tobacco and opioids
TRANSCRIPT
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TOBACCO AND OPIOIDSCarolyn Warner-Greer MD MS FACOG FASAM
Otis R Bowen Center for Health and Human Services
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COMPARATIVE CAUSES OF DEATH IN THE US
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• IN 1963, AMERICANS SMOKED ENOUGH CIGARETTE FOR EVERY ADULT TO SMOKE MORE THAN ½ PACK A DAY
• TODAY, LESS THAN 15 % OF ADULT AMERICANS SMOKE
• THIS HAS DECLINED FROM 21% IN 2005
TOBACCO USE IS DECLINING
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Guydish, 2011
DISPROPORTIONATEPREVALANCE
90%+
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• ONE OF 5 NEW OTP’S LICENSED BY DMHA IN 2018; OPENED 6-14-18
• WAIT…..
BOWEN RECOVERY CENTER
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• ONE OF 5 NEW OTP’S LICENSED BY DMHA IN 2018; OPENED 6-14-18
• ENROLLED 349 CLIENTS-ALL HAVE SEVERE OUD, TREATED WITH MTD
• 100% HAVE DOCUMENTED TOBACCO USE HISTORY AT INTAKE
• INITIAL RATE: 91.7%
BOWEN RECOVERY CENTER
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• 95% smoke when entering treatment
• Increased risk for those with oud
• Increased risk of tobacco related death
• Health insurance costs
“THE UNHEALTHY CONNECTION ”Tobacco addiction among people with
substance use disorders
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• INCREASE INDIANA CIGARETTE TAX BY $2.00
• PREVENT 48,700 <18 YO FROM STARTING
• INCREASED FUNDING FOR :
• PROGRAMMING AT SUBSTANCE USE TREATMENT CENTER FOR TOBACCO CESSATION
• PROVISION OF CESSATION PRODUCTS
• DEVELOPMENT OF TECHNOLOGY
• (RAISE LEGAL AGE TO 21 YEARS)
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• HIGHER RATE OF TOBACCO USE
• HIGHER NUMBER OF CIGARETTES SMOKED/DAY
• LOWER CESSATION RATE
SMOKING BEHAVIOR AMONG PERSONS WITH OUD
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• Tobacco related illness is a major cause of death:
• 51% died of tobacco related causes
• Death rate of smokers was 4 times higher than that of non-smokers
Tobacco related mortality WITH OUD
Hurt et al, JAMA, 1996
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STUDY FINDING
National Epidemiologic Study (Weinbeger et al. 2017) Tobacco use initiation or continuation increases risk of relapse
Meta Analysis of 19 RCT (Prochaska et al. 2004) 25% increased likelihood of long term abstinence from alcohol and drugs
RCT (Shoptaw et al. 2002) Smoking cessation correlates with opioid and cocaine abstinence
SMOKING THREATENS RECOVERY;CESSATION PROMOTES IT
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The brain, opioids and tobacco
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It’s always about dopamine…
NICOTINEENTERS
NICOTINE RECEPTOR STIMULATED
DOPAMINE
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• PERIPHERAL-EPINEPHRINE
• CENTRAL-DOPAMINE, EPINEPHRINE, ENDOGENOUS OPIOIDS
• GENETICS-MOR A118G
• BLOCK NA-VTA→ DECREASED TOBACCO USE?
NICOTINE-->NEUROTRANSMITTERS
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CIGARETTES ARE THE MOST
ADDICTIVE DRUG OF ABUSE
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“THE EXPERIENCE OF SMOKING FOR ME, WHEN I’M JONESING AND I TAKE IN THAT FIRST HIT, IT’S LIKE SCRATCHING AN
ITCH. IT’S LIKE TAKING A DRINK ON A REALLY THIRSTY DAY. IT’S LIKE TAKING A BREATH OF AIR WHEN YOU’VE HAD YOUR
HEAD UNDER WATER AND YOU POP BACK UP.”
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CIGARETTES-THE ULTIMATE DELIVERY MODEL
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HOW CAN WE HELP PERSONS WITH OUD STOP SMOKING?
PROVIDE EVIDENCED BASED TREATMENT
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• IN OPIOID TREATMENT USING MEDICATIONS
• METHADONE>BUPRENORPHINE
• SMOKERS INTERESTED IN QUITTING
• BEHAVIORAL AND PHARMACOLOGICAL INTERVENTIONS
WHAT IS THE EVIDENCE?
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• MULTIPLE SURVEYS OF SUD PROGRAMS:
• 18-45% PROVIDE SMOKING CESSATION COUNSELING
• 12-33% PROVIDE CESSATION PHARMACOTHERAPY
• NUMBER OF PEOPLE TREATED IS LOW
• DECLINE IN TREATMENT PROVISION OVER TIME
HOW ARE OUD TREATMENT PROGRAMS DOING?
RICHTER ET AL, 2004; FRIEDMANN ET AL, JSAT 2008, HUNT ET AL, JSAT 2012, EBY ET AL. JSAT 2015
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• ASK ABOUT TOBACCO USE
• ADVISE TO QUIT
• ASSESS WILLINGNESS TO QUIT
• ASSIST IN QUIT ATTEMPT
• ARRANGE FOLLOW UP
BRIEF COUNSLEING: THE 5 A’S
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PATIENTS TREATED WITH BUP
CURRENT SMOKERS FORMER SMOKERS NEVER SMOKED NO STATUS DOCUMENTED
ASK: SMOKING STATUS AT FQHC
NAHVI, JSAT 2014
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SMOKERS IN OUD TREATMENT
PRESCRIBED MEDS NOT PRESCRIBED
SMOKING CESSATION TREATMENT
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IF NOT USE, WHO PROVIDES INFORMATION ON CESSATION?
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• LIMITED PERCEIVED EFFICACY
• OVERESTIMATED RISKS
• PERSON PROVIDING INFORMATION ALSO SMOKES
MISCONCEPTIONS ABOUT SMOKING CESSATION AND SUD POPULATION
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PAM IS A 62 YEAR OLD WOMAN WHO HAS BEEN IN LONG TERM RECOVERY FROM HEROIN USE AND IN METHADONE
MAINTENANCE THERAPY. SHE HAS BEEN HOSPITALIZED TWICE FOR PNEUMONIA. SHE HAS NEVER STOPPED
SMOKING AND DOESN’T WANT TO STOP.
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• 2ND “A”-ADVISE
• 3RD “A”-ASSESS
BRIEF COUNSELING INTERVENTION
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• RELEVANCE TO QUITTING SMOKING
• RISKS ASSOCIATED WITH CONTINUED SMOKING
• REWARDS TO BEING TOBACCO FREE
• ROADBLOCKS TO SUCCESSFULLY QUITTING
• REPETITION OF ASSESSMENT
MOTIVATIONAL 5R’S FOR SMOKERS NOT READY TO QUIT
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• INDUCTION OF CYP1A2 INCREASES METABOLISM OF METHADONE AND BUPRENORPHINE
• REAL CONCERN IS TO ADDRESS POTENTIAL SEDATION WITH TOBACCO CESSATION
• HOWEVER…WORKS BOTH WAYS!
Drug interactions with tobacco use
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• ONLY THREE TRIALS INCUDE SMOKERS EVEN IF THEY WERE PRECONTEMPLATIVE
• BUT…
• ENHANCED CESSATION
• IMPROVED HEALTH
• ENGAGED SMOKERS NOT READY TO QUIT
EVIDENCE BASE IS LIMITED
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PAM HAS BEEN IN THE EMERGENCY DEPARTMENT THREE TIMES THIS MONTH FOR DYSPNEA AND HAS TROUBLE WALKING THROUGH THE OTP EACH DAY. SHE NOW IS
ASKING ABOUT HELP WITH CESSATION.
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• 4TH “A”-ASSIST
• BRIEF (3 MINUTE) COUNSELING BY PHYSICIAN INCREASES CESSATION RATE BY 30%
• DOSE RESPONSE BETWEEN NUMBER OF CLINICAN TYPES OFFERING COUNSELING AND CESSATION SUCCESS
• COUNSELORS
BRIEF COUNSELING INTERVENTION
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• FREQUENT PATIENT CONTACT
• SKILLS TO ASSESS OUD SAME AS ADDRESSING TOBACCO USE
• BRC-60% PATIENTS IN SUSTAINED REMISSION FROM OUD
• GREAT OPPORTUNITY
COUNSELORS/CASE MANAGERS IN OTP SETTING
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• THREE RCT’S
• (2) OTP’S, (1) OBOT
• MINIMAL EFFICACY REFLECTS LOWADHERENCE AND LOW UPTAKE
NO CESSATION WITH LOW INTENSITY COUNSELING
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• ADD TO ELECTRONIC HEALTH RECORD
• ADDRESS DURING COUSELING SUPERVISION
INTERVENTIONS WITH COUNSELORS IN SUD TREATMENT
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0
10
20
30
40
50
60
70
80
90
Time 1 Time 2
IMPACT OF ADDING TOBACCO CESSATION TO EHR
IDENTIFICATION OF TOBACCO USE
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0
5
10
15
20
25
30
TIME 1 TIME 2
IMPACT OF ADDING TOBACCO CESSATION TO EHR
PERCENTAGE OF COUNSELING ENCOUNTERS
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• NOT JUST CHANGE IN EHR
• ALL STAFF TRAINING
• POLICY DEVELOPMENT
• LEADERSHIP SUPPORT
• ACCESS TO NRT
• INCENTIVE FOR PRODUCTIVITY, SIMILAR TO Meaningful USE?
ORGANIZATIONAL CHANGE INTERVENTION
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MOTIVATION INTERVIEWING
4.40%
4.50%
4.60%
4.70%
4.80%
4.90%
5.00%
5.10%
5.20%
5.30%
Max Min
TOBACCO ABSTINENCE
STEIN, ADDICTION 2006
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• POTENT SHORT TERM EFFECTS
• EFFECTS NOT MAINTAINED
CONTINGENCY MANAGEMENT
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• MULTIPLE CALLS INCREASES (OR 1.41) SUCCESSFUL QUIT ATTEMPTS
• EFFICACY FOR LONG TERM CESSATION
• EFFICACY IN REACING RACIAL/ETHNIC MINORITY SMOKERS
QUITLINE EFFICACY FOR PATIENTS WITH OUD
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• 112 PATIENTS AT OTP WHO ALSO SMOKE IN CLINICAL TRIAL
• ALL OFFERED TELEPHONE QUIT LINE REFERRAL
• 22% UTILIZED THE QUITLINE COUNSELING
• COMPARABLE TO PRIMARY CARE
• MUCH HIGHER THAN POPULATION BASED
TELEPHONE QUITLINE REFERRAL
GRIFFIN ET AL.NIC AND TB RSCH 2016
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BASELINE TELEPHONE ACCESS N (%)
NO CELLPHONE 15 (13%)
CELLPHONE SERVICE LAPSE 31 (28%)
PROBLEMS CHARGING CELLPHONE 15 (13%)
RUNNING OUT OF MINUTES 28 (25%)
NO LANDLINE 57 (51%)
TELEPHONE QUITLINE BARRIERS
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• COMPETING LIFE DEMANDS
• SKEPTICAL OF QUITLINE EFFICACY
TELEPHONE QUITLINE BARRIERS
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TOBACCO CESSATION MEDICATIONS
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• 72% QUIT ATTEMPTS ARE WITHOUT TREATMENT
• 3-5% SELF QUITTERS ACHIEVE PROLONGED ABSTINENCE
• MOST RELAPSE WITHIN 8 DAYS
“COLD TURKEY METHOD”
Successful Unsuccessful
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TOBACCO ABSTINENCE RATES
0%
5%
10%
15%
20%
25%
30%
35%
GENERAL POPULATION
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• COMMON ELIGIBILITY CRITERIA FOR STUDIES ELIMINATES 50% OF DAILY SMOKERS
• ALMOST NEVER INCLUDES
• MENTAL ILLNESS
• ADDICTIVE DISORDERS (OUTSIDE, OF COURSE, TOBACCO)
EFFICACY OF NRT/MEDICATION IN SUD POPULATION
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0%
10%
20%
30%
40%
50%
VARENICLINE BUPROPRION PLACEBO
CO VERIFIED CONTINUOUS ABSTINENCE
WEEK 12 WEEK 52
EFFICACY OF VARENICLINE VS. BUPROPRION VS. PLACEBO
JORENBY, 2006; GONZALES, 2006
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• EXCLUDED
• PSYCHIATRIC CO-MORBIDITIES
• MEDICAL CO-MORBIDITIES
• SUBSTANCE USE DISORDERS
• EAGLES TRIAL• DESIGNED TO ADDRESS OUR POPULATION!
• STILL REQUIRED THOSE WITH SUD• SUSTAINED RECOVERY FOR ONE YEAR
• NO MEDICAL INTERVENTIONS (MTD, BUP)
BUT…..
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“ARE PHARMACOTHERAPIES INEFFECTIVE IN OPIOID-DEPENDENT SMOKERS? REFLECTIONS ON THE
SCIENTIFIC LITERATURE AND FUTURE DIRECTION”
MILLER, SIGMON. NIC AND TOB RSCH 2015
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225 PATIENTS IN OP SUD TREATMENT
8 WEEKS PATCH, GROUP COUNSELING, SUD
TREATMENT10% ABSTINENCE AT 8 WEEKS
TAU: SUD TREATMENT 0% ABSTINENCE AT 8 WEEK
RULE #1-WITHOUT TREATMENT, NO CESSATION
REID, JSAT, 2008
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112 PATIENT FROM OTP (METHADONE)
12 WEEKS, VARENICLINE, IN PERSON AND TELEPHONE
COUNSELING
10.5% ABSTINENT AT 12 WEEKS
12 WEEKS PLACEBO, IN PERSON AND TELEPHONE
COUNSELING0% ABSTINENT AT 12 WEEKS
NAHVI, ADDICTION 2012
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TREATMENTS HELP
EFFECTS MAY BE MODEST
DOING NOTHING DOES NOTHING
ONE PERSON ACHIEVING ABSTINENCE IS 100% FOR THEM
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OPTIMIZE EFFICACY
OPTIMIZE IMPLEMENTATION
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• LIMITATIONS IN OUR SYSTEMS OF CARE
• UNIQUE CHARACTERISTICS IN OUR PATIENT POPULATION
WHY ARE CESSATION RATES SO LOW IN SUD POPULATION?
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• LIMITED INITIAL ABSTINENCE
• EFFECTS ARE NOT SUSTAINED
SHORT TERM TREATMENT INTERVENTIONS
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0%
2%
4%
6%
8%
10%
12%
2 WEEKS 4 WEEKS 8 WEEKS 12 WEEKS 24 WEEKS
CO VERIFIED ABSTINENCE %
PLACEBO VAREICLINE Column1Column2 Column3
LIMITED INITIAL ABSTINENCE
INTERVENTION ENDS
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PRE-CESSATION PATCH TREATMENT
• META ANALYSIS OF 4 STUDIES
• PATCH ON QUIT DATE VS. 6 WEEKS PRIOR
• “PRE-LOADING” DOUBLED ODDS OF QUITTING
• “PRE-QUIT” DECREASED ENJOYMENT
• “GIVING A BACKPACK” OF TOOLS BEFORE THE TRIPSHIFFMAN AND FERGUSON, 2008
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• RCT, 101 SMOKERS, RANDOMIZED TO:
• VARENICLINE X 4 WEEKS PRE QUIT DATE
• PLACEBO X 3 WEEKS, VARENICLINE X 1 WEEK PRE QUIT DATE
• VARENICLINE X 3 MONTHS (BOTH GROUPS, AFTER QUIT DATE)
• PRELOADING:
• REDUCED PREQUIT SMOKING ENJOYMENT
• INCREASED 12 WEEK ABSTINENCE RATES (47.2% VS 28%)
VARENICLINE “PRE-LOADING”
HAJEK, ET AL, ARCH INT MED 2011
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“EVEN WHEN I QUIT FOR A FEW MONTHS, I ALWAYS GO BACK TO SMOKING….IT
NEVER LASTS!”
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225 PATIENTS IN OP SUD TREATMENT
8 WEEKS PATCH, GROUP
COUNSELING, SUD TREATMENT 5.7% ABSTINENT AT
52 WEEKS10% ABSTINENT AT
8 WEEKS
TAU: SUD TREATMENT
0% ABSTINENT AT 8 WEEKS
0% ABSTINENT AT 52 WEEKS
EFFECTS ARE NOT SUSTAINED WITH SHORT TERM TREATMENT
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112 SUD PATIENT IN OTP
12 WEEKS VARENICLINE, INPERSON AND
TELEPHONE COUNSELING
10.5% ABSTINENT AT
12 WEEKS
5.3% ABSTINENT AT
52 WEEKS
12 WEEKS PLACEBO, IN PERSON AND TELEPHONE
COUNSELING
0% ABSTINENT AT 12 WEEKS
0% ABSTINENT AT 52 WEEKS
EFFECTS ARE NOT SUSTAINED WITH SHORT TERM TREATMENT
NAHVI, ADDICTION 2012
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STUDY N INTERVENTION
SCHNOLL ET AL, 2010 568 PATCH 2 VS 6 MONTHS
HAYS ET AL, 2001 784 BUPROPRION 7 VS 52 WKS
TONSTAD ET AL 2006 1210 VARENICLINE 3 VS 6 MONTHS
SCNOLL ET AL, 2015 525 PATCH 2 VS 6 VS 12 MONTHS
EXTENDED TREATMENT WORKS
ALL SHOWED:
LONGER DURATION=
INCREASED ABSTINENCE
INCREASED TIME TO RELAPSE
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• INCREASED MOTIVATION :
• MORE QUIT ATTEMPTS
• CHANGE GOAL TO COMPLETE ABSTINENCE
• ADVANCE CHANGE OF STAGE
EXTENDED TREATMENT ALSO:
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CESSATION RATES ARE LOW DUE TO POOR ADHERENCE TO
TREATMENT PLAN
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LOW ADEHERENCE=LOW CESSATON
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
9.00%
VARENICLINE PATCH+GUM PLACEBO
TOBACCO ABSTINENCE- 6 MONTH
34.2%. 48.8%. 34.4%ADHERENCE TO MEDSSTEIN, DRUG ALC DEP 2013
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PARTICIPANTS FINDINGS
N=225; SMOKERS WITH SUD #WEEKS ABSTINENT CORRELATED WITH:COUNSELING ADHERENCENICOTINE PATCH ADHERENCE
N=383; SMOKERS WITH OUD 44.1% NICOTINE PATCHES USED ON DAYS PATCHES WERE USED-
7.1X HIGHER SMOKING ABSTINENCEFEWER CIGS/DAY
ADHERENCE IMPROVES OUTOMES
REID ET AL JSAT 2008STEIN ET AL JGIM 2006
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• FEW STUDIES HAVE EVALUATED ADHERENCE AND IT’S IMPACT
• DIRECTLY OBSERVED THERAPY (DOT) IMPROVES ADHERENCE AND CLINICAL OUTCOMES
• ONE OF OUR FEW MODIFICABLE INTERVENTIONS!
• OPIOID TREATMENT PROGRAMS ARE THE CORNERSTONE FOR DIRECTLY OBSERVED THERAPIES (HEPATITIS C, HIV, TB)
ADHERENCE MATTERS
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0
20
40
60
80
100
120
WEEK 1 WEEK 2 WEEK 3 WEEK 6 WEEK 9 WEEK 12
DOT SAT
VARENICLINE ADHERENCE
0
20
40
60
80
100
120
WEEK 1 WEEK 2 WEEK 3 WEEK 6 WEEK 9 WEEK 12
DOT SAT
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SMOKERS IN OTP
DOT VARENICLINE X
12 WEEKS
CO VERIFIED ABSTINENCE=18%
SAT VARENICLINE X
12 WEEKS
CO VERIFIED ABSTINENCE=10%
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• HIGHER ADHERENCE WITH DOT
• CESSATION RATES DOUBLED
• BEST INTERVENTION IN OTP REPORTED (ON PAR WITH CONTINGENCY MANAGEMENT)
• SUSTAINABLE?
• IMPLEMENTED IN OTHER RECOVERY ENVIRONMENTS?
SO….
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• SIGNIFICANT BURDEN OF TOBACCO USE IN OUD POPULATION
• NEED TO IDENTIFY TOBACCO USE AS PROBLEM
• BECOME FAMILIAR WITH EVIDENCE BASED TREATMENT (MEDICAL AND COGNITIVE)
• SYSTEM WIDE OPTIMIZE INTERVENTIONS TO ENHANCE EFFICACY
• SCALE INTERVENTIONS TO REACH UNIQUE POPULATION
CONCLUSIONS
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• UNASSISTED CESSATION RATES 0%
• ASSISTED CESSATION RATES MODEST
• SHORT TERM TREATMENTS ARE INSUFFICIENT
• ADHERENCE IMPROVES OUTCOMES
CONCLUSIONS
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CAROLYN WARNER-GREER
BOWEN RECOVERY CENTER 260-471-9357
BOWEN CENTER-ALLEN CO. OFFICE 260-471-3500
QUESTIONS