAMA 2014; Pachas et al., JDD 2012
  25. 25. No treatment effect on psychiatric symptoms, health, BMI Evins, JAMA 2014; Pachas et al., JDD 2012
  26. 26. Improved Mental Health with Quitting Smoking • Meta‐analysis 26 studies (14 gen pop, 4 psychiatric, 3  physical conditions, 2 psychiatric or physical, 2 pregnant, 1  post‐op)  Taylor et al, BMJ, 2014
  27. 27. Reduced Access to Tobacco Treatment in Behavioral Health Settings • Nicotine dependence documented in 2% of mental health records • Only 1.5% of patients seeing an outpt psychiatrist received treatment for smoking Peterson 2003; Montoya 2005; Himelhoch 2014 Less than half (44%) of clinicians in community mental health sites ask their patients about smoking
  28. 28. State Hospital Smoking Survey 2011; 206 Hospitals Surveyed; 80% response rate Almost 80% no‐smoking on premises Less than 35% treatment Schacht et al., NASMHPD Research Institute, Inc. 2012 0 20 40 60 80 100 2006 2007 2011 % Tobacco Free State Hospitals Treatment 35%
  29. 29. Less than Half of US Substance  Abuse Facilities Treat this Substance National survey of  550 OSAT units (2004–2005) – 88% response rate 41% offer smoking  cessation counseling or pharmacotherapy 38% offer individual/group counseling 17% provide quit‐smoking medication  Friedmann et al., JSAT 2008 41%
  30. 30. This probably isn't the best way to quit smoking
  31. 31. Conclusions Reduced lifetime quitting  Higher levels of nicotine dependence and  psychosocial factors  Need for combination (medications +  counseling) approaches Treatments safe and do not worsen illness Reduce barriers to treatment in behavioral  health setting

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