Addressing Co-Occurring Schizophrenia and Nicotine

Dependence

Addressing Co-Occurring Schizophrenia and Nicotine

Dependence

Douglas Ziedonis, M.D., MPHDepartment of Psychiatry,

Robert Wood Johnson Medical School – UMDNJ

UMDNJ School of Public Health

Rutgers University Center of Alcohol Studies

Douglas Ziedonis, M.D., MPHDepartment of Psychiatry,

Robert Wood Johnson Medical School – UMDNJ

UMDNJ School of Public Health

Rutgers University Center of Alcohol Studies

Schizophrenia and Nicotine Dependence Schizophrenia and Nicotine Dependence

Most common co-occurring addiction & schizophrenia subtype (dual diagnosis)

High smoking rates due to patient & system issues Accounts for a BIG increase in medical illnesses &

mortality rates in this population Tobacco effects medication levels & effectiveness Nicotine may have some beneficial aspects, but can be

delivered without tobacco Treatment Works & patients are grateful for the help Medications & Behavioral therapy are effective Also need Program & System changes: culture, policy &

enforcement, training, funding, and staff training

Most common co-occurring addiction & schizophrenia subtype (dual diagnosis)

High smoking rates due to patient & system issues Accounts for a BIG increase in medical illnesses &

mortality rates in this population Tobacco effects medication levels & effectiveness Nicotine may have some beneficial aspects, but can be

delivered without tobacco Treatment Works & patients are grateful for the help Medications & Behavioral therapy are effective Also need Program & System changes: culture, policy &

enforcement, training, funding, and staff training

The time is now to begin addressing tobacco in Mental Health Settings The time is now to begin addressing tobacco in Mental Health Settings

Remember when: Drug versus Alcohol Treatment Programs Mental Health versus Addiction Treatment Programs

SAMHSA’s definition of co-occurring disorders Model MH programs are better addressing tobacco NIDA is funding new research initiatives for

Schizophrenia and Nicotine Dependence Recent Robert Wood Johnson Foundation Initiative UMDNJ State-Wide Program

July 2003 issue of Psychiatric Annals

Remember when: Drug versus Alcohol Treatment Programs Mental Health versus Addiction Treatment Programs

SAMHSA’s definition of co-occurring disorders Model MH programs are better addressing tobacco NIDA is funding new research initiatives for

Schizophrenia and Nicotine Dependence Recent Robert Wood Johnson Foundation Initiative UMDNJ State-Wide Program

July 2003 issue of Psychiatric Annals

Addressing Tobacco in Addiction and Mental Health SettingsAddressing Tobacco in Addiction and Mental Health Settings

44% of all cigarettes consumed in the US are by individuals with a current mental disorder

$256 Billion Dollars on Cigarettes– Estimates of about $2 billion spent by smokers

with schizophrenia on cigarettes annually 75% of individuals with either a mental disorder

(addiction or mental illness) smoke cigarettes Most smoke and die due to smoking caused

diseases Nicotine use is a trigger for other substance use

44% of all cigarettes consumed in the US are by individuals with a current mental disorder

$256 Billion Dollars on Cigarettes– Estimates of about $2 billion spent by smokers

with schizophrenia on cigarettes annually 75% of individuals with either a mental disorder

(addiction or mental illness) smoke cigarettes Most smoke and die due to smoking caused

diseases Nicotine use is a trigger for other substance use

Unique Features of Schizophrenia Unique Features of Schizophrenia Schizophrenia about 1% of the population

– developmental brain disorder– stress & gene / environment vulnerabilities interact– heterogeneous population (onset, course, symptoms, end

state) positive & negative symptoms cognitive limitations and aberrant sensory processing Low Motivation Low Self-Efficacy Limited Interpersonal Skills & therapeutic alliance More Cravings during Withdrawal

– Cocaine dependence (Smelson et al, 2002)

Schizophrenia about 1% of the population– developmental brain disorder– stress & gene / environment vulnerabilities interact– heterogeneous population (onset, course, symptoms, end

state) positive & negative symptoms cognitive limitations and aberrant sensory processing Low Motivation Low Self-Efficacy Limited Interpersonal Skills & therapeutic alliance More Cravings during Withdrawal

– Cocaine dependence (Smelson et al, 2002)

Schizophrenia and TobaccoSchizophrenia and Tobacco 70-90% are tobacco dependent (setting specific) 50% of the smokers are heavy smokers Heavy smoking associated with:

– Increased positive symptoms and decreased negative symptoms

– More other substance use disorders– More frequent psychiatric hospitalizations– Fewer parkinsonian EPS medication side-effects– Increased suicide risk – Polydipsia

70-90% are tobacco dependent (setting specific) 50% of the smokers are heavy smokers Heavy smoking associated with:

– Increased positive symptoms and decreased negative symptoms

– More other substance use disorders– More frequent psychiatric hospitalizations– Fewer parkinsonian EPS medication side-effects– Increased suicide risk – Polydipsia

Schizophrenia and TobaccoSchizophrenia and Tobacco Effective and efficient smokers

– high CO & cotinine levels Many low motivated to quit

– but growing interest to seek help Most first episode schizophrenics already smoke PH efforts today have not helped this population Tobacco alters medication blood levels

Effective and efficient smokers – high CO & cotinine levels

Many low motivated to quit– but growing interest to seek help

Most first episode schizophrenics already smoke PH efforts today have not helped this population Tobacco alters medication blood levels

Tobacco Smoking Effects Some Psychiatric Medication Blood Levels Tobacco Smoking Effects Some Psychiatric Medication Blood Levels

Smoking induces the P450’s 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 doesn’t effect medication blood levels Nicotine may modulate cognition, psychiatric symptoms,

and medication side effects

Smoking induces the P450’s 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 doesn’t effect medication blood levels Nicotine may modulate cognition, psychiatric symptoms,

and medication side effects

Are patients better off smoking?Are patients better off smoking? Nicotine modulates both dopamine and glutamate

– Nicotinic acetylcholine receptors on dopamine neurons– Stimulates glutamate neurons in prefrontal cortex– Schizophrenia – gene defect – low alpha 7 Nic receptors

Nicotine transiently improves attention and sensory gating and reduces number of leading saccades during smooth pursuit eye movement.

MAO type B inhibition by tobacco smoke components also induces dopamine transmission

Smoking may enhance visuospatial working memory in this population (George et al, 2002)

Nicotine modulates both dopamine and glutamate– Nicotinic acetylcholine receptors on dopamine neurons– Stimulates glutamate neurons in prefrontal cortex– Schizophrenia – gene defect – low alpha 7 Nic receptors

Nicotine transiently improves attention and sensory gating and reduces number of leading saccades during smooth pursuit eye movement.

MAO type B inhibition by tobacco smoke components also induces dopamine transmission

Smoking may enhance visuospatial working memory in this population (George et al, 2002)

Nicotine may help SchizophreniaNicotine may help Schizophrenia

If nicotine helps schizophrenia – assess benefits of providing Nicotine replacement (NRT) alone without Tobacco

Belief – quitting smoking worsens schizophrenia? What’s the evidence?– Worse withdrawal?

If nicotine helps schizophrenia – assess benefits of providing Nicotine replacement (NRT) alone without Tobacco

Belief – quitting smoking worsens schizophrenia? What’s the evidence?– Worse withdrawal?

Reduced life expectancy Reduced life expectancy 20% shorter life span in schizophrenia versus the

general population Tobacco caused diseases that also lead to death are

more prominent in schizophrenia than the general population

Higher standardized mortality rates than general pop for: – Cardiovascular disease 2.3x– Respiratory disease 3.2x

-Brown et al., 2000; Br J Psychiatry

20% shorter life span in schizophrenia versus the general population

Tobacco caused diseases that also lead to death are more prominent in schizophrenia than the general population

Higher standardized mortality rates than general pop for: – Cardiovascular disease 2.3x– Respiratory disease 3.2x

-Brown et al., 2000; Br J Psychiatry

                                                                                                                                         

                         

Monthly Budget as a Percentage of Public Assistance Received ($596.00)

Food, Shelter, Other73%

Tobacco Products

27%

Steinberg, M. L., Williams, J. M., & Ziedonis, D. M. (2004). Financial Implications of Cigarette Smoking Among Individuals With Schizophrenia. Tobacco Control, 13(2).

Tobacco use increases alcohol and other drug use intake and cravings

Tobacco Craving Laboratory with schizophrenic smokers

Animal and human laboratory research on effect of tobacco use on increasing consumption and cravings.

Tobacco use correlates in dose-dependent fashion with cocaine and heroin use

Frosch, Shoptaw, Nahom, Jarvik, Exptl Clin Psychopharm. 2000; 8:97-103

Why the high rates of nicotine

dependence among these groups ?

Biological / Genetic Psychological (Self-Medication?) Social / Environmental / Cultural Institutional / MH System Factors

Hypotheses for initiation, maintenance, and difficulty quittingHypotheses for initiation, maintenance, and difficulty quitting

Increased propensity to dependence? Illness modulation effect? Side effect reduction? Immediate

self-medicating

effect? Social factors?

Increased propensity to dependence? Illness modulation effect? Side effect reduction? Immediate

self-medicating

effect? Social factors?

Biological FactorsBiological Factors

Brain Reward Systems: Mesolimbic Dopamine system– Ventral Tegmental Area (VTA)

– Nucleus Accumbens (NAc)

– Projections to Medial Prefrontal Cortex

Genetics Tryptophan Depletion study – increases smoking

intensity but not negative symptoms or depression

Brain Reward Systems: Mesolimbic Dopamine system– Ventral Tegmental Area (VTA)

– Nucleus Accumbens (NAc)

– Projections to Medial Prefrontal Cortex

Genetics Tryptophan Depletion study – increases smoking

intensity but not negative symptoms or depression

Acetylcholine hypothesis of SchizophreniaAcetylcholine hypothesis of Schizophrenia

A malfunction in interneuronal function involving Acetylcholine transmission may be a core abnormality in schizophrenia:

alpha- 7 nicotinic receptor malfunction Alpha 7 receptor ligand gated Ca ion channel Function effects attention, memory and cognitive

functions This receptor is involved in the sensory gating

deficit (abnormal P50 auditory-evoked potential)

(R. Freedman, U of Colorado)

A malfunction in interneuronal function involving Acetylcholine transmission may be a core abnormality in schizophrenia:

alpha- 7 nicotinic receptor malfunction Alpha 7 receptor ligand gated Ca ion channel Function effects attention, memory and cognitive

functions This receptor is involved in the sensory gating

deficit (abnormal P50 auditory-evoked potential)

(R. Freedman, U of Colorado)

Psychological Factors • Low self-efficacy • Poor coping• Poor compliance• Low motivation• Fear of worsening symptoms• Patients perceive tobacco helps them reduce anxiety,

boredom, and idle time• May perceive the reinforcement value of cigarette

smoking as being stronger than non-psychiatric patients and feel they would require more incentives to quit (Spring et al, 2003)

Social Factors

Cultural differences– Japanese patients with schizophrenia – tobacco dependence

at 34% similar to the general population– Taiwan 40% smokers; India 38% (lack of economic

independence and family restrictions may account) Family support – restrictions Few non-smoking social supports Live with other smokers - Group home smoking Smoking within the mental health settings

– Smoking as behavioral reinforcer by staff Smoking as a normalizing behavior - substance users

are perceived as “friends”

Stigma vs SchizophreniaStigma vs Schizophrenia• “other than increase morbidity and mortality why

should we address tobacco for those patients?”• Staff are upset when they hear of small towns with

smoking rates of 80% in some states but not within mental health settings

• “what else will they be able to do in their free time?”

• Interestingly, patients have reported feeling less stigmatized when they smoke (promote sense of freedom).

• “other than increase morbidity and mortality why should we address tobacco for those patients?”

• Staff are upset when they hear of small towns with smoking rates of 80% in some states but not within mental health settings

• “what else will they be able to do in their free time?”

• Interestingly, patients have reported feeling less stigmatized when they smoke (promote sense of freedom).

Institutional Barriers to Tobacco Dependence Treatment

Lack of staff training “not my role” – go to primary care Staff fear that patients will misuse NRT or smoke

while taking NRT Staff who smoke – normalize smoking, staff may

help patients access cigarettes, program may sell cigarettes

Restrictive formulary or insurance coverage of the cost of medications

Limited income and cannot afford OTC medications

Under-Diagnosis & Under-TreatmentUnder-Diagnosis & Under-Treatment

Nicotine dependence documented in 2% of mental health records – although tobacco use more frequently documented– Peterson 2003, Am J Addiction

Few physicians treat smokers with psychiatric diagnoses - Primary care counseled more than psychiatrists – Thorndike 2001, N&TR; National Ambulatory Medical Care Survey

1991-1996

– APA Psychiatric Research Network (Montoya et al)

Nicotine dependence documented in 2% of mental health records – although tobacco use more frequently documented– Peterson 2003, Am J Addiction

Few physicians treat smokers with psychiatric diagnoses - Primary care counseled more than psychiatrists – Thorndike 2001, N&TR; National Ambulatory Medical Care Survey

1991-1996

– APA Psychiatric Research Network (Montoya et al)

Smoke-Free Inpatient UnitsSmoke-Free Inpatient Units

1991 JCAHO policy change increased the awareness and need to address smoking

Inpatient units went tobacco-free Going Smoke-Free does not cause new

problems– No Increase in disruptive behaviors

– No Increase in AMA discharges

– No Additional seclusion and restraints

– No Increase in use of PRN medications » Patten et al., 1995; Haller et al., 1996

1991 JCAHO policy change increased the awareness and need to address smoking

Inpatient units went tobacco-free Going Smoke-Free does not cause new

problems– No Increase in disruptive behaviors

– No Increase in AMA discharges

– No Additional seclusion and restraints

– No Increase in use of PRN medications » Patten et al., 1995; Haller et al., 1996

Why Address?Why Address? Nicotine Dependence is an addiction – a mental illness Major Public Health concern – need to reduce tobacco-

caused medical illness and death, improve QOL and recovery

Second Hand Smoke Impacts Non-smokers Smokers have a right to smoke (it’s legal) – but there is

a hierarchy of rights; smokers also should have the right to compassion from others and the right for treatment and the right for legal action against the tobacco industry

Nicotine Dependence is an addiction – a mental illness Major Public Health concern – need to reduce tobacco-

caused medical illness and death, improve QOL and recovery

Second Hand Smoke Impacts Non-smokers Smokers have a right to smoke (it’s legal) – but there is

a hierarchy of rights; smokers also should have the right to compassion from others and the right for treatment and the right for legal action against the tobacco industry

Strategies to Treat Tobacco AddictionStrategies to Treat Tobacco Addiction

6 FDA approved Medications– other promising meds: Nortriptyline, ? others

Psychosocial treatment– Behavioral therapies– Motivational Enhancement Therapies

Harm reduction versus Abstinence Goal

6 FDA approved Medications– other promising meds: Nortriptyline, ? others

Psychosocial treatment– Behavioral therapies– Motivational Enhancement Therapies

Harm reduction versus Abstinence Goal

Evidence Based Studies in SchizophreniaEvidence Based Studies in Schizophrenia Nicotine Replacement Medications

– Nicotine Patch» 5 published studies – no placebo control» Numerous unpublished posters and clinical experience» All supportive

– Nicotine Spray (3 small studies)– Nicotine Gum (1 small study)– Nicotine Inhaler and Lozenge: Clinical Experience

Bupropion (Zyban)– 3 Studies – 2 with placebo

Behavioral Therapy & Motivational Enhancement Therapy approaches – 5 studies– Action stage– Precontemplator, Contemplators, and Preparation Stages

Nicotine Replacement Medications– Nicotine Patch

» 5 published studies – no placebo control» Numerous unpublished posters and clinical experience» All supportive

– Nicotine Spray (3 small studies)– Nicotine Gum (1 small study)– Nicotine Inhaler and Lozenge: Clinical Experience

Bupropion (Zyban)– 3 Studies – 2 with placebo

Behavioral Therapy & Motivational Enhancement Therapy approaches – 5 studies– Action stage– Precontemplator, Contemplators, and Preparation Stages

Harm Reduction versus Abstinence Harm Reduction versus Abstinence Formal studies needed In abstinence oriented studies – many patients are able

to reduce the quantity and frequency of usage and increase their commitment to addressing tobacco

Many MH staff desire to use the harm reduction approach

Clinical approaches tried – reducing number of cigarettes, switching some NRT for some cigarettes, behavioral modifications (not smoke in house, in car, etc). Compensatory change in smoking style to keep same nicotine levels is concern - TRACK biomarkers.

A motivation based option - ? Long-term or short-term harm reduction?? NRT maintenance options?

Formal studies needed In abstinence oriented studies – many patients are able

to reduce the quantity and frequency of usage and increase their commitment to addressing tobacco

Many MH staff desire to use the harm reduction approach

Clinical approaches tried – reducing number of cigarettes, switching some NRT for some cigarettes, behavioral modifications (not smoke in house, in car, etc). Compensatory change in smoking style to keep same nicotine levels is concern - TRACK biomarkers.

A motivation based option - ? Long-term or short-term harm reduction?? NRT maintenance options?

Rationale Pharmacology: How much nicotine consumed?Rationale Pharmacology: How much nicotine consumed?

Each cigarette contains about 13 mgs nicotine – about 1 – 3 mgs of nicotine are absorbed per cigarette

SMI tend to absorb the 2 - 3mgs nicotine per cigarette– Higher CO and Cotinine levels than expected

Some practitioners and researchers are matching nicotine level to nicotine replacement dosage

Example: 3 packs per day = 20 cigarettes times 2 mgs per cigarette times 3 packs per day = 120 mgs nicotine

Each cigarette contains about 13 mgs nicotine – about 1 – 3 mgs of nicotine are absorbed per cigarette

SMI tend to absorb the 2 - 3mgs nicotine per cigarette– Higher CO and Cotinine levels than expected

Some practitioners and researchers are matching nicotine level to nicotine replacement dosage

Example: 3 packs per day = 20 cigarettes times 2 mgs per cigarette times 3 packs per day = 120 mgs nicotine

American Psychiatric Association Treatment GuidelinesAmerican Psychiatric Association Treatment Guidelines

Treatment Guidelines for Psychiatric Disorders, including substance use disorders and nicotine dependence

www.psych.org call APPI press: 1-800-368-5777 also guidelines are published in the American

Journal of Psychiatry (AJP) Nicotine Dependence Guidelines in November

1996 AJP

Treatment Guidelines for Psychiatric Disorders, including substance use disorders and nicotine dependence

www.psych.org call APPI press: 1-800-368-5777 also guidelines are published in the American

Journal of Psychiatry (AJP) Nicotine Dependence Guidelines in November

1996 AJP

Have Nicotine Dependence follow the same Principles of Dual Diagnosis Treatment Have Nicotine Dependence follow the same Principles of Dual Diagnosis Treatment

Dual diagnosis changes treatment as usual Integrate addiction treatment approaches Match treatment to recovery stage and

motivational level Timing of treatments Address tobacco across the continuum Consider a long-term treatment perspective

Dual diagnosis changes treatment as usual Integrate addiction treatment approaches Match treatment to recovery stage and

motivational level Timing of treatments Address tobacco across the continuum Consider a long-term treatment perspective

Motivation Based Dual Diagnosis Treatment ModelMotivation Based Dual Diagnosis Treatment Model

Engagement & Empathy Match Goals and Techniques to 5 Stages

– Precontemplation, contemplation, preparation, action, and maintenance

Services matched to motivational levels– “healthy living groups”

– contemplation vs action phase specific treatments

– Link with MICA treatments

– NICOTINE ANONYMOUS

Engagement & Empathy Match Goals and Techniques to 5 Stages

– Precontemplation, contemplation, preparation, action, and maintenance

Services matched to motivational levels– “healthy living groups”

– contemplation vs action phase specific treatments

– Link with MICA treatments

– NICOTINE ANONYMOUS

MANAGEMENT: AssistMANAGEMENT: Assist

Assist patient in developing a quit plan Encourage nicotine replacement therapy Provide practical problem-solving counseling Provide supportive clinical environment Help patient develop social support for quit Provide supplementary materials

Assist patient in developing a quit plan Encourage nicotine replacement therapy Provide practical problem-solving counseling Provide supportive clinical environment Help patient develop social support for quit Provide supplementary materials

Setting a Target Quit DateSetting a Target Quit Date

For those who are motivated to quit Provides time and target date to mobilize

resources for quitting’ Date should allow for sufficient time to

acquire skills for quitting

For those who are motivated to quit Provides time and target date to mobilize

resources for quitting’ Date should allow for sufficient time to

acquire skills for quitting

Arrange Follow-upArrange Follow-up

Arrange in-person or phone follow-up shortly after the quit date

Timing – One contact within a week after quit date– Second contact within the first month

At follow-up contact:– Reinforce success– Problem-solve difficulties– Encourage view of slips as learning experiences– Assess nicotine replacement therapy– consider referral to intensive, specialized program

Arrange in-person or phone follow-up shortly after the quit date

Timing – One contact within a week after quit date– Second contact within the first month

At follow-up contact:– Reinforce success– Problem-solve difficulties– Encourage view of slips as learning experiences– Assess nicotine replacement therapy– consider referral to intensive, specialized program

NIDA Technology Model of Behavioral therapy Research

Specify Treatments

* Manuals, dose, setting Reduce Therapist Variability

* Selection, training program Standardize Treatment Delivery

* Ongoing supervision, monitoring Reduce Patient Heterogeneity Optimize Outcome Measurement

* multidimensional assessments, raters

4 Stages of NIDA Psychosocial Therapy Development

Stage I: Demonstrate Premise. Develop manuals, adherence scales, training program, assess feasibility

Stage II: Demonstrate Efficacy, RCT, component analysis (e.g.dismantling, predictor/matching, and optimization)

Stage III: Demonstrate Generalizability across patients, therapists, and sites.

Stage IV: Technology Transfer. Large Scale Training. Demonstration research

Adapting Motivational Enhancement Therapy for Tobacco Dependence Brief Therapy - 4 Sessions in Project MATCH Blends MI and Feedback Tools Tools: Personalized Feedback & Change Plan

with Menu of Options Focused Heavily on Developing Discrepancy

– Use of decisional balance (pros / cons)– engaging a SO– Eliciting Change Talk– Provide feedback and promote self-efficacy

MET = MI + FeedbackMET = MI + Feedback

Motivational Interviewing (Style)– Empathy, Client-Centered, Respects readiness to

change, embraces ambivalence– Directive – one problem focused (needs adaptation for

poly-drug & COD) Personalized Feedback (Content)

– Assessment– Personalized Feedback – Values / Decisional Balance: Pros & Cons– Change Plan & Menu of Options

Motivational Interviewing (Style)– Empathy, Client-Centered, Respects readiness to

change, embraces ambivalence– Directive – one problem focused (needs adaptation for

poly-drug & COD) Personalized Feedback (Content)

– Assessment– Personalized Feedback – Values / Decisional Balance: Pros & Cons– Change Plan & Menu of Options

Steinberg ML, Ziedonis DM, Krejci JA, Brandon TH. Journal of Consulting & Clinical Psychology, in press

Steinberg ML, Ziedonis DM, Krejci JA, Brandon TH. Journal of Consulting & Clinical Psychology, in press

Motivational Interviewing With Personalized Feedback:

A Brief Intervention for Motivating Smokers With Schizophrenia To Seek Treatment for Tobacco Dependence

Motivational Interviewing With Personalized Feedback:

A Brief Intervention for Motivating Smokers With Schizophrenia To Seek Treatment for Tobacco Dependence

78 Smokers with Schizophrenia who were unmotivated to quit

Motivational Interviewing

N=32

Psychoeducation

N=34

Minimal Control

N=12

One week and one month post-interventionfollow-up by R.A. blind to treatment condition

Steinberg ML, Ziedonis DM, Krejci JA, Brandon TH. Motivational Interviewing With Personalized Feedback: A Brief Intervention for Motivating Smokers With Schizophrenia To Seek Treatment for Tobacco Dependence. Journal of Consulting & Clinical Psychology, in press.

25.8%

32.3%

0.0%

11.4%

0.0% 0.0%

0%

5%

10%

15%

20%

25%

30%

35%

Motivational (N=32) Psychoeducational (N=34) Control (N=12)

Figure 1. Percentage of participants receiving each intervention following up on referral to tobacco dependence treatment at one-week and one-month post-intervention

One-Week One-Month

MI with Personalized Feedback Increases motivation to quit at one week and one month:

Personalized feedback: what mattered Personalized feedback: what mattered

Carbon Monoxide score and feedback– Big impact on patients

– Short-term benefits to quit Cost of Cigarettes for the year Medical conditions affected by tobacco Links with other substances, relapses, etc

Carbon Monoxide score and feedback– Big impact on patients

– Short-term benefits to quit Cost of Cigarettes for the year Medical conditions affected by tobacco Links with other substances, relapses, etc

Clinical ImplicationsClinical Implications

MI appears to be a better strategy than more commonly utilized techniques

Indicates this population can benefit from brief interventions

Should offer brief interventions to engage in treatment

MI appears to be a better strategy than more commonly utilized techniques

Indicates this population can benefit from brief interventions

Should offer brief interventions to engage in treatment

Steinberg ML, Ziedonis DM, Krejci JA, Brandon TH. Motivational Interviewing With Personalized Feedback: A Brief Intervention for Motivating Smokers With Schizophrenia To Seek Treatment for Tobacco Dependence. Journal of Consulting & Clinical Psychology, in press.

What Intensity of Treatment?What Intensity of Treatment?

Studies underway– Different medications– Different psychosocial treatments

TANS (Treating Addiction to Nicotine in Schizophrenia) vs Medication Management

Studies underway– Different medications– Different psychosocial treatments

TANS (Treating Addiction to Nicotine in Schizophrenia) vs Medication Management

Medication issues Medication issues Primary antipsychotic

– Atypicals versus Traditional antipsychotics– Other adjunctive medications to enhance cognition and

reduce negative symptoms Medication for Nicotine Dependence

– NRT– Bupropion– Combinations– Others? Galantamine (Allen et al, 2002); Donepezil

(cholinesterase inhibitor – negative study).– NEED for Patient Education

Primary antipsychotic– Atypicals versus Traditional antipsychotics– Other adjunctive medications to enhance cognition and

reduce negative symptoms Medication for Nicotine Dependence

– NRT– Bupropion– Combinations– Others? Galantamine (Allen et al, 2002); Donepezil

(cholinesterase inhibitor – negative study).– NEED for Patient Education

Atypicals versus Typicals Atypicals versus Typicals Clozapine helps spontaneously reduce tobacco use

(especially heavy smokers)– Marcus and Snyder, 1995

– McEvoy et al, 1995

– George et al, 1995

Use of atypicals improves outcomes versus traditionals in NRT tobacco dependence treatment study (George, Ziedonis, et al 2000)

Similar weight gain smokers and non-smokers with olanzapine vs risperidone (Lasser / Janssen study)

Clozapine helps spontaneously reduce tobacco use (especially heavy smokers)– Marcus and Snyder, 1995

– McEvoy et al, 1995

– George et al, 1995

Use of atypicals improves outcomes versus traditionals in NRT tobacco dependence treatment study (George, Ziedonis, et al 2000)

Similar weight gain smokers and non-smokers with olanzapine vs risperidone (Lasser / Janssen study)

Nicotine Abstinence Rates at 12-weeks Nicotine Abstinence Rates at 12-weeks

Self-Report & CO < 10 ppm 35% both therapy groups with NRT

– (6/17 ALA & 10/28 Specialized)

– Specialized had significantly higher rates of continuous abstinence during the last 4 weeks compared to ALA

22% Typical antipsychotic & NRT 56% Atypical antipsychotic & NRT

» 71% (5/7) Olanzapine

» 60% (3/5) Risperidone

» 50% (2/4) Clozapine

Self-Report & CO < 10 ppm 35% both therapy groups with NRT

– (6/17 ALA & 10/28 Specialized)

– Specialized had significantly higher rates of continuous abstinence during the last 4 weeks compared to ALA

22% Typical antipsychotic & NRT 56% Atypical antipsychotic & NRT

» 71% (5/7) Olanzapine

» 60% (3/5) Risperidone

» 50% (2/4) Clozapine

NRT for SchizophrenicsNRT for Schizophrenics

More research needed – placebo controlled NRT in variety of routes of administration, variable

doses and duration for schizophrenic patients Higher dose transdermal patch (42mg) and trials of

longer duration (24 weeks) – Jill Williams et al, 2004 In heavy smokers, under dosing may be one of the

reasons for the limited efficacy of transdermal nicotine Blood cotinine levels at baseline and steady state

measures for assessing adequacy of nicotine replacement

More research needed – placebo controlled NRT in variety of routes of administration, variable

doses and duration for schizophrenic patients Higher dose transdermal patch (42mg) and trials of

longer duration (24 weeks) – Jill Williams et al, 2004 In heavy smokers, under dosing may be one of the

reasons for the limited efficacy of transdermal nicotine Blood cotinine levels at baseline and steady state

measures for assessing adequacy of nicotine replacement

Nicotine Nasal Spray for SchizophreniaNicotine Nasal Spray for Schizophrenia NNS: Rapid onset of action, intermittent

dosing, and more immediate craving relief Case series 12 schizophrenic smokers

– failed prior treatments– well tolerated, 75% used at least 30 sprays per

day, 25% continuously abstinence, 40% three months abstinent, 25% substantial CO lowering (21 to 3)

– Williams, Ziedonis, Foulds, in press, Psych Services

NNS: Rapid onset of action, intermittent dosing, and more immediate craving relief

Case series 12 schizophrenic smokers – failed prior treatments– well tolerated, 75% used at least 30 sprays per

day, 25% continuously abstinence, 40% three months abstinent, 25% substantial CO lowering (21 to 3)

– Williams, Ziedonis, Foulds, in press, Psych Services

Long-term NRTLong-term NRT The long term health effects of NRT are unknown Felt to outweigh risks from exposure to carbon

monoxide and carcinogens. Long term use of the patch has not been a

problem. Gum is almost never misused, thus lacking true

abuse liability Weaning of the gum usually requires only

education and reassurance even in long term users.

The long term health effects of NRT are unknown Felt to outweigh risks from exposure to carbon

monoxide and carcinogens. Long term use of the patch has not been a

problem. Gum is almost never misused, thus lacking true

abuse liability Weaning of the gum usually requires only

education and reassurance even in long term users.

What works for this populationWhat works for this population Lead in Engagement Period using Motivational Enhancement

Therapy - ? Harm reduction ? Meds and therapy Use of Nicotine Replacement and / or Zyban Integrating behavioral therapy for more than 10 weeks

– CBT / relapse prevention– Eclectic blends – SST, ALA, support, educational sessions

Follow-up & Brief individual contact / sessions / phone Group support Community support

– Peer support– Modified NicA

Multimodal presentation of material

Lead in Engagement Period using Motivational Enhancement Therapy - ? Harm reduction ?

Meds and therapy Use of Nicotine Replacement and / or Zyban Integrating behavioral therapy for more than 10 weeks

– CBT / relapse prevention– Eclectic blends – SST, ALA, support, educational sessions

Follow-up & Brief individual contact / sessions / phone Group support Community support

– Peer support– Modified NicA

Multimodal presentation of material

Tactics of TreatmentTactics of Treatment

Medications– Start Bupropion two weeks prior to quit date– Start NRT Patch on quit date– PDR versus Clinical Practice

» Use of NRT prior to quit date as a replacement for cigarettes

» Use of Bupropion plus patch (plus gum, etc)» Dosage of NRT» Use of multiple NRT strategies (multiple patches,

multiple NRTs)» Length of time on NRT or Bupropion

Medications– Start Bupropion two weeks prior to quit date– Start NRT Patch on quit date– PDR versus Clinical Practice

» Use of NRT prior to quit date as a replacement for cigarettes

» Use of Bupropion plus patch (plus gum, etc)» Dosage of NRT» Use of multiple NRT strategies (multiple patches,

multiple NRTs)» Length of time on NRT or Bupropion

Other Tactics Other Tactics

Primary antipsychotic choice Intensity and type of psychosocial treatments Tobacco Metabolism and Medications

– Monitor side effects and dosage Ongoing monitoring and reassessment

– Critical periods: first three days, first two weeks and first six months

– CO, cotinine, and self-report of tobacco usage

Primary antipsychotic choice Intensity and type of psychosocial treatments Tobacco Metabolism and Medications

– Monitor side effects and dosage Ongoing monitoring and reassessment

– Critical periods: first three days, first two weeks and first six months

– CO, cotinine, and self-report of tobacco usage

Forced Abstinence (Environmental Tobacco Smoke issue) on inpatient psych units

Assessment Psychiatric management

– System issues– Negotiating– Patient education– Monitoring

Use of Psychosocial treatments Use of pharmacological therapies

Perceived Advantages to address tobacco on the psychiatric inpatient unit

A healthier environment and health promotion Consistency with other Center policy May facilitate addressing nicotine dependence in patients

at a later date A safer environment with less likelihood of fires An increase in involvement of smokers with activities

other than smoking A decrease is sub grouping smokers and non-smokers An opportunity for patients to learn healthier ways of

coping with problems than by smoking

Perceived disadvantages to addressing tobacco on the psychiatric unit

There might be an– increase in patient acting out– increase in rule infraction– increase in AMA discharges

Tobacco withdrawal may increase psychiatric symptoms and require more meds and restraints

Infringement of involuntary patients’ rights Loss of business and decreased admissions Medications will be needed to assist patients through

smoking withdrawal on the unit Antipsychotic medication blood levels will be less stable

UMDNJ Tobacco ProgramUMDNJ Tobacco Program

Addressing Tobacco in MH Settings Agenda– 8 Day Specialist Training– Ongoing consultation and clinical suggestions – Tertiary treatment – Email listserve– Program Consultation: Addressing Tobacco

N.J. Guidelines for Tobacco Dependence Treatment

www.tobaccoprogram.org

Addressing Tobacco in MH Settings Agenda– 8 Day Specialist Training– Ongoing consultation and clinical suggestions – Tertiary treatment – Email listserve– Program Consultation: Addressing Tobacco

N.J. Guidelines for Tobacco Dependence Treatment

www.tobaccoprogram.org

NJ ExperienceNJ Experience 60 system consultations to MH Agencies per year

(mostly outpatient, some inpatient; often linked with MICA staff; Community Health Fairs - Wellness)

Development of relationship with program– Starts with 1:1 consult– Big Packet sent with evidence based materials– Initial staff training onsite (3 hours)– F/U Support – more trainings on site; policy changes;

treatment supervision of groups / clinical consults– List Serve link– Manuals for treatment – cookbooks – ALA, Smoke Enders;

Trying to Kick Butts; NicA– About 33% do our 5 or 8 day training after about 6 months

60 system consultations to MH Agencies per year (mostly outpatient, some inpatient; often linked with MICA staff; Community Health Fairs - Wellness)

Development of relationship with program– Starts with 1:1 consult– Big Packet sent with evidence based materials– Initial staff training onsite (3 hours)– F/U Support – more trainings on site; policy changes;

treatment supervision of groups / clinical consults– List Serve link– Manuals for treatment – cookbooks – ALA, Smoke Enders;

Trying to Kick Butts; NicA– About 33% do our 5 or 8 day training after about 6 months

NJ ExperienceNJ Experience Want harm reduction strategies that decrease ETS risks (smoking in

vehicles; group homes)– Patients can be helped down to 10 cig / day

“What are other programs doing?” Staff smokers (fewer than our consults to addiction programs) Staff buy cigarettes for patients (internet, mail order, drive to reservations:

buy for group of patients – starts through money management discussions – credit cards)

Staff smokers referred to NJ network of free services for help Staff reaction to posters in clinics Few Tobacco Free Grounds NRT resistant staff Consumer Wellness Programs good opportunity Evening and Weekends – BIG triggers for patients

Want harm reduction strategies that decrease ETS risks (smoking in vehicles; group homes)– Patients can be helped down to 10 cig / day

“What are other programs doing?” Staff smokers (fewer than our consults to addiction programs) Staff buy cigarettes for patients (internet, mail order, drive to reservations:

buy for group of patients – starts through money management discussions – credit cards)

Staff smokers referred to NJ network of free services for help Staff reaction to posters in clinics Few Tobacco Free Grounds NRT resistant staff Consumer Wellness Programs good opportunity Evening and Weekends – BIG triggers for patients

Addressing Tobacco in Smokers with Mental IllnessAddressing Tobacco in Smokers with Mental Illness

Consultation and Program Development Single clinical site Mental health agency Professional organizations Consumer advocacy organizations Family advocacy organization State Division of Mental Health Services

Consultation and Program Development Single clinical site Mental health agency Professional organizations Consumer advocacy organizations Family advocacy organization State Division of Mental Health Services

Program Level Changes to Address Tobacco (1st)

Acknowledge the challenge Establish a leadership group and commitment to change Create a Change Plan and Implementation timeline Start with the Easier System Changes Conduct staff training Provide Treatment and Recovery Assistance for

interested nicotine dependent staff Document Assessment and Treatment Planning

Program Level Changes to Address Tobacco (2nd) Incorporate tobacco issues into patient education curriculum Provide Medications for Nicotine Dependence Treatment and

Required Abstinence Periods Integrate Motivation-Based Treatments throughout system Develop onsite Nicotine Anonymous meetings and establish

ongoing communication with 12-Step Recovery groups, professional colleagues, and referral sources about system change

Develop Addressing Tobacco Policies and clear consequences

A BIG next step: Creating a totally Tobacco-Free Environment – Tobacco-free facility and grounds– Implement comprehensive approach

Consumer advocacy organizationsConsumer advocacy organizations

Mental Health Association of New Jersey Create a consumer advocacy movement for

tobacco services in NJ Consumer connections Consumer forums Wellness forums Outreach to self-help centers

Mental Health Association of New Jersey Create a consumer advocacy movement for

tobacco services in NJ Consumer connections Consumer forums Wellness forums Outreach to self-help centers

Stigma/ Counter-AdvocacyStigma/ Counter-Advocacy

Tobacco is devalued; not acute problem Misinformation is common Family and professional advocates

protecting use of tobacco Patients seeking employment see smokers

as being stigmatized and this is a reason to quit smoking

Tobacco is devalued; not acute problem Misinformation is common Family and professional advocates

protecting use of tobacco Patients seeking employment see smokers

as being stigmatized and this is a reason to quit smoking

THREE LEVELS OF TREAMENT

QUIT CENTERS: Specialist Tobacco Treatment Centerswww.tobaccoprogram.org

THREE LEVELS OF TREAMENT

QUIT CENTERS: Specialist Tobacco Treatment Centerswww.tobaccoprogram.org