No Ifs, Ands or Butts - Continuing Medical Education

ASSIST‣ Negotiate quit date‣ Counsel to support cessationand build coping skills‣ Discuss pharmacotherapy‣ Offer Help Line: QUITPLAN 1-888-354-PLAN‣ Provide supplementarymaterialsJAMA 259:2883-89; J Gen Intern Med 6:1-8,199113 14Developing a quit plan• Set a quit date• Review past quit attempts• Anticipate challenges• Other smokers in the household• AlcoholReality Check• Connect your patient to FREE programsthat will make it EASIER for them to quit.1516ARRANGERelapse Rate Over Time‣ Relapse prevention- Withdrawal symptoms mostintense first 2-5 daysirritabilityincreased hungerincreased tensioncravinginsomnialack of concentration17% Abstainers10090807060504030201000 1 2 3 4 5 6 7 8 9 10 11 122 weeks Time (Months)HeroinSmokingAlcohol183

RELAPSE PREVENTION• Early follow-up• Lack of support• Negative mood• Prolonged withdrawal• Weight gain19ARRANGERecycleRelapse?ASKPrecontemplationActionStageASSISTContemplationPlanningStageADVISEASSESS20MOTIVATIONALINTERVIEWINGMOTIVATIONALINTERVIEWINGI. EXPRESS EMPATHY● Ask/Invite patient to tell about behavior- Listen empathetically- Reflect what you hearII.ASSESS DISCREPANCY● Conviction 1-10● Confidence 1-10● Stage of readiness21III. ROLLING WITH RESISTANCE● Increase confidence- Explore past experience● Increase conviction- Explore ambivalence (pros vs. cons)IV. SUPPORT SELF EFFICACY● Build on past successes● Offer range of alternative approachesMiller and Rollnick, 200222Modified Tobacco ProductsWhat pharmacotherapies are available toASSIST in the quit attempt?By using the pharmacotherapiesfound to be effective in the PHSGuideline, you can double or tripleyour patients’ chances of abstinence.23244

Nicotine Gum• OTC• Do Not Use Within 15 Minutes Of Drinking AnyAcidic Beverage (Coffee, Tea, OJ)• Chew To Release Nicotine• Use As Needed (6-16 pieces/day)• Park In Cheek• No Concurrent Nicotine Use• Side Effects May Include Hiccups31 32• Strength– 2mg ~ 1ppd– 4mg ~ 2 – 3 ppd•FlavorsNicotine Gum33 34Nicotine Nasal Spray• Prescription Only• Use By Inhaling And Holding Breath• Citric Acid Based Formula• Side Effects May Include Nasal MembraneIrritation• Use As Needed• No Concurrent Nicotine Use35 366

Nicotine Inhaler• Prescription Only• Uses Delivery Device With AerosolizedNicotine Cartridge• Use As Needed (6-16 cartridges/day)• Frequent Puffing is Required• No Concurrent Nicotine Use37 38Nicotine Lozenge• OTC• 2 or 4 mg• Use enough (6-16 lozenges/day)• Do Not Use Within 15 Minutes Of Drinking AnyAcidic Beverage (Coffee, Tea, OJ)• Place In Mouth, Allow To Dissolve• No Concurrent Nicotine Use• Side Effects May Include Hiccups39 40Bupropion SRBupropion SR• Non-nicotine medication approved by theFDA as an aid to smoking cessationtreatment• Available by prescription only• Mechanism of action: presumably blocksneural reuptake of dopamine and/ornorepinephrine• Also called Zyban or Wellbutrin41427

Bupropion SR• Contraindicated if Head Injury orSeizure Disorder• MAO Inhibitor within previous 2 Weeks• Current Use of Wellbutrin• Hx of Anorexia Nervosa or Bulimia• Can Lower Seizure Threshold• Recommend No Concurrent AlcoholUseJornby et al, 1999; NEJ 340(9), p. 685Bupropion SR• May Be Used In Combination WithNicotine Replacement• Side Effects Include Dry Mouth andHeadache4344Bupropion SR• Dosing:– start 1-2 weeks before quit date– 150 mg orally once daily x 3 day– 150 mg orally twice daily x 7-12 weeks– no taper necessary at end of treatmentLong-term Pharmacotherapy• Long-term NRT presents low health risk• Persistent withdrawal symptoms (physicalurges and psychological cravings• FDA approved bupropion SR• Maintenance - efficacious as maintenancemedication for 6 months• Delays weight gain associated withstopping smoking.4546www.askandact.orgTable of Meta AnalysesFor EfficacyOfCessation Products47Product Author Follow-upPointNumberof TrialsEfficacyMeasureN. Patch Fiore et al, 1994 6 months 13 O.R. = 3.0(2.4, 3.7)N. Gum Silagy et al, 1994 12monthsN. Inhaler Leischow et al,1996N. Spray Blondal et al,1997N. Lozenge Wallstrom et al,20001 O.R. = 1.6(1.5, 1.8)6 months 1 O.R. = 3.05(1.42, 6.57)6 months 1 R.R. = 1.88(0.88, 3.99)6 months 1 O.R. = 2.42(1.02, 5.85)Bupropion SR Jornby et al, 1999 6 months 1 O.R. = 2.3(1.4, 3.7)Bupropion SR +PatchBehavioralCounselingJornby et al, 1999 6 months 1 O.R. = 2.7(1.7, 4.4)AHRQ 2 months 15 O.R. = 2.7(2.2, 3.2) 488

VareniclineVarenicline: A Highly Selective α4β2 ReceptorPartial Agonist• Approved by FDA in May, 2006• Marketed as Chantix• A non-nicotine medication• A selective α4β2 NicotinicAcetylcholine Receptor Partial Agonist• “Like methadone for smokers”• Black Box for Depression and SuicideRisk49NicotineBinding of nicotine at the α4β2 nicotinic receptor inthe Ventral Tegmental Area (VTA) is believed tocause release of dopamine at the Nucleus Accumbens(nAcc)ChantixChantix is an α4β2 nicotinic receptor partial agonist, acompound with dual agonist and antagonistactivities. This is believed to result in both a lesseramount of dopamine release from the VTA at thenAcc as well as the prevention of nicotine binding atthe α4β2 receptors50Varenicline Phase 3 Studies: EfficacyMeasurements: CO-Confirmed ContinuousAbstinence Rates Wks 9-52Varenicline: MostCommon Adverse EventsFrom 12-Week Fixed-Dose, Placebo-Controlled Studies5152Rates of DiscontinuationVarenicline – Prescribing Information400350300250200150100500Varenicline Bupropion SR PlaceboRandomizedDiscontinuedAE• Start varenicline one week before the quit date formaximum effectiveness• Recommended treatment is 12 weeks:– Days 1-3………..1 pill (0.5 mg) per day– Days 4-7………..1 pill (0.5 mg) twice a day (am & pm)– Day 8-end………1 pill (1 mg) twice a day (am & pm)• An additional course of 12 weeks for maintenance can beconsidered• First Month – starter month pak• Subsequent Months – continuing month pak53549

Nicotine Assisted Reductionwith Intent to Stop• Do not cause significant adverse reactions• Reduces smoke inhalation• Helps reduce cigarette consumption• Increased motivation to stop smokingSo What’s Really New?• Vaccines• Cannabinoid receptor 1 blocker(Rimonabant)Source: http://www.treatobacco.net/faq/default.cfm?questionID=16Raw M, McNeil A, West R, Armstrong M, Arnott D, NARS; Guidance forhealth professionals. London, ASH, 2005.http://www.ash.org.uk/html/cessationdetail.php#reduction55Http://www.treatobacco.net/faq/default.cfm?questionID=18Karl Fagerstrom, PhD, Smokers Information Centre,56Helsingborg, SwedenCounseling• Group programs increase cessation, OR2.04 (95% CL 1.60-2.60)• Individual counseling is effective• Telephone counseling compared to lessintensive intervention increases quit rates,OR 1.56 (95% Cl 1.38-1.77)Efficacy of and estimated rates for interventionsdelivered by different providers (41 studies)Type ofProviderNumber ofarmsEstimated oddsratio (95% CI)Estimatedcessation rate(95% CI)No provider 38 1.0 8.2MultipleprovidersNon-medical(social worker)14 3.8 (2.6-5.6)23 1.8 (1.5-2.2)25.5 (18.1-32.7)14.1 (12.0-16.3)Physician 36 1.5 (1.2-1.9) 12.0 (9.6-14.3)57Non-physician(dentist, nurse)JAMA, 199620 1.4 (1.1-1.8) 11.5 (9.0-14.0)58% of Patients706050403020100How are we doing?Patient's Report of Tobacco Treatment at CurrentVisit (n=2581)AskAdviseAssist-MedsF/UReferralWhen your patient wants to quit andyou are double-booked…• ASK about tobacco use.• ADVISE to quit.• ASSESS willingness to make a quit attempt.• Prescribe & REFER596010

So, how can youget paid for your workon tobacco cessation?Medicare Payment• Effective March 22, 2005, tobaccocessation counseling covered forsmokers (8 visits annually with 4sessions per attempt)• Effective January 2006, prescriptiondrug benefit covers treatmentsprescribed by a physician (OTC notcovered)67Source: www.askandact.org 68PaymentHCPCS Billing Codes• Counseling < 3 minutes covered under E &M code• 99406: 3-10 minutes counseling ($13)1/1/08• 99407: >10 minutes counseling ($25) 1/1/08• Use modifier 25 for an appropriate E&Mservice on that same day• Face-to-Face counseling timeSource: www.askandact.org 69http://www.momedicare.com/provider/viewarticle.aspx?pf=yes&articleid=5685Payment• If plans cover counseling use ICD-9 Codes• 305.1 Tobacco Dependence• 292 Nicotine Withdrawal• V15.82: History of Tobacco Use• Provide clinically relevant diagnosis code suchas; cough 786.2 or lung cancer 162• Document time spent counselingSource: www.askandact.com70Private InsurersMost insurers provide coverage for at leastone type of pharmacotherapy for tobaccocessation and at least one type ofbehavioral intervention.Source: www.askandact.org71Private Insurers• Use billing codes in the categories of:• Preventive Medicine Treatments• Tobacco Dependence Treatment aspart of the initial or periodiccomprehensive preventive medicineexam• Tobacco Dependence Treatment asspecific counseling and/or risk factorreduction72www.askandact.org12

MedicaidThirty-seven states now coverone or more treatment fortobacco dependenceWRAP-UP‣ Tobacco use is a chronic disease‣ Methods of intervention:-5 A’s- Motivational interviewing- Treatment modalities:pharmacological and counseling‣ Quitting is a processwww.askandact.org7374Video of Frank Cerra75 76RESPONSES TO PATIENTS’ REASONS TO USE TOBACCO, CONTINUED“Helping Tobacco Users Quit: Tobacco Cessation Training for Health Care Professionals” CD Rom created by Myra A77 78Crawford, PhD, MPH & Lesa L. Woodby, PhD, MPH, Department of Family & Community Medicine, University ofAlabama at Birmingham13

SMOKELESS TOBACCO• Higher prevalence in young males• Absorptions depends on pH of buccalmucosa• Snuff and chewing tobacco• Graded levels of nicotine• Addictive• Associated with oral cancers leukoplakiaand gingivial disease79 80Smokeless TobaccoCIGARS• Varying levels of nicotine• Large cigars nicotine absorbed throughoral mucosa• Smaller cigars inhaled818214