MI.smokingcme.cs2day
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The document provides information about using motivational interviewing to help patients quit smoking. It discusses the key concepts of MI including expressing empathy, developing discrepancy, avoiding argumentation, and supporting self-efficacy. Treatment options that are discussed include pharmacotherapy, behavioral modification, and arranging follow-up to monitor progress.
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MI.smokingcme.cs2day
- 1. Smoking Cessation Using motivational interviewing
- 5. Jay Lee Suzanne Mitchell
- 7. ASK… about smoking status at every adult patient visit
- 9. Advise… your patients to quit smoking
- 10. Assess… your patient’s current willingness to quit smoking
- 12. And There is the Problem: How do you Assess and Proceed? And avoid the lecture.
- 15. Motivational Interviewing Miller and Rollnick
- 16. Motivational interviewing is a person-centered directive (guided) method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence and resistance.
- 18. Let’s explore the key concepts…
- 31. R oll With R esistance
- 34. R oll With R esistance You try it.
- 36. E xpress E mpathy
- 39. E xpress E mpathy You try it.
- 41. A void A rgumentation
- 44. D evelop D iscrepancy
- 48. S upport S elf-Efficacy
- 51. It’s a Wrap!
- 55. Homework
- 58. Assist… your patients in understanding the physical and behavioral implications of tobacco addiction
- 73. Arrange… to follow up with your patients to monitor their smoking cessation progress
Editor's Notes
- 99406 Smoking and Tobacco Cessation Counseling Visit (Intermediate, 3-10 minutes) 99407 Smoking and Tobacco Cessation Counseling Visit (Intensive, 10+ minutes)
- Note: the focus on ambivalence and resistance – this is the key!
- Agape Caring Collaboration Patient is the focus, not me Asthma patient, 27-year-old male smoker “ You people” “ I only signed up for the decrease in premiums and no, I don’t want to quit smoking”
- When people resist change, the worst strategy is persuasion it forces them to defend the very behavior you are trying to change When people are ambivalent, the pros=cons When they are resistant, the cons >pros When faced with ambivalence or resistance, explore don’t explain 2 types of resistance Issue Relational
- Your Strategy? Empathize with the core concern (issue) and explore the line of reasoning
- Persuasion The Righting Reflex Produces paradoxical responses Give more information
- Anxiety or discomfort when goals, thoughts, and behaviors don’t match up We want to create dissonance in our patients between where they are now in their health behaviors and where they need to be regarding health Creating dissonance A look over the fence Realistic goals and then behaviors that don’t match Discrepancies in what patients say vs what they do
- Anxiety or discomfort when goals, thoughts, and behaviors don’t match up We want to create dissonance in our patients between where they are now in their health behaviors and where they need to be regarding health Creating dissonance A look over the fence Realistic goals and then behaviors that don’t match Discrepancies in what patients say vs what they do
- This model interview is with karen. Encourage feedback and suggestions from the participants in local chat.
- 23 Patient blaming wife for not being able to quit (resistance) Doctor acknowledges resistance and then shifting focus from wife to patient
- 21 Suggested Answer: You are right…there are many people whose blood pressure is quite a bit higher. So, you recognize that high blood pressure is risky but you don’t’ think your in any danger. (Right.); Tell me more about that.
- 23
- 23 Suggested Answer: You realize that smoking can have harmful effects on your health, yet it has been difficult for you to quit because your friends smoke and they are important to you.
- 23
- 23 Suggested Answer: It doesn’t sound like you’re ready to consider this right now. I’m happy to help you, when you are.
- 23 On the one hand, you hate feeling ashamed because you keep going back to smoking. On the other hand, you actually started to feel better when you quit, but stress in your life triggers your smoking. If you were to wake up tomorrow and you were no longer a smoker, what would you like about that? What would be the benefits to you?
- 23
- 23 Suggested answer: Great. Tell me more about what you have been thinking. What’s got you thinking about it? Support the baby step. Maybe talk about the readiness ruler (should be above a “7”)
- Do you want to add in summary bullets here?
- This model interview is with Neil.
- Non-Pharmacologic Cold Turkey Gradual Tapering Behavioral Modification Aversion Therapy Reward Systems Use in conjunction with other modalities Set aside monetary reward at weekly intervals Convert to longer periods after the first few months
- JAY SAYS CUT What other factors may influence medication selection? Pragmatic factors may also influence selection, such as insurance coverage or out-of-pocket patient costs, likelihood of adherence, dentures when considering the gum, or dermatitis when considering the patch. What medications should be used with a highly nicotine dependent patient? The higher dose preparations of nicotine gum, patch, and lozenge have been shown to be effective in highly dependent smokers. Also, there is evidence that combination NRT therapy may be particularly effective in suppressing tobacco withdrawal symptoms. Is medication adherence important? Yes. Patients frequently do not use cessation medications as recommended and this may reduce their effectiveness. May medications ever be combined? Yes. Among first-line medications, evidence exists that combining the nicotine patch long-term (> 14 weeks) with either nicotine gum or nicotine nasal spray, the nicotine patch with the nicotine inhaler, or the nicotine patch with bupropion SR, increases long-term abstinence rates relative to placebo treatments. Combining varenicline with NRT agents has been associated with higher rates of side effects (nausea, headaches).
- JAY SAYS CUT Should nicotine replacement therapies be avoided in patients with a history of cardiovascular disease? NO . The nicotine patch in particular has been demonstrated as safe for cardiovascular patients. Are there medications that should be especially considered in patients with a past history of depression? Bupropion SR and nortriptyline appear to be effective with this population, but nicotine replacement medications also appear to help individuals with a past history of depression. Which medications should be considered with patients particularly concerned about weight gain? Data show that bupropion SR and nicotine replacement therapies, in particular 4 mg nicotine gum and 4 mg nicotine lozenge, delay, but do not prevent, weight gain.
- Inclusion/exclusion criteria at: www.cmaj.ca/cgi/content/full/179/2/135/DC2
- JAY REDID