Smoking Cessation and Chronic Mental Illness CSAM May

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Smoking Cessation and Chronic Mental Illness CSAM May 15, 2009 David Kan, M. D.

Smoking Cessation and Chronic Mental Illness CSAM May 15, 2009 David Kan, M. D. E-mail: David. Kan 2@va. gov San Francisco VA Medical Center Asst. Clinical Professor, UCSF

Overview n n Epidemiology Nicotine & Tobacco n n Aka: Dr. Jekyll & Mr.

Overview n n Epidemiology Nicotine & Tobacco n n Aka: Dr. Jekyll & Mr. Hyde Smoking Cessation n n Psychosocial Pharmacological

Epidemiology n Total n 47. 2 million adults (24. 1%) were current smokers n

Epidemiology n Total n 47. 2 million adults (24. 1%) were current smokers n n n 24. 8 million men and 22. 4 million women. 82. 4% of all smokers were everyday smokers Age n n The highest rate of smoking was in 18 -24 year olds: 27. 9% and 25 -44 year olds: 27. 5%. Smoking rates drop with Age Source: CDC 1998 Survey

Epidemiology n Ethnicity n n Native Americans/Alaska Natives: 40%, 25% of Caucasians and 24.

Epidemiology n Ethnicity n n Native Americans/Alaska Natives: 40%, 25% of Caucasians and 24. 7% of African Americans smoke. Hispanics: 19. 1% and Asians/Pacific Islanders: 13. 7%. Education and income n n More Education = Less Smoking More Income = Less Smoking Source: CDC Survey 1998

Smoking and Mental Illness, Lasser, et al. JAMA. 2000; 284: 2606 -2610.

Smoking and Mental Illness, Lasser, et al. JAMA. 2000; 284: 2606 -2610.

Smoking Rates & Mental Illness n In general 2 x Non-Mentally Ill Diagnosis In

Smoking Rates & Mental Illness n In general 2 x Non-Mentally Ill Diagnosis In Past Month US Population, % Current Smokers, % Lifetime Smokers, % Quit Rate, % Major Depression 4. 9 44. 7 60. 4 26 Non Affective Psychosis 0. 2 45. 3 0 Drug Abuse or Dependence 1 67. 9 87. 5 22. 4 Bipolar Disorder 0. 9 60. 6 81. 8 25. 9 National Comorbidity Study – 1989 US NHIS

Nicotine vs. Tobacco

Nicotine vs. Tobacco

Nicotine n Ideal CNS Drug Very Effective n. Very Safe n

Nicotine n Ideal CNS Drug Very Effective n. Very Safe n

Neurochemical Effects Slide Courtesy: David Sachs, M. D.

Neurochemical Effects Slide Courtesy: David Sachs, M. D.

Why Cigarettes? n Ideal Drug Delivery System Very Rapid Delivery n High Dose n

Why Cigarettes? n Ideal Drug Delivery System Very Rapid Delivery n High Dose n Highly Concentrated n

What is the Problem with Cigarettes? n Toxic Delivery System

What is the Problem with Cigarettes? n Toxic Delivery System

SMOKE is the PROBLEM NOT NICOTINE!!!

SMOKE is the PROBLEM NOT NICOTINE!!!

Smoking Related Illness 1/3 rd of Smokers will die prematurely of tobacco-related illness

Smoking Related Illness 1/3 rd of Smokers will die prematurely of tobacco-related illness

Tobacco – Drug Interactions n Pharmacokinetic n n n Polycyclic aromatic hydrocarbons (PAHs) are

Tobacco – Drug Interactions n Pharmacokinetic n n n Polycyclic aromatic hydrocarbons (PAHs) are some of the major lung carcinogens found in tobacco smoke PAHs - potent inducers of the hepatic cytochrome P-450 (CYP) isoenzymes 1 A 1, 1 A 2, and, possibly, 2 E 1 CYP 1 A 2 – largest effect Kroon, L “Drug interactions with smoking. ” Am J Health Syst Pharm. 2007 Sep 15; 64(18): 1917 -21

Tobacco – Drug Interactions n Drugs Affected n n n Clozapine Fluvoxamine Olanzapine Caffeine

Tobacco – Drug Interactions n Drugs Affected n n n Clozapine Fluvoxamine Olanzapine Caffeine Tacrine UP TO 50% REDUCTION IN BLOOD LEVELS Kroon, L “Drug interactions with smoking. ” Am J Health Syst Pharm. 2007 Sep 15; 64(18): 1917 -21

Tobacco – Drug Interactions n Hormone Contraceptives n n Increased risk of Stroke and

Tobacco – Drug Interactions n Hormone Contraceptives n n Increased risk of Stroke and Heart Attack Inhaled Corticosteroids n Decreased Efficacy Kroon, L “Drug interactions with smoking. ” Am J Health Syst Pharm. 2007 Sep 15; 64(18): 1917 -21

What About Quitting?

What About Quitting?

Tobacco Dependence In Perspective n Approximately 35% try to quit each year n 70%

Tobacco Dependence In Perspective n Approximately 35% try to quit each year n 70% to 80% try to quit “cold turkey” n n n Most Relapse — 95% Cold turkey quit rates at 1 year are 5% Physician-assisted quit rates (short-term counseling + medications) at 1 year are 10% to 30% Fiore MC, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Dept of Health & Human Services. Public Health Service. June 2000. (www. surgeongeneral. gov/tobacco/default. htm)

Disease Model of Tobacco Dependence Acute Disease n Short-Term Disorder n Severe n Sudden

Disease Model of Tobacco Dependence Acute Disease n Short-Term Disorder n Severe n Sudden in Onset n Single, Time-limited intervention n Examples: n n Common Cold Broken Bone Chronic Disease n Long-Term Disorder n Periods of relapse and remission n Requires ongoing rather than acute care n Examples: n Diabetes Hypertension Addiction n Smoking! n n

Psychiatric Conditions n n Depressed Smokers n n 2 x as likely to smoke

Psychiatric Conditions n n Depressed Smokers n n 2 x as likely to smoke More Depression less likely to quit Psychiatric Conditions n n Data mixed or lacking as to long-term outcomes Many studies show interventions work as well as with those not mentally ill Ranny, et al: Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med. 2006 Dec 5; 145(11): 845 -56. Epub 2006 Sep 5. Review.

Substance Abuse n Alcohol & Tobacco Alcohol Use Triggers / exacerbates tobacco use n

Substance Abuse n Alcohol & Tobacco Alcohol Use Triggers / exacerbates tobacco use n Quitting both led to higher quit rates for both n Joseph, AM et al A randomized trial of concurrent versus delayed smoking intervention for patients in alcohol dependence treatment. Stud Alcohol. 2004 Nov; 65(6): 681 -91

Indications for Longer/More Intensive Treatment n High Nicotine Dependence n n High Serum Cotinine

Indications for Longer/More Intensive Treatment n High Nicotine Dependence n n High Serum Cotinine n n >250 ng/ml Depression n n FTQ >5 Beck Depression Inventory > 9 Smoker in Household n Decreases chances by 50% Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary Rehabilitation Guidelines to Success, 3 rd Edition 2000: 261 -301

Indications for Longer/More Intensive Treatment n Smoking Initiation at Younger Age n n <17

Indications for Longer/More Intensive Treatment n Smoking Initiation at Younger Age n n <17 years old Heavy Smoker n >1 Pack Per Day n # of Prior quit attempts n Alcohol or Drug Abuse n Psychotic Spectrum Illness Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary Rehabilitation Guidelines to Success, 3 rd Edition 2000: 261 -301

Treatment Recommendations

Treatment Recommendations

Psychosocial Interventions n Counseling n Behavioral Therapy n Quit Line (1 -800 -NO-BUTTS) n

Psychosocial Interventions n Counseling n Behavioral Therapy n Quit Line (1 -800 -NO-BUTTS) n Motivational Enhancement

FDA Approved Medications n CONTROLLER MEDICATIONS n n Bupropion SR (Zyban, Wellbutrin SR, Wellbutrin

FDA Approved Medications n CONTROLLER MEDICATIONS n n Bupropion SR (Zyban, Wellbutrin SR, Wellbutrin XL) Nicotine Patch Varenicline (Chantix) RESCUE MEDICATIONS n n Nicotine Inhaler Nasal Spray - Fastest Polacrilex Gum (Nicorette) – p. H dependent Polacrilex Lozenge (Commit) – p. H dependent

Slide Courtesy: David Sachs, MD

Slide Courtesy: David Sachs, MD

Success Strategies n Combined Strategies n Behavioral + Medication n Always at least 1

Success Strategies n Combined Strategies n Behavioral + Medication n Always at least 1 controller n Almost always need Rescue

Nicotine Replacement “Clean vs. Dirty” 1 n Start with Patch n Add lozenge, gum,

Nicotine Replacement “Clean vs. Dirty” 1 n Start with Patch n Add lozenge, gum, nasal spray, inhaler n Target 30 -60 days smoke free prior to tapering n n Taper short acting first Weeks to YEARS! 1. Peter Banys, MD – Personal Communication

Nicotine Replacement n Dosing? n n n 80% of 1 -PPD smokers not adequately

Nicotine Replacement n Dosing? n n n 80% of 1 -PPD smokers not adequately replaced with 21 mg nicotine patch Clear Dose-Response Curve 1 Serum Cotinine n n 24 -Hour half-life of nicotine metabolism Dose to level n No absolute maximum n 10 -15% smoke free at one year 1. Sachs DPL. J Smoking-Related Dis 1994; 5: 183 -193

Bupropion (Wellbutrin/Zyban) n Mechanism n n Dosing n n Affects dopaminergic projections Start 1

Bupropion (Wellbutrin/Zyban) n Mechanism n n Dosing n n Affects dopaminergic projections Start 1 week before quit date 150 mg SR x 3 -6 days then 150 mg BID Psychosocial treatment recommended Contraindications n n Seizure Disorder Eating Disorder

Bupropion (Wellbutrin/Zyban) n Common SE n n n Insomnia – 28 -35% vs. 22%*

Bupropion (Wellbutrin/Zyban) n Common SE n n n Insomnia – 28 -35% vs. 22%* Headache – 30% vs. 28% Dry Mouth – 15% vs. 5%* Dizziness – 8 -9% vs. 8% Nausea – 5 -7% vs. 5% Uncommon SE n n Seizures (1/1000 patients) Psychosis Hypertension Suicidal Ideation * Statistically significant

Varenicline (Chantix) n Mechanism n n Α 4β 2 - Nicotinic Receptor Partial Agonist

Varenicline (Chantix) n Mechanism n n Α 4β 2 - Nicotinic Receptor Partial Agonist Dosing n n 0. 5 mg PO qd x 3 days 0. 5 mg PO BID x 4 days 1 mg BID thereafter Quit date is day #8

Varenicline (Chantix) n Duration 3 months initial n 6 months total (if pt. can

Varenicline (Chantix) n Duration 3 months initial n 6 months total (if pt. can get 10 days smoke-free in first 3 months n

Varenicline Warnings n Common SE: n n n Nausea Abnormal Sleep / Dreams Dizziness

Varenicline Warnings n Common SE: n n n Nausea Abnormal Sleep / Dreams Dizziness Fatigue Uncommon AE but reported: n n n Aggressive and erratic behavior Suicidal thoughts Possible suicide attempts

Varenicline vs. Bupropion Weeks 9 -52 Abstinence

Varenicline vs. Bupropion Weeks 9 -52 Abstinence

Varenicline Maintenance

Varenicline Maintenance

Conclusions & Recommendations 1. 2. 3. 4. 5. 6. Tobacco Use is the #1

Conclusions & Recommendations 1. 2. 3. 4. 5. 6. Tobacco Use is the #1 preventable cause of death Psychiatric Patients carry a large disease burden both medical and physical Tobacco is the problem - NOT Nicotine Tobacco Use Disorder is a Chronic Illness needing repeated intervention Smoking Cessation Works Combine your treatments