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Module 5 - Co-Occurring Disorders:
Integrating Tobacco Use Interventions
into Chemical Dependence Services
Welcome
 Add Trainer Name(s)
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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
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Housekeeping
 Hours of Training
 Breaks
 Restrooms
 Tobacco Use Policy
 Cell Phones
 Active Participation
 Complete Training Evaluation Form
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Introductions
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Training Modules
Module 1 - Foundations
Module 2 - Assessment, Diagnosis, and
Pharmacotherapy
Module 3 - Behavioral Interventions
Module 4 - Treatment Planning
Module 5 - Co-occurring Disorders
E-Learning - All Modules
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PM 9
Module 5 Agenda
 Review of prior modules
 Personal attitudes and beliefs
 Prevalence and co-morbidity
 Basic neurobiology of tobacco
dependence
 Review of tobacco treatment strategies
 Case Studies
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PM 10
Module 5 Objectives
Please review page 10 in your manual
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PM 10
Unit 1
Attitudes and Beliefs, Challenges
and Barriers
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PM 11
Review
Learning points from prior modules
New knowledge or skills integrated into
practice
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PM 12
Defining Co-occurring Disorders
How do you define co-occurring disorders?
Co-occurring disorders - when a person has a
substance use disorder and mental health
disorder at the same time.
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PM 13
Defining Co-morbidity
How do you define co-morbidity?
Co-morbidity - two or more disorders are
present at the same time and they interact in
ways that affect the course and/or prognosis of
each disorder.
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PM 13
Setting the Context
• Currently very little research on co-occurring
disorders (COD)and tobacco dependence.
• Tobacco treatment is effective for wide range of
people, including those with mental health
(MHD) and substance use disorders (SUD).
• What is known about tobacco users with a MHD
or SUD, may be applicable for COD
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PM 14
Activity #1
Confidence, Attitudes, and Beliefs
Assess your current confidence, attitudes, and
beliefs about tobacco use among people
with MHD and SUD
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PM 15
Debriefing Activity #1
Examining how attitudes and beliefs about
tobacco, affect staff and patient behavior to
examine and address tobacco use.
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Activity #2
Video - Smoke Alarm
Produced by Clubhouse of Suffolk Ronkonkoma,
NY
www.clubhouseofsuffolk.com
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PM 16
Video - Vignettes 1 to 3
• What is the relationship of tobacco to
people’s mental health disorder?
• What are common fears about stopping
tobacco use?
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PM 16
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Vignette #1
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Vignette #2
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Vignette #3
Video - Vignettes 4 and 5
• What are the barriers and challenges
mentioned about stopping tobacco use?
• How might treatment for people with COD
need to be modified or enhanced?
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PM 16
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Vignette #4
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Vignette #5
Summary
Definition of co-occurring disorders and comorbidity
Confidence, attitudes, and beliefs
Patient perspectives on tobacco use/dependence
Challenges and barriers to addressing tobacco
use by people with SUDs and MHDs
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PM 17
Unit 2
Prevalence and
Co-morbidity Factors
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PM 19
Discussion
What is the frequency of patients having a cooccurring mental health disorder and substance
use disorder?
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National and NYS Data
National Data:
• 50 - 75% of SUD patients have MHD
• 25 - 50% of MHD patients have SUD
(Center for Substance Abuse Treatment, 2005)
NYS Chemical Dependence Programs:
• 23% - 46% of SUD patients have MHD,
rates varies by modality
(Office of Alcoholism and Substance Abuse Services, 2008)
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PM 20
Activity #3
Tobacco and Co-occurring Disorders
Knowledge Activity
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PM 21 - 23
1.
Average Rate of Tobacco Smoking
70%
About 70% of people
with a mental health
disorder (MHD)
and/or a substance
use disorder (SUD),
also smoke tobacco.
Studies vary as to each disorder and people with some disorders
have smoking rates up to 80 - 90%.
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PM 24
2.
Percentage of Cigarettes Consumed
44-46%
About half of all
cigarettes consumed
in the US are by
people with MHD
and/or SUD.
Results in significant illness, death, and health disparity for
two vulnerable populations.
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PM 24
3.
Average Reduced Life Span
25 years!
32%
The average lifespan in US is
77.8 years.
For smokers with MHD or
SUD, this life span is
reduced by 32%.
Primary cause of death is cardiovascular disease (CVD) and
diabetes. #1 cause of CVD is tobacco smoke and tobacco is a
key factor in onset of diabetes.
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PM 24
4.
Average percent of monthly income
spent on tobacco
27%
Average percentage
of monthly income
spent on tobacco
Averages about $142 per month
based upon 2000 - 2002 costs.
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PM 25
5.
Daily smoking can predict suicidal
thinking and attempts
Facts !
Increased suicide thinking and attempts even
considering a prior history of depression, substance
use disorder, and prior suicide attempts.
Increased risk of suicide for people with bipolar illness
and schizophrenia.
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PM 25
6.
Heavy smoking can be a predictor of
suicide risk and completion
Facts !
Increased suicide completion rates for tobacco using
adolescents and greater number of attempts,
especially for females
Heavy tobacco smoking is highly associated with
increased suicide completion
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PM 26
7.
Nicotine causes cancer and CVD
Facts !
Nicotine is not a carcinogen and is not a major risk
factor of cardiovascular disease (CVD).
Tobacco smoke is the disease-causing agent.
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PM 26
8.
Nicotine can affect metabolism of
psychiatric medications
Facts !
Nicotine does not affect the metabolism of medications.
Tobacco smoke induces the liver to increase the
metabolism rate of some psychiatric and some nonpsychiatric medications.
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PM 26
9.
Stopping smoking requires an
increase in psychiatric medications
Facts !
Many people can stop without changes in medication levels.
Some may require lower doses to avoid medication toxicity
(i.e., clozapine, olanzepine) or to avoid increased side
effects (i.e., amitriptyline, nortriptyline, and imipramine).
See Table 1 - Common Drugs Affected by Tobacco Smoke
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PM 27
10. Use of tobacco increases anxiety
Facts!
Increased feelings of general anxiety from using tobacco.
Patients often confuse nicotine withdrawal symptoms
with primary anxiety symptoms of MHD or SUD.
Many mistakenly assume using tobacco causes their
general anxiety symptoms to stop.
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PM 28
11. Stopping tobacco leads to panic
attacks, and smoking reduces panic
attacks and panic disorder
Facts !
Tobacco use is a significant risk factor for panic
disorder, agoraphobia, and generalized anxiety
disorder (GAD).
Also refer back to answer in Statement 10.
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PM 28
12. Most people with MHD or SUD are
not interested in stopping tobacco use
Facts !
70% expressed an interest in stopping in the past year.
People with MHDs and/or SUDs express an interest in
stopping tobacco use as often as smokers in the general
population.
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PM 28
13. Most people with MHD or SUD
cannot stop using tobacco
Facts !
Many can stop and need more frequent treatment, more
intense treatment, and more engagement.
No increased problems after stopping and recent research
shows MH symptoms decrease after tobacco abstinence.
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PM 29
14. Chantix reduces the effects of some
psychiatric medications
Facts !
About 92% of Chantix is eliminated unchanged from
body by kidneys.
Chantix has no drug-to-drug interactions.
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PM 29
15. Smoking increases MHD/SUD risk
Facts!
Tobacco is a common “gateway drug” for AOD use
Smoking increases risk for mental illness and doubles the
risk for major depression when used in adolescence.
Adolescent tobacco use associated with increased adult risk
for panic disorder, anxiety disorder, agoraphobia,
depression, suicidal behavior, SUD, and schizophrenia.
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PM 30
15. Smoking increases MHD/SUD risk,
cont’d
Facts !
Active psychiatric disorders are associated with daily
smoking and progression to dependence.
Risk of major depression in women who smoke is
increased 93%.
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PM 30
Knowledge Summary
How many of these answers did you already
know?
Were there any surprises from what you just
learned?
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Biopsychosocial Approach to Substance
Dependence
Tobacco dependence is a biopsychosocial disease
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PM 31
Neurobiological Factors and Neurochemical Effects of Tobacco/Nicotine
• Various genes are involved for first tobacco use, risk of
dependence, withdrawal severity, and inability
to stop using.
• Different neurotransmitters are affected by nicotine and
likely by other chemicals in tobacco smoke.
• Nicotine provides some short-term benefits, but tobacco
use aggravates MHDs and SUDs.
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PM 32 - 33
Other Factors Affecting Tobacco Use
• Psychological
• Behavioral
• Social
• Treatment / Recovery
• Large System (Tobacco Industry, Media, etc).
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PM 34 - 35
Interaction between Tobacco Dependence
and Other Substance Use Disorder
Tobacco Dependence
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PM 36
Other Substance Use Disorder
Interaction between Substance Use
Disorder and Mental Health Disorder
Substance Use Disorder
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PM 37
Mental Health Disorder
Interaction between Tobacco Dependence
Mental Health Disorder and
Tobacco Dependence
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PM 38
Mental Health Disorder
Interaction between Tobacco Dependence,
Mental Health Disorder, and Substance
Use Disorder
Tobacco Dependence
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PM 39
Substance Use Disorder
Mental Health Disorder
Discussion
What are the common factors between tobacco
dependence, substance use disorders, and
mental health disorders?
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PM 40 - 41
Summary
All have common chemical pathways affecting the brain
All are chronic, biopsychosocial diseases
The disorders negatively interact and result in co-morbid
conditions
Treatment using medication, behavioral, psychoeducation,
and supportive therapies
Recovery is possible and requires lifestyle changes
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PM 42
Unit 3
Treatment Strategy Review and
Case Studies
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PM 43
Tobacco Treatment Review
• First Line Tobacco Medications
–
–
–
–
OTC (patch, gum, lozenge)
Prescription (inhaler and nasal spray)
Chantix
Bupropion
• Second Line Tobacco Medications
– Nortriptyline
– Clonidine
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PM 44
Tobacco Treatment Review, cont’d
• Nicotine medications are well-tested and have
margin of safety.
high
• Tobacco medications often used incorrectly, not often
enough, or doses used are too low.
– As a result when people have withdrawal symptoms, they
think the medications don’t work and/or stop using them.
• Some people need higher doses of nicotine
medications and/or long-term medication.
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PM 45 - 47
Tobacco Treatment Review, cont’d
• Combinations of two or more medications works
work better than a single medication.
• MI, CBT, and RPT are effective first line methods.
• Medication plus counseling is more effective, than
either alone.
• Peer counseling and peer support may be helpful.
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PM 48
Important Reminders
• Tobacco dependence is a biopsychosocial disease that
aggravates and complicates SUDs and MHDs
• People with COD often need more engagement, and
longer and more frequent treatment
• Not addressing tobacco use for all patients sends an
unhealthy and wrong message
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PM 49
Case Studies
• Three cases studies
• Read the assigned case
• Answer the questions related to that case
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PM 50
Case Studies
PM 53 - 54
PM 55 - 56
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PM 51 - 52
Smoking/Drug Chart PM 57
Discussion of Case Study Questions
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Summary
Tobacco dependence treatment for people with MHD
or COD is not different from other populations
Often requires higher intensity and frequency of
treatment episodes, and often more engagement
Tobacco treatment medications are important to use along
with counseling, psychoeducation, and supportive
therapies
Anticipate possible need to modify medication dosage
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PM 58
Revisit Confidence, Attitudes and
Beliefs
Revisit your confidence, attitudes, and beliefs
from the questions posed earlier
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PM 59
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: [email protected]
BeBetter Networks (NRT)
http://www.nrtdistribution.com/Welcome.aspx
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PM 61-62
Workshop Evaluation
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