Smokers with MI or SMI Reduced Quitting over Lifetime
Mental Illness (MI) = anxiety, MDE, PTSD, psychoses, bipolar, drug dependenceSerious Mental Illness (SMI)= measured by K6
Hagman 2007; McClave 2010; Lasser 2000; Pratt & Brody 2010
Form
er S
mok
ers (
%) E= N x S
Exsmokers =(number trying to quit) x (success of attempts)
R West, 2013
Smokers with Depression Less Likely to Quit
fewer former smokers
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
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
Smokers with Depression Smoke More CPD & Are
More Dependent
Greater Nicotine Dependence in Serious Psychological Distress
0
10
20
30
40
50
60
70
NDSS TTFC 5 Mins TTFC 30 Mins
SPD
noSPD
%
2002 National Survey on Drug Use and Health; Hagman et al., 2008
SPD= Estimate of Serious Mental Illness
Smokers in Addiction Treatment Moderately to Severely Addicted
to Nicotine
N=1882 smokers in NJ addictions treatment, 2001-2002; Williams et al., 2005
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
Tobacco WithdrawalEmerge hours after last cigarette
Can last for (4) weeks
Depressed moodInsomniaIrritability, frustration or angerAnxietyDifficulty concentratingRestlessnessIncreased appetite or weight gain
DSM-5
Reduced Success Quitting in Smokers with Anxiety
Disorders
panic, social anxiety or GAD
More withdrawal symptoms
Piper et al., 2010
NRT and Agitationin 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
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
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 assessmentfrom charts (49/117) reviewed same study
77% 83%
020406080100120
Himelhoch Williams
Williams et al., in press; Himelhoch et al., 2014
Which Approach to TakeImplement current
evidence based practices?
Public health modelPrimary care Brief strategies Limited insurance
coverageTelephone
counseling
Develop tailored approaches?
Clinical/ co-occurring treatment model
Behavioral healthFace to face Longer treatmentExpanded Medicaid and
Medicare coverage for treatment
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
Need for Pharmacotherapy in Tobacco Users w/MI and SUD
No reason not to useNRT is not a “new drug”First line treatment/ Recommended all Comfortable detox for temporary abstinenceHigher levels of nicotine dependencePsychiatric inpatients not given NRT were > 2X likely to be discharged from the hospital AMA
Fiore 2008; Prochaska 2004
Old NRT Guidelines
With caution (talk to doctor) if:Recent MISmokes < 10 cpdPregnant/breastfeeding Adolescents (Not FDA approved)
Mild side effectsMostly localSystemic, 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 safeAPRIL2013 www.fda.gov/ForConsumers/ConsumerUpdates/ucm345087.htm
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
Review of Studies forNeuropsychiatric 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
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 significantAnthenelli et al., Ann Int Med, 2013
No Worsening of Depression ScoresNo difference in AEs (abnormal dreams, anxiety, agitation, restlessness, SI)
Anthenelli et al., Ann Int Med, 2013
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
Parti
cipa
nts
(%)
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
Abs
tinen
t sub
ject
s (%
)
Week24
By weekVareniclinePlacebo
VareniclinePlacebo
No Worsening SchizophreniaPANSS by Week Mean Score
Mean baseline total scoreVarenicline: 55.8Placebo: 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
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
No treatment effect on psychiatric symptoms, health, BMI Evins, JAMA 2014; Pachas et al., JDD 2012
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
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
State Hospital Smoking Survey2011; 206 Hospitals Surveyed; 80% response rate
Almost 80% no‐smoking on premisesLess than 35% treatment
Schacht et al., NASMHPD Research Institute, Inc. 2012
020406080100
2006 2007 2011
% TobaccoFree StateHospitals
Treatment
35%
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 counselingor pharmacotherapy
38% offer individual/group counseling17% provide quit‐smoking medication
Friedmann et al., JSAT 2008
41%
This probably isn't the best way to quit smoking
Conclusions
Reduced lifetime quitting Higher levels of nicotine dependence and psychosocial factors
Need for combination (medications + counseling) approaches
Treatments safe and do not worsen illnessReduce barriers to treatment in behavioral health setting
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