_interventions for tobacco dependence对烟草依赖的心理干预课件

GIM Primary Care Conference Presentation GIM Primary Care Conference Presentation October 25, 2006October 25, 2006 University of Wisconsin School of Medicine and Public Health University of Wisconsin School of Medicine and Public Health Center for Tobacco Research and InterventionCenter for Tobacco Research and Intervention Stevens S. Smith, Ph.D.Stevens S. Smith, Ph.D. Assistant Professor / Licensed PsychologistAssistant Professor / Licensed Psychologist Department of MedicineDepartment of Medicine University of Wisconsin School of Medicine and Public University of Wisconsin School of Medicine and Public HealthHealth Center for Tobacco Research and InterventionCenter for Tobacco Research and Intervention Psychiatric Morbidity and Psychiatric Morbidity and Smoking Cessation Smoking Cessation 1 1 Disclosure StatementDisclosure Statement I have received research support (but no consulting I have received research support (but no consulting or speaking fees) from the following companies that or speaking fees) from the following companies that market smoking cessation medications:market smoking cessation medications: SmithKline BeechamSmithKline Beecham GlaxoSmithKline GlaxoSmithKline Elan Corporation, plc Elan Corporation, plc 2 2 Learning ObjectivesLearning Objectives Psychiatric morbidity and cessation Psychiatric morbidity and cessation in two case studiesin two case studies Influence of psychiatric morbidity on Influence of psychiatric morbidity on smoking cessationsmoking cessation Evidence-based cessation treatment Evidence-based cessation treatment for smokers with psychiatric disordersfor smokers with psychiatric disorders 3 3 Case StudiesCase Studies Patient APatient APatient BPatient B Psychiatric Psychiatric DiagnosisDiagnosis DysthymiaDysthymia, , Tobacco Use DisorderTobacco Use Disorder AdjAdj Disorder w/Anxiety, Disorder w/Anxiety, Tobacco Use DisorderTobacco Use Disorder Age, Race, SexAge, Race, Sex60 60 y.oy.o., White, Female., White, Female25 25 y.oy.o., White, Female., White, Female OccupationOccupationSocial WorkerSocial WorkerAutism Therapist Autism Therapist Marital StatusMarital StatusNever married; not in Never married; not in relationship currentlyrelationship currently Never married; in 7-yr Never married; in 7-yr relationshiprelationship General General Medical Medical ConditionsConditions DM Type II, Hypothyroidism,DM Type II, Hypothyroidism, HyperlipidemiaHyperlipidemia, , Hypertension,Hypertension, AtherosclerAtheroscler. Heart Dis Heart Dis. NoneNone MedicationsMedicationsAspirin, Aspirin, BupropionBupropion, XL, , XL, DesloratadineDesloratadine, , EnalaprilEnalapril, , VytorinVytorin, , GlyburideGlyburide, , MetforminMetformin, , LevothyroxineLevothyroxine, , RosigliatazoneRosigliatazone KarivaKariva 4 4 Case StudiesCase Studies Patient APatient APatient BPatient B Psychiatric Psychiatric DiagnosisDiagnosis DysthymiaDysthymia, , Tobacco Use DisorderTobacco Use Disorder AdjAdj Disorder w/Anxiety, Disorder w/Anxiety, Tobacco Use DisorderTobacco Use Disorder Age, Race, SexAge, Race, Sex60 60 y.oy.o., White, Female., White, Female25 25 y.oy.o., White, Female., White, Female Weight, Ht., BMIWeight, Ht., BMI151 lbs, 61”, BMI=28.5151 lbs, 61”, BMI=28.5 (no (no signifsignif change in years) change in years) 159 lbs, 64”, BMI=27.3159 lbs, 64”, BMI=27.3 (181 lbs, 64”, BMI=31.1)(181 lbs, 64”, BMI=31.1) BPBP130/70130/70126/86126/86 LipidsLipidsTot Tot CholChol=155, =155, TriglycTriglyc=122,=122, HDL=57, LDL=74HDL=57, LDL=74 Tot Tot CholChol=232, =232, TriglycTriglyc=96,=96, HDL=67, LDL=146HDL=67, LDL=146 TSHTSH3.71 (119 in Sept 2005)3.71 (119 in Sept 2005)1.401.40 Exercise / DietExercise / DietNo exercise, no special No exercise, no special diet diet Exercise 30 min 3x/wk,Exercise 30 min 3x/wk, Weight WatchersWeight Watchers HbA1c %HbA1c %7.8% (10.2% in Sept 2005)7.8% (10.2% in Sept 2005)N/AN/A Other Other HxHxHxHx of Alcoholism; no of Alcoholism; no alcalc for for 20+ years20+ years NoneNone 5 5 Case Studies: Smoking HistoryCase Studies: Smoking History Patient APatient APatient BPatient B Psychiatric DiagnosisPsychiatric DiagnosisDysthymiaDysthymia, , Tobacco Use DisorderTobacco Use Disorder AdjAdj Disorder w/Anxiety, Disorder w/Anxiety, Tobacco Use DisorderTobacco Use Disorder Age, Race, SexAge, Race, Sex60 60 y.oy.o., White, Female., White, Female25 25 y.oy.o., White, Female., White, Female Age 1Age 1st st Cig Cig18 years old18 years old13 years old13 years old Daily smokingDaily smoking23 years old23 years oldStarted at age 15, 20 Started at age 15, 20 cpdcpd # years smoking# years smoking42 years42 years10 years10 years Most recent cigs/dayMost recent cigs/day1 pack/day1 pack/day10-15 cigs/day10-15 cigs/day # prior quit attempts# prior quit attempts“Many” but no serious “Many” but no serious quit attemptsquit attempts 6 (3 serious)6 (3 serious) Longest quitLongest quit1 day1 day2 months (2005)2 months (2005) Prior Cessation Prior Cessation TxTxN/AN/ABupropionBupropion SR, tapering SR, tapering Other infoOther infoWork stress, caretaker Work stress, caretaker for Mom w/Alzheimers, for Mom w/Alzheimers, shaky social supportshaky social support Partner smokesPartner smokes 6 6 Progress: Dramatic Decrease in Adult Progress: Dramatic Decrease in Adult Smoking Prevalence Over 40 YearsSmoking Prevalence Over 40 Years 19651965 20052005 Number PercentNumber Percent Number PercentNumber Percent Current 50 million Current 50 million 42.4%42.4% 47 million 47 million 20.9%20.9% Former 16 million Former 16 million 13.6%13.6% 51 million 51 million 21.5%21.5% Never 52 million Never 52 million 44.0%44.0% 135 million 135 million 57.6%57.6% (Source: National Health Interview Surveys, 1965-2005)(Source: National Health Interview Surveys, 1965-2005) 7 7 20.9% 20.9% 42.4% 42.4% 8 8 400,000 deaths per year nationally (8000 in WI) 400,000 deaths per year nationally (8000 in WI) 2,000 children and adolescents become regular 2,000 children and adolescents become regular smokers each daysmokers each day $75 billion in added healthcare costs$75 billion in added healthcare costs $80 billion in lost productivity$80 billion in lost productivity Low rates of clinical assistance with quittingLow rates of clinical assistance with quitting Remaining ChallengesRemaining Challenges 9 9 2003 Wisconsin Tobacco Survey2003 Wisconsin Tobacco Survey Long-term success rate of “cold turkey” method is about 5%Long-term success rate of “cold turkey” method is about 5% 1010 Disproportionate Smoking RatesDisproportionate Smoking Rates The highest rates of smoking are seen in individuals :The highest rates of smoking are seen in individuals : living below the poverty levelliving below the poverty level with the least educationwith the least education working in blue-collar and service jobs working in blue-collar and service jobs with psychiatric and substance use disorderswith psychiatric and substance use disorders 1111 Tobacco Dependence and Mental IllnessTobacco Dependence and Mental Illness Individuals with mental disorders typically smoke more Individuals with mental disorders typically smoke more cigarettes per day and they have greater difficulty cigarettes per day and they have greater difficulty quitting smokingquitting smoking Individuals with a current psychiatric disorder currently Individuals with a current psychiatric disorder currently make up about 30% of the population but consume 46% make up about 30% of the population but consume 46% percent of all cigarettes smoked inpercent of all cigarettes smoked in the U.S.the U.S. 1212 (Source: (Source: LasserLasser et al., JAMA. 2000;284:2606-2610) et al., JAMA. 2000;284:2606-2610) Smoking Status and Mental Illness:Smoking Status and Mental Illness: The National Comorbidity SurveyThe National Comorbidity Survey U.S. PopulationU.S. Population CurrentCurrent SmokersSmokers Lifetime EverLifetime Ever SmokersSmokers No Mental IllnessNo Mental Illness50.7%50.7%22.5%22.5%39.1%39.1% Mental Illness Mental Illness During LifetimeDuring Lifetime 49.3%49.3%34.8%34.8%55.3%55.3% Any Past Month Any Past Month Mental IllnessMental Illness 28.3%28.3%41.0%41.0%59.0%59.0% 1313 % Current% Current Past 30 DaysPast 30 Days SmokingSmokingQuit Rate, %Quit Rate, % No Mental Illness No Mental Illness2323 43 43 Major Depression Major Depression4545 26 26 Nonaffective Psychosis Nonaffective Psychosis4545 0 0 Gen. Anxiety Disorder Gen. Anxiety Disorder5555 29 29 Alcohol Abuse or Dependence Alcohol Abuse or Dependence5656 17 17 Bipolar Disorder Bipolar Disorder6161 26 26 Drug Abuse or Dependence Drug Abuse or Dependence6868 22 22 (Source: (Source: LasserLasser et al., JAMA. 2000;284:2606-2610) et al., JAMA. 2000;284:2606-2610) Smoking Status and Mental Illness:Smoking Status and Mental Illness: The National Comorbidity SurveyThe National Comorbidity Survey 1414 (Adapted from (Adapted from LasserLasser et al., 2000) et al., 2000) Smoking Rate and Number of Smoking Rate and Number of Lifetime Psychiatric DiagnosesLifetime Psychiatric Diagnoses 1515 Tobacco Dependence and Tobacco Dependence and Mental IllnessMental Illness Smokers with mental illnesses are aware of the Smokers with mental illnesses are aware of the health risks of smokinghealth risks of smoking However, nicotine may alleviate positive and However, nicotine may alleviate positive and negative psychiatric symptoms as well as side negative psychiatric symptoms as well as side effects of psychiatric medicationseffects of psychiatric medications Effective smoking cessation treatments are Effective smoking cessation treatments are available for smokers with mental illnessavailable for smokers with mental illness 1616 U.S. Public Health ServiceU.S. Public Health Service Clinical Practice GuidelineClinical Practice Guideline Michael C. Fiore, MD, MPHMichael C. Fiore, MD, MPH Panel ChairPanel Chair Published June, 2000Published June, 2000 Evidence-basedEvidence-based 50 meta-analyses of 50 meta-analyses of 6000 articles (1975-1999)6000 articles (1975-1999) 1717 Putting the 5 As into PRACTICE: Putting the 5 As into PRACTICE: ASKASK ADVISEADVISE ASSESSASSESS ASSISTASSIST- ARRANGE- ARRANGE Help develop a quit planHelp develop a quit plan Provide practical counselingProvide practical counseling Provide intra-treatment social supportProvide intra-treatment social support Encourage the smoker to seek social supportEncourage the smoker to seek social support Recommend pharmacotherapy except in special Recommend pharmacotherapy except in special circumstancescircumstances Provide supplementary materialsProvide supplementary materials 1818 The Guideline recommends the use of FDA-approved The Guideline recommends the use of FDA-approved pharmacotherapy, except when contraindicatedpharmacotherapy, except when contraindicated First-line medicationsFirst-line medications: : Bupropion SR, nicotine patch, Bupropion SR, nicotine patch, nicotine gum, nicotine inhaler,nicotine gum, nicotine inhaler, nicotine nasal spraynicotine nasal spray Second-line medicationsSecond-line medications: Clonidine, nortriptyline: Clonidine, nortriptyline (Although not available when the 2000 Guideline was (Although not available when the 2000 Guideline was developed, consider OTC nicotine lozenge, developed, consider OTC nicotine lozenge, vareniclinevarenicline) ) ASKASK ADVISEADVISE ASSESSASSESS ASSISTASSIST- ARRANGE- ARRANGE PharmacotherapyPharmacotherapy 1919 The Guideline recommends that The Guideline recommends that ALLALL smokers smokers trying to quit should be offered cessation trying to quit should be offered cessation medication except for special circumstances:medication except for special circumstances: - medical contraindications- medical contraindications - smoke 10 cigarettes/day- smoke 10 cigarettes/day - pregnant/breastfeeding- pregnant/breastfeeding - adolescent smokers- adolescent smokers Who Should Receive Pharmacotherapy?Who Should Receive Pharmacotherapy? 2020 Guideline Recommendations for Smokers Guideline Recommendations for Smokers With Psychiatric With Psychiatric ComorbiditiesComorbidities The antidepressants The antidepressants bupropionbupropion SR and SR and nortriptylinenortriptyline should be considered for smokers with current or past should be considered for smokers with current or past history of depressionhistory of depression Stopping smoking may affect the pharmacokinetics of Stopping smoking may affect the pharmacokinetics of certain psychiatric medications: need to monitorcertain psychiatric medications: need to monitor No specific recommendations in the Guideline for No specific recommendations in the Guideline for treating smokers with anxiety disorderstreating smokers with anxiety disorders 2121 General Recommendations for General Recommendations for Depressed Smokers Depressed Smokers Smoking cessation treatment can be initiated in Smoking cessation treatment can be initiated in depressed smokers who are motivated to quit and depressed smokers who are motivated to quit and clinically stableclinically stable Consider prescribing Consider prescribing bupropionbupropion SR or SR or nortriptylinenortriptyline (as (as appropriate given other possible psychotropic meds)appropriate given other possible psychotropic meds) Consider nicotine replacement therapy (NRT) either as Consider nicotine replacement therapy (NRT) either as a first-line pharmacotherapy or to augment a first-line pharmacotherapy or to augment bupropionbupropion SR or SR or nortriptylinenortriptyline 2222 General Recommendations for General Recommendations for Depressed Smokers Depressed Smokers Consider Consider vareniclinevarenicline as another first-line as another first-line pharmacotherapy but do not combine with pharmacotherapy but do not combine with NRTsNRTs There are no clinical studies of There are no clinical studies of vareniclinevarenicline in in combination with combination with bupropionbupropion SR or SR or nortriptylinenortriptyline (no (no concern about drug interactions according to concern about drug interactions according to MichaelMichael Fiore, M.D.)Fiore, M.D.) Consider referral to a mental health specialist Consider referral to a mental health specialist especially if the smokers depression is not responding especially if the smokers depression is not responding to antidepressant pharmacotherapy aloneto antidepressant pharmacotherapy alone 2323 General Recommendations for General Recommendations for Smokers With an Anxiety DisorderSmokers With an Anxiety Disorder Smoking cessation treatment can be initiated in anxious Smoking cessation treatment can be initiated in anxious smokers who are motivated to quit and clinically stablesmokers who are motivated to quit and clinically stable Neither Neither bupropionbupropion SR nor SR nor nortriptylinenortriptyline are are recommended for patients with anxiety disordersrecommended for patients with anxiety disorders SSRIsSSRIs and benzodiazepines