Improving Recovery Outcomes: Addressing Co-Occurring Nicotine and Opioid Use

Chad Morris, PhDSeptember 5, 2019

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Trends in U.S. Adult Smoking

~14% of adults are current cigarette

smokers

49-90% Other Drug Abuse

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Smoking in Addiction Treatment Programs

A review of smoking prevalence in U.S. addiction treatment programs, from 1987 to 2009, found a median annual smoking

prevalence of 76%.

(Guydish et al., 2011, 2017)

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Rates of UseAny Tobacco Product

75%

25%

General Population

People whoare tobacco-freePeople whouse tobacco

80%

20%

Criminal Justice Population

People who usetobacco

People who aretobacco-free

In the United States, the smoking rate among the justice-involved population is approximately 3 times

higher than the general population

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>70,000

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Behavioral Causes of Death in U.S.

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Dopamine Reward Pathway

Nicotine enters brain

Stimulation of nicotine receptors

Dopamine release

Prefrontal cortex

Nucleus accumbens

Ventral tegmental area

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SmokingIllicit Opioid Use

MethadoneBuprenorphine

Priming & Tolerance

Chronic Pain

Treatment Outcomes for SmokersIncreased Opioid Withdrawal

Increased CravingsLower Detox Completion/

Methadone Taper

Opioids and Smoking

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§ Stigma§ Low SES§ Discrimination§ Chronic Stress§ Psychological Distress§ Coping Skills§ Environmental Exposure § Industry Targeting§ Biology§ Access to Treatment

Addiction

Social Determinants

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Coping Through Addictions

§The majority recognize they are unhealthy and life threatening

§ But mistakenly believe it has positive psychological functions

§ In particular relief from isolation, stress, anxiety, and depression

– Used as an indirect coping strategy– Reinforces coping through addiction – Perceived stress reduction is often relief of withdrawal symptoms

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An addiction… is an addiction…

is an addiction.

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Co-Treatment

§ Co-Treatment is the only adequate solution§ Bio-psycho-social underpinning are similar § And unrelated to the age, sex, race and

ethnicity, gender identity, or culture

Surgeon General’s Report, 2016

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Tobacco Use Affects Treatment & Recovery from Addiction

Addressing tobacco dependence during treatment for other substances is associated with a 25% increase in long-term abstinence

rates from alcohol and other substances

(Prochaska et al., 2004)

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Is This a Social Justice

Issue?Recent

Community of Practice

Findings

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2019 Opioid Planning Summit Potential Key Areas of Overlap

• Training specific to health disparity populations• Reducing stigma • Trauma informed care• Referral and access to quality care• Diversion and other health neighborhood programming• One-stop services• Workforce development - Peer-to-peer services

https://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/opioid-planning-summit-summary.pdf

Implicit Bias and Stigma

Societal isolation Keeping secrets from medical providers, interfering with quality healthcareDelayed care

Un-aided attempts at abstinence

Corner, Hopkinson, & Roffe, 2006; Tod, Craven & Allmark, 2008; Gysels & Higginson, 2008

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A Whole Health Approach

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Motivational Interviewing

Planning

Evoking

Focusing

Engaging

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ASK

ADVISE

ASSESSASSIST

ARRANGE

The 5As

• Evidence-based best practice• Applicable across chronic

disease prevention efforts• Nutrition improvement• Physical activity• Diabetes management• High blood pressure mgmt.• Addiction

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§ Screen for nicotine and other drug use at the same time

§ Address all addictions as part of the treatment plan

Integration into Standard Care

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Referral

1-800-55-66-222

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Behavioral Strategies

Behavioral Treatments§ Cognitive Behavioral Therapy§ Contingency management§Motivational enhancement

School-based

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Medication Assisted Treatment

Combination of behavioral interventions and medications

Highly effective treatment option for alcohol, opioid, or tobacco dependence

Reduces illicit drug use and overdose deaths

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Determinants of Health

Medical Care: 11%

Physical Environment: 7%

Individual Behaviors: 38%

Genetics & Biology: 21%Social Circumstances: 23%

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Sequential Intercept Model

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• Evidence-based information about the effectiveness of peer support programs

• Step-by-step instructions to create a successful and sustainable peer support program

http://www.bhwellness.org/resources/toolkits/

Peer Support

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Creating Healthy Habits Through Policy

Cue Routine Reward

① Identify Cues②Change the Reward Pathway③Shape the Environment

Behavioral Health & Wellness Program

303.724.3713bh.wellness@ucdenver.edu

www.bhwellness.org

BHWP_UCDBehavioral Health and Wellness Program