Module 1 The Foundation Integrating Tobacco Use Interventions

Module 1 - The Foundation: Integrating Tobacco Use Interventions into Chemical Dependence Services

Welcome Add Trainer Names 2

This training was developed by the Professional Development Program, under a contract with the NYS Department of Health, Tobacco Control Program. PDP developed five classroom-based curricula and seven online modules, which are available at www. tobaccorecovery. org 3

Housekeeping § Hours of Training § Breaks and Restrooms § Tobacco Use Policy § Cell Phones § Active Participation § Complete Training Evaluation 4

Introductions 5

Training Modules Module 1 - The Foundation Module 2 - Assessment, Diagnosis, Pharmacotherapy Module 3 - Behavioral Interventions Module 4 - Treatment Planning Module 5 - Co-occurring Disorders E-Learning - All Modules (www. tobaccorecovery. org) 6 PM 8

Module 1 Agenda § Introductions § Attitudes and Beliefs Activity § A Brief History § Rationale § Tobacco Dependence § NYS OASAS Regulation Part 856 7 PM 9

Module 1 Objectives Please refer to the list of objectives in your manual. 8 PM 9

Unit 1 Setting the Stage 9 PM 11

Attitudes and Beliefs The purpose of this activity is to help you explore your attitudes and beliefs about: § Tobacco use § Integrating tobacco interventions into chemical dependence services § Tobacco use, dependence, and recovery 10 PM 12

Attitudes and Beliefs, cont’d Debrief and Process 11 PM 12

Timeline • 1798 – 1970 s: Recognition of Tobacco Dependence - Lost and Found • 1980 s - 1990 s: Emerging Awareness • 2003 - 2008: A New Century 12 PM 13

RECOGNITION OF TOBACCO DEPENDENCE Lost and Found 1798 13 PM 13 1870 s late 1800 s, early 1900 s 1930 s 1960 s-1970 s

1798: Benjamin Rush, a physician and signer of the Declaration of Independence, identifies tobacco use as a harmful substance and observes that use supports excess alcohol consumption. RECOGNITION OF TOBACCO DEPENDENCE 1798 14 PM 13 1870 s late 1800 s, early 1900 s 1930 s 1960 s-1970 s

1870 s: Tobacco is identified as both a harmful addictive substance and as contributing factor in relapse from alcoholism and drug dependence. RECOGNITION OF TOBACCO DEPENDENCE 1798 15 PM 13 1870 s late 1800 s, early 1900 s 1930 s 1960 s-1970 s

Late 1800 s and early 1900 s: Tobacco dependence is routinely treated along with alcoholism and other drug dependence in inebriate clinics and asylums. RECOGNITION OF TOBACCO DEPENDENCE 1798 16 PM 13 1870 s late 1800 s, early 1900 s 1930 s 1960 s-1970 s

1930 s - Oxford Group principles used to help support early recovery efforts; Oxford Group frowns on tobacco use. 1935: Beginning of Alcoholics Anonymous. Alcoholism counseling begins to evolve. Tobacco use becomes embedded in recovery practices and the recognition as a serious addiction and recovery issue is lost for many years. RECOGNITION OF TOBACCO DEPENDENCE 1798 17 PM 13 1870 s late 1800 s, early 1900 s 1930 s 1960 s-1970 s

1964: Surgeon General Report on Smoking and Health indentifies the adverse health effects of tobacco use. 1960 s: Alcoholism counseling continues to evolve. 1970 s: Many former drug users become drug abuse counselors. Most counselors in both groups use tobacco. RECOGNITION OF TOBACCO DEPENDENCE 1870 s 18 PM 13 late 1800 s, early 1900 s 1930 s 1960 -1970 s

EMERGING AWARENESS 1985 19 PM 14 1992 1996

1985: Geraldine Delaney, founder of Little Hill-Alina Lodge in New Jersey, makes this the first tobacco-free chemical dependence treatment program. EMERGING AWARENESS 1985 20 PM 14 1992 1996

1992: John Slade, M. D. begins the Addressing Tobacco in the Treatment of Other Addictions Project at the University of Medicine and Dentistry of New Jersey (UMDNJ) EMERGING AWARENESS 1985 21 PM 14 1992 1996

1996: Van Dyke and Norris Addiction Treatment Centers (ATC) become the first tobaccofree chemical dependence inpatient treatment programs in New York State. Stutzman ATC follows in 1997. EMERGING AWARENESS 1985 22 PM 14 1992 1996 -1997

A NEW CENTURY 2003 23 PM 15 2004 2005 2006 2007 2008 2009

2003: Passage of NYS Clean Indoor Air Act, which exempts substance abuse and mental health treatment programs. 2003: American Cancer Society and ASAP of NYS create a mission statement to promote tobacco-free chemical dependence programs. OASAS task force convenes to discuss tobacco regulations and resources. 2003: NYS Partnership for the Treatment and Prevention of Tobacco Dependence convenes. A NEW CENTURY 2003 24 PM 15 2004 2005 2006 2007 2008 2009

2004: Founding of Tobacco Recovery Coalition of the Capital District, Albany, NY. 2004: OASAS Commissioner William Gorman Policy Statement that stated: Prevention and treatment providers should address all addictions including nicotine. A NEW CENTURY 2003 25 PM 15 2004 2005 2006 2007 2008 2009

2005: All 13 OASAS-operated Addiction Treatment Centers (ATCs) in transition to be tobacco-free programs. August 2005: OASAS Medical Director letter to all OASAS certified providers: “Addiction providers are best positioned to help patients become tobacco free to increase the quality of their lives in recovery. ” 2005: Some NYS chemical dependence providers begin implementing similar policies, becoming tobacco-free agencies A NEW CENTURY 2003 26 PM 16 2004 2005 2006 2007 2008 2009

May 2006: ASAP opens NYS Tobacco Dependence Resource Center. November 2006: ASAP launches www. tobaccodependence. org. December 2006: OASAS releases Local Services Bulletin No. 2006 – 10: Tobacco Dependence Practice Guidelines. A NEW CENTURY 2003 27 PM 16 2004 2005 2006 2007 2008 2009

July 2007: OASAS Commissioner, Karen Carpenter-Palumbo - Announcement of Regulation Part 856 Tobacco-Free Services, to be effective by July 24, 2008. ASAP Questions and Answers about Tobacco-Free Chemical Dependence Services teleconference series begins. August 2007: NY Tobacco Control Program issues RFP to provide statewide training and technical assistance to integrate tobacco interventions into services. A NEW CENTURY 2003 28 PM 16 2004 September 2007: TCP starts providing $4 M in Over-the-Counter Nicotine Replacement Therapy (OTC NRT) products to Patients and Staff of OASAS programs. 2005 2006 2007 2008 2009

January 2008: TCP awards training and technical assistance contract to Professional Development Program, University at Albany. March - July 2008: PDP begins training and technical assistance, launches www. tobaccorecovery. org website, selects Regional Training Centers, designs Modules 1 and 2, and begins statewide training. July 24, 2008: OASAS Regulation Part 856 Tobacco-Free Services goes into effect. October - December 2008: PDP launches Module 3 and Online Modules 1 and 2. A NEW CENTURY 2003 29 PM 16 2004 2005 2006 2007 2008 2009

January – December 2009: PDP launches Modules 4 – 5, Online Modules 3 – 7, and completes statewide classroom training. 2009: Family Smoking Prevention and Tobacco Control Act enacted. The FDA is finally given the legal authority to regulate tobacco, nicotine levels, and tobacco additives, excluding menthol. States of Washington and Texas: decide to implement tobaccofree addiction treatment services. A NEW CENTURY 2003 30 PM 16 2004 2005 2006 2007 2008 2009

Rationale 31 PM 17

Mission and Purpose § Treating tobacco dependence is consistent with the mission and purpose of chemical dependence services 32 PM 17

Mission Statement Example “We provide quality, cost-effective care to those suffering from alcoholism and chemical dependency and to the many whose lives are affected by the diseases of addiction. ” 33 PM 17

Mission Statement Example 2 “Our mission is to provide a quality continuum of comprehensive treatment and related services, in a caring atmosphere and at a reasonable price, for all people experiencing problems with alcohol or other drug use. ” 34 PM 17

Skills and Knowledge § Treating tobacco dependence requires the same skills and knowledge that addiction professionals already have to treat chemical dependence 35 PM 17

Tobacco’s Relationship to Alcohol and Other Drugs Prevalence of Tobacco Use (National Data) § General Population 19. 8% § Addiction Treatment 60 – 95% § Serious Mental Illness 75 – 80% § HIV and AIDS 50 – 70% 36 PM 18

Tobacco Use 7 Days Prior To Admission in 2006 Level of Care % Using % Males % Females Intensive Residential 76 % 74 % 82% Community Residential 73% 71% 80% Supportive Living 81% 79% 84% Inpatient Rehabilitation 80% 79% 82% Outpatient Clinic 63% 65% Outpatient Rehab 77% 76% 79% Methadone Clinic 83% 82% 84% 37 PM 18 -19 Data: 2006, OASAS Certified Programs

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Tobacco Industry Practices § Knowingly sells a product that when used as intended causes serious disease and death § Targets youth and denies doing so § Lots of money and no morals § Continues to lobby against further tobacco regulation § Uses massive advertising campaigns, plus insidious and deceptive marketing 41 PM 20

Toll of Tobacco Use General Population - Annually Deaths over 438, 000 Health care and productivity cost $194. 3 billion 42 PM 21

Toll of Tobacco Use Tobacco-Related Deaths are greater than Alcohol or Drug-Related Deaths among people treated for chemical dependence 43 PM 21

Toll of Tobacco Use § Bill W. § Dr. Bob § Marty Mann 44 PM 21

Toll of Tobacco Use § For every person who dies from their tobacco use, there are twenty people living with serious health problems caused by their tobacco use. 45 PM 22

Toll of Tobacco Use Tobacco-Related Health Consequences: 46 PM 22 -23 § Commonly known § Less commonly known

Integrated Tobacco Dependence Treatment § Efficacy § Improved Outcomes 47 PM 24 - 25

Unit Two Tobacco Dependence

Tobacco Dependence Why do people use tobacco? 49 PM 28

Tobacco Dependence (cont’d) Nicotine Dependence vs. Tobacco Dependence DSM III / III-R used the term “tobacco dependence. ” Why did this change to “nicotine dependence” in the DSM-IV / DSM IV-TR? 50 PM 28

Nicotine dependence compared to cocaine and amphetamine dependence amphetamine DA cocaine ACh nicotine 51 PM 29

Theories for Tobacco Use Prevalance § Shared Characteristics § Reinforcing Effects § Shared Brain Pathways § Modulating Effects 52 PM 30

DSM-IV-TR Criteria § Nicotine dependence criteria is not unique or different § DSM-IV-TR substance dependence criteria is used for diagnosing nicotine dependence (a. k. a. tobacco dependence) 53 PM 31

DSM-IV-TR Criteria, cont’d § Nicotine Withdrawal § Daily use for several weeks § Cessation is followed within 24 hours by four or more physical or behavioral signs. § Symptoms causes significant distress and impairment and are not due to medical condition or other mental disorder 54 PM 32

Tobacco Dependence Treatment § Management of withdrawal is critical to successful recovery § Strong evidence of medication effectiveness § Medication effective for many populations § Insufficient evidence of effectiveness only with a few populations 55 PM 33 - 34

Tobacco Dependence Treatment (cont’d) § First-Line medications § Nicotine Replacement Therapy (NRT) § Non-nicotine medications § Combination of medications is best § Other medication levels may be affected after stopping tobacco use § Few medical contraindications 56 PM 35 - 36

Tobacco Dependence Treatment (cont’d) § Supportive Counseling The combination of counseling and medication is more effective than either alone Motivational Interviewing, Cognitive Behavioral Therapy, Skills Training, and Relapse Prevention Therapy are all effective 57 PM 37

Summary - Nicotine Replacement Therapy § Nicotine medications have wide margin of safety § Dose should be at least equivalent to tobacco use § Combining tobacco medications is more effective § Patients with other chemical dependencies may require higher dosage and longer term NRT § Under-dosing may not manage withdrawal symptoms and often results in relapse 58 PM 37

Comparison of Nicotine Delivery Diagram shows rise in nicotine levels in plasma after smoking a cigarette and after using different nicotine replacement therapy products (Adapted from Royal College of Physicians Website, per MAH Russell, 1987 Nicotine intake and its regulation by smokers) 59 PM 38

The Cigarette: A Perfect Drug Delivery Device § Cigarettes - highly engineered nicotine delivery device § 1 cigarette can peak the nicotine blood level 5 - 7 x higher than the effect of a 21 mg nicotine patch § 300 hits per 1 ½ pack of cigarettes § Exact Titration: frequency of use, intensity, and ability to fine tune delivery of nicotine 60 PM 39

The Cigarette: A Perfect Drug Delivery Device (cont’d) § Allows exact dosing by user § Severely addicted smokers and those with limited income often re-light § Menthol cigarettes – allows deeper inhalation using less cigarettes to achieve higher nicotine levels 61 PM 39

How Tobacco Dependence Differs from AOD Dependence § Tobacco use does not cause intoxication § Tobacco use generally does not cause adverse behavioral outcomes § Tobacco use does not produce intense euphoria § Tobacco use may minor perceived improvements in cognitive functioning and mood 62 PM 40

How Tobacco Dependence is Similar to AOD Dependence § Affects release of dopamine and other neurotransmitters in the brain § Continued use despite serious harmful effects § Withdrawal syndrome § Rapid rates of relapse after attempts to stop § Nicotine self-administration in animal studies 63 PM 40

Reframing Language Public Health Terminology smoking smoker quit date cessation 64 PM 41 Recovery Terminology

Challenges in Treating Tobacco Dependence § Nicotine has strong negative and positive reinforcement § Nicotine has some perceived beneficial effects § Smoking tobacco provides most intense reward effects § Nicotine is not intoxicating § Nicotine withdrawal 65 PM 42 - 43

Unit Three OASAS Regulation Part 856 66 PM 45

Part 856 Tobacco-Free Services § What is the OASAS regulation? § What is expected of: § Patients § Staff and Volunteers § Program Administrators 67 PM 45

Part 856 Tobacco-Free Services (cont’d) § OASAS Regulation effective July 24, 2008 § Requires all OASAS certified and funded programs to “determine and establish written policies, procedures and methods governing the provision of a tobacco-free environment. ” - Section 856. 5 (a) 68 PM 46 -47

Tobacco-Free Environment § Tobacco-Free: No use of tobacco products in a program’s facilities, grounds or vehicles owned by or under the control of the program § Facility: The space used by the program’s patients, staff, volunteers, and visitors § Limited to space “under the direct control” of the program - Section 856. 4 69 PM 48

Minimum Policy Requirements § Define the facilities, vehicles and grounds. § Prohibit patients and visitors from bringing tobacco products and paraphernalia to the program. § Notify patients, staff, volunteers and visitors of the policy in writing. § Prohibit staff from using tobacco products while at work, during work hours. 70 PM 49

Minimum Policy Requirements (cont’d) § Establish tobacco-free policy for staff while on the work site. § Establish treatment modalities for patients who use tobacco. § Describe tobacco training available to all staff. § Describe tobacco prevention and education programs available to patients, staff, volunteers, and others. 71 PM 49

Minimum Policy Requirements (cont’d) § Establish procedures to address patient tobacco relapse. § “… every effort shall be made to provide appropriate treatment services…” § Establish procedures to address staff tobacco § “relapse consistent with the employment procedure…” - Section 856. 5 72 PM 49

Implications of the Regulation § Patients, staff, volunteers, and visitors may not use tobacco on program’s buildings, grounds, and vehicles. § Patients, family members, and other visitors may not bring tobacco or paraphernalia to the program. § Staff may not use tobacco products at work, during work hours. 73 PM 50

Program Administrator Responsibilities § Write a tobacco-free environment policy. § Post notices and provide policy to all patients, staff, volunteers, and visitors. § Identify tobacco prevention and education programs available to patients, staff, volunteers, and visitors. § Establish treatment modalities for patients who use tobacco. 74 PM 50

Program Administrator Responsibilities § Identify tobacco use and dependence training available for staff and volunteers. § Establish procedures for patient and staff policy violations. § Manage organization’s change process. 75 PM 50

Regulation 856 – True or False? Patients, family members, or other visitors may not bring tobacco or tobacco paraphernalia to the program or service. 76 PM 51

Regulation 856 – True or False? OASAS-funded Permanent Supportive Housing and Vocational Rehabilitation programs are exempt from the regulation. 77 PM 51

Regulation 856 – True or False? Staff may use tobacco during work hours, while on break, and off premises. 78 PM 51

Regulation 856 – True or False? For residential treatment programs, patients who relapse on tobacco must be administratively discharged. 79 PM 51

Regulation 856 – True or False? For outpatient treatment programs, all patients must stop using tobacco for the duration of their treatment. 80 PM 51

Resources The Tobacco Recovery Resource Exchange http: //www. tobaccorecovery. org E-Learning and Online Resources OASAS http: //www. oasas. state. ny. us/tobacco/index. cfm Email: Tobacco. Free@oasas. state. ny. us 81 PM 53 -54

Workshop Evaluation Form and Post Test 82