improving outcomes for alliance clients
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Improving Outcomes for the People We ServeTobacco use treatment, behavioral health & the QuitlineNCStephanie Gans LCAS, LCSWA, CTTS
Smoking Rates
•Nationally: 19.3% (NHIS)General
population smoking rates
•Ranges from 32% - 98% depending upon diagnosis
Behavioral health pop.
smoking rates
© 2012 BHWP© 2019 BHWP
Behavioral Causes of Death in US, 2016500,000
100,000
300,000
200,000
400,000
MVAs
Suicide
Drug-Induced
Weight-Related
Alcohol
HIV/AIDS
Homicide6,160
170,143
67,625
44,965
40,32734,865
19,362Tobacco
383,087
480,000
*
* Persons with BH conditions
Dying Sooner
• In the US, folks with a behavioral health condition who use tobacco lose 25 years of life, on average
.
Dying Sooner
• In the US, folks with a behavioral health condition who use tobacco lose 25 years of life, on average
• Life expectancy 14.5 years lower for people with schizophrenia
– largely attributable to higher rates of tobacco use
.
Dying Sooner• In the US, folks with a behavioral health
condition who use tobacco lose 25 years of life, on average
• Life expectancy 14.5 years lower for people with schizophrenia– largely attributable to higher rates of tobacco
use
• More than half of those in treatment for substance use disorders die, not from their SUD, but from tobacco related illnesses and disease
What we know• 2011 Metanalysis of the effect of quitting smoking on mental health: • “The effect (of quitting smoking on mood) is equal to or larger than those of antidepressant
treatment for mood and anxiety disorders.”
• 2013 Metanalysis by Ragg et al.:“There is no published evidence to support the hypothesis that quitting smoking is harmful to
the mental health of people with schizophrenia. ”
Weinberger et al. 2017, “Continuing or starting to smoke increases the risk of returning to substance use after
treatment.”
Prochaska et al. 2004,“Smoking cessation interventions provided during addictions treatment were associated with a
25% increased likelihood of long-term abstinence from alcohol and illicit drugs.”
In 2015…
Nationally, about 70% of smokers saw a physician…
A Call to Action for our Health Care System
In 2015…
Nationally, about 70% of smokers saw a physician…
Only about half of cigarette smokers were advised to quit…
A Call to Action for our Health Care System
In 2015…
Nationally, about 70% of smokers saw a physician…
Only about half of cigarette smokers were advised to quit…
Fewer than one third of smokers who tried to quit received evidence-based cessation treatments.
A Call to Action for our Health Care System
Less than half of substance use disorder treatment centers (42%) offer tobacco cessation services, and only 34% offer cessation counseling.
~ Substance Abuse and Mental Health Services Administration, 2013
Tobacco Use is a Substance Use Disorder & We Know What works
Research indicates the most effective tobacco treatment is a combination of:
Evidence-based coaching and
FDA approved medications.
*Those with co-occurring behavioral health disorder may require longer & more intensive treatment*
The 5As of Tobacco Use Treatment
How to Ask
Ask everyone
Use a system- Build it into your Electronic Health Record or assessments
Ask parents, offer them treatment too!
Ask well:
• How frequently do you use tobacco?• Have you used tobacco products in the past?• How frequently do you use an e-cigarette (e.g. vape,
JUUL, hookah pen)?
Ask- e-cigarettes
• Make sure EHR can document e-cig use• Standardized questions = important
• “Do you use any kind of tobacco, such as cigarettes? What about electronic smoking devices like e-cigarettes, JUUL, or vape pens?”
• Useful to mention examples of types/brands
Advise
Advice should be: clear, strong, & personalized:
• “It sounds like playing with your grandkids is really important to you, becoming tobacco free is the best thing you can do to maintain your health so you can keep up with them”
• “You really value your recovery, one of the best things you can do to be successful is quitting smoking”
• “The thing you care about the most is music and rapping, and it sounds like you’re good at it! Quitting JUULing is the best thing you can do to maintain your talent.”
What is good about tobacco use? What do you enjoy about it?
What is not so good about it?
What makes it hard for you to quit? What scares you about quitting?
What would be good about being tobacco-free?
Reasons to stay the same Reasons to change
Assess- How can I make a change?
0123456789
10
1 2 3 4 5 6 7 8 9 10
Impo
rtan
ce
Confidence
Importance and Confidence of Quitting
Likelihood of Making a Change
where change happens!
• Ask about past quit attempts
• Use motivational interviewing to explore ambivalence
• Reflect change talk
• Identify if confidence or importance is low
• Offer evidence based treatment
Assist
• Discuss (or prescribe) evidence based medication & counseling• Set a goal(s)
• I will make my car tobacco free this week• My quit date will be 10/23/19• I will try using nicotine gum and patches
• Make a plan• What has worked in the past? What hasn’t?• Identify triggers, and plan ways to cope
Withdrawal Symptoms
• Depressed mood• Feelings of frustration, impatience, anger• Anxiety• Irritability• Urge to smoke• Difficulty concentrating• Restlessness• Insomnia• Increased appetite
7 First Line Cessation Medications for Adults
• Nicotine replacement therapies:• Nicotine Patch• Nicotine Gum• Nicotine Lozenges• Nicotine Inhaler• Nicotine Nasal Spray
• Non-nicotine Medications:• Varenicline (Chantix)• Bupropion (Wellbutrin)
*Those with co-occurring behavioral health disorder may require longer & more intensive treatment*
Arrange for follow up
• Make an appointment or follow up by phone on:
• Progress towards patient goals
• Medication (adherence, side effects)• Withdrawal symptoms• Successes/Challenges
• Set new goals• Referrals to the QuitlineNC and other
resources
QuitlineNCHelping clients access evidence based treatment
Quitline NC- What is it?
• An evidence-based telephone tobacco treatment service• Consists of four treatment sessions• Special 10 treatment sessions and protocol for women who plan to
become pregnant in 3 months, pregnant women, and women who gave birth in past year
• Available free to all North Carolina residents • Accessible 24 hours a day, 7 days a week• English, Spanish and translation• Integrated with an interactive web-based tobacco treatment program• Online registration • Web only treatment program• Text service
Spanish Speaking1-855-Déjelo-Ya
Insurance Type and ProtocolCategories
Scheduled Calls Medication
Uninsured 4 Calls 8 weeks nicotine patches + gum/lozenges
Medicare 4 Calls 2 weeks nicotine patches + gum/lozenges
Medicaid 4 Calls 2 weeks nicotine patches + gum/lozenges PLUS standing order for 12 more weeks
Blue Cross Blue Shield NC 4 Calls 12 weeks nicotine patches +gum/lozenges
Commercial Insured 1 Call none
Planning to be pregnant, pregnant, 12 months after delivery
10 Calls 8 weeks nicotine gum or nicotine lozenge with medical override
One or more behavioral health condition 7 Calls 12 weeks nicotine patches + gum/lozenge
Under 18 5 Calls none
TEXTING AND WEB ONLY FOR ALL CATEGORIES
6 Month Quit Rates Comparison
47
39
27
10
0 5 10 15 20 25 30 35 40 45 50
QLNC COUNSELING + COMBO NRT***47%
QLNC COUNSELING + NRT** 39%
QUITLINENC COUNSELING ** 27%
PHYSICIAN ADVICE ALONE* 10%
*Fiore, Treating Tobacco Use and Dependence, Clinical Practice Guidelines 2008 Update** Alere Wellbeing and TPEP, QuitlineNC Comprehensive Evaluation Reports***State Health Plan for Teachers & State Employees, Evaluation Report, 2017Responder rates at 30 days point prevalence
Quit Rates for those with Behavioral Health Conditions by NC Standard Protocols
19 %
Behavioral Health Protocol
Quit Outcomes for BH Protocol
Quit
37%
30 Day Prevalence Quit Rates
33%
46%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Tier 1 Conditions Teir 2 Conditions
30 Day Prevalence Quit Rates by Condition Tier
Send referral via fax machine or secure e-mail
Assure patient agrees to referral
Best phone # & time to call
increase effectiveness!
QuitlineNC Fax Referral
Outcome Reports
• Clinic Information• Patient Information • 3rd Call Outcomes
THIS IS QUITTINGEVIDENCE-BASED TEXT PROGRAM TO HELP TEENS QUIT VAPING
ONE MORE THING THAT MAKES IT TOUGH TO QUIT…
…IN MANY CASES, SEEKING BEHAVIORAL HEALTH TREATMENT MEANS EXPOSURE TO TOBACCO USE
Tobacco Free Policy Case Study
Contact Information
Stephanie Gans LCAS, LCSWA, CTTSTobacco Treatment Specialist at NC Division of Public [email protected]