residential treatment for tobacco dependence · residential treatment for tobacco dependence 3. ......

Residential Treatment for Tobacco Dependence:p

Michael Burke, EdDTreatment Program Coordinator

Mayo Clinic Ni ti D d C tNicotine Dependence Center

Presentation ObjectivesPresentation Objectives

At the end of the presentation the participants will be able toAt the end of the presentation the participants will be able to….

1. Discuss comparative research on inpatient and outpatient treatment

2. Describe demographics of patients who participate in residential treatment for tobacco dependenceresidential treatment for tobacco dependence

3 Discuss effectiveness and cost of residential treatment for3. Discuss effectiveness, and cost of residential treatment for tobacco dependence

4. Describe typical day in residential treatment

Three ShieldsThree Shields

Nicotine Dependence CenterNicotine Dependence Center

Patient Care Patient Care –– Primary value: Take the best care Primary value: Take the best care of every patient every dayof every patient every dayy p y yy p y y

ResearchResearch –– Answers clinical questions and then Answers clinical questions and then translate answers to clinical practicetranslate answers to clinical practice

EducationEducation Sharing knowledge to improve patient careSharing knowledge to improve patient careEducation Education –– Sharing knowledge to improve patient care Sharing knowledge to improve patient care practicespractices

4

Education ResearchClinical Practice

@ 2009 Mayo Foundation for Medical Education and Research. All rights reserved

Patient Care

Th M Cli i Ni i D d CTh M Cli i Ni i D d CThe Mayo Clinic Nicotine Dependence Center The Mayo Clinic Nicotine Dependence Center (NDC) has treated about 50,000 people since it (NDC) has treated about 50,000 people since it opened in 1988opened in 1988opened in 1988opened in 1988

People from over 60 countries have come toPeople from over 60 countries have come toPeople from over 60 countries have come to People from over 60 countries have come to the Mayo Clinic Nicotine Dependence Centerthe Mayo Clinic Nicotine Dependence Center

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TreatmentProviding various solutions to meet patient’s needsProviding various solutions to meet patient’s needs

Individualized counselingIndividualized counseling

Hospital patient supportHospital patient support

Residential Treatment Program Residential Treatment Program

T l h tT l h tTelephone supportTelephone support

Electronic support www.becomeanex.org Electronic support www.becomeanex.org pp gpp g

@ 2011 Mayo Foundation for Medical Education and Research. All rights reserved 7

TreatmentProviding various solutions to meet patient’s needsProviding various solutions to meet patient’s needs

Residential Treatment Program Residential Treatment Program

@ 2011 Mayo Foundation for Medical Education and Research. All rights reserved 8

Tobacco dependence is an addictionTobacco dependence is an addiction


Inpatient treatment for other addictions

dd h d b• Inpatient addiction treatment had been preferred mode

• Reviews in 1980’s and 90’s found no significant differences between inpatient and g poutpatient outcomes– Miller and Hester, (1986)Miller and Hester, (1986)

• Outpatient recommended for cost• Outpatient recommended for cost containment


Inpatient vs. outpatient for other addictionsaddictions

j C (1998)• Project MATCH (1998)– Possible advantage for inpatient followed by aftercare

• Inpatient more effective for those who are more pdependent or more co‐occurring problems– Rychtarik et. al. (2000)y ( )

• Not which is better, but which is better for whomNot which is better, but which is better for whom


• Currently 28% of patients treated addictions inCurrently 28% of patients treated addictions in US receive inpatient care

– Weiss, Sharpe Potter, and Iannucci (2007) in Gallenter et. Al. American PsychiatricWeiss, Sharpe Potter, and Iannucci (2007) in Gallenter et. Al. American Psychiatric Textbook on Substance Abuse Treatment


Residential programResidential program

Eight day program

I id tIn residence stay

24 hour coverage by staff

Hotel license

Each pt has own bedroom with bathEach pt. has own bedroom with bath

Maximum of 10 per program

Common eating and lounge area

Exercise facilityy

Who comes to the program?Who comes to the program?

Comparison of NDC residential patients and outpatients 2006‐2007

Residential Residential N 226N 226

OutpatientOutpatientN 4328N 4328N = 226N = 226 N = 4328N = 4328

GenderGender 47% female47% female 44% female44% female

Mean ageMean age 54 54 4949

Mean CPDMean CPD 3131 2121

Mean FTNDMean FTND 6.96.9 5.15.1@ 2009 Mayo Foundation for Medical Education and Research.

All rights reserved

Higher intention to quitAlcoholism, depression hx more common

ResidentialResidential OutpatientOutpatient

More highly More highly 96%96% 83%83%motivated (intention motivated (intention to quit)to quit)Prior treatment for Prior treatment for alcoholismalcoholism

26%26% 15%15%

Prior treatment for Prior treatment for 56%56% 42%42%depressiondepression


Who are they????

Very diverse group of peopley g p p p

What do they have in common?What do they have in common?

Tried ‘everything’ to stop smoking

Believe that the only way they will be able to i i b ‘l k d ’quit is to be ‘locked away’

Question why these programs are not more common


Residential ProgramResidential Program"It has been almost three years now since I smokedyears now since I smoked and I have never been so happy. I have decided to happy. I have decided tolive and enjoy all of life." a program participant.


StaffingStaffing

A di i i Ph i i• Attending or supervising Physician: – Medical exam, daily rounds, 2‐3 lectures, medication managementmanagement.

• 2 Counselorsindividual and group counseling as well as stress– individual and group counseling as well as stress management and relapse prevention education.

• 1 Support person at all times1 Support person at all times• Exercise specialist (wellness coach)• Outside speakers• Outside speakers

– Respiratory therapist, Cardiac nurse, Dietician


First DayFirst Day• Limited Medical Exam• Pulmonary Function Test• Blood draw (serum cotinine)Blood draw (serum cotinine)• Meet with counselor• Introduction to facility• Introduction to facility• Pick up prescriptions

d ll ll• 4:30 meet in common area and collect all cigarettes and paraphernalia

l d h• Group rules and group therapy


A Typical Day in the Residential Treatment Program

• 7:15 Medical Rounds

• 8:45 Individual counseling

• 9:15 Group session: Understanding Nicotine Dependence• 9:15 Group session: Understanding Nicotine Dependence

• 10:15 Break

• 10:30 Group therapy

• 12:00 Lunch

• 1:30 Group session: Stress Management

2 30 B k• 2:30 Break

• 3:00 Group session: Relapse Prevention

• 4:00 Exercise session4:00 Exercise session

• 5:15 Dinner


Daily rounds/check on medicationsDaily rounds/check on medications


Group support education and healthy activityGroup support, education and healthy activity


Gradual exposure to outsideGradual exposure to outside


Follow Up ServicesFollow‐Up Services

• One pre‐scheduled phone call each week x 4 weeksweeks.

• At the end of 4 weeks, frequency of calls negotiated with the patient.

• Patients encouraged to become active in:Patients encouraged to become active in: ‐ Their local tobacco‐free support groups ‐ Support groups on internet‐ Support groups on internet‐ Remaining connected to Residential group members

@ 20011Mayo Foundation for Medical Education and Research. All rights reserved

Retrospective clinical dataRetrospective clinical data

5522 patients seen

246 residential 5276 outpatient

24 Excluded949 excluded

24 Excluded6 denied authorization

12 non cigarette6 incomplete data

222 included 4327 included 173 denied authorization734 other tobacco

42> 18


OutcomesOutcomes

• More severe dependence • More co‐occurring mental health or otherMore co occurring mental health or other addiction problemsSi ifi l hi h b i• Significantly higher abstinence rate–52% vs. 27%

• (OR = 3.0; 95% C.I. 2.3‐3.9)


CostsCosts

• Fee for service

• Changing insurance coverage situation

• Out of pocket with no insurance about $5 000Out of pocket with no insurance about $5,000 per patients


Tobacco Dependence treatment is relatively cost effectiveTobacco Dependence treatment is relatively cost effective

Therapy Patient Cost per yrs of life saved

Physician counseling and medication Tobacco dependent $1 300 $3 900Physician counseling and medication smoking cessation

Tobacco dependent $1,300-$3,900

B-blocker Post MI

Low risk $ 20,200

Intensive glucose control Diabetes

Newly diagnosed type 2

$ 35,300type 2

Lovastatin Cholesterol > 300 mg/dL

Men aged 55-64 with no other risk factors

$ 78,300

©2011 MFMER | slide-32

CABG Two-vessel CAD, severe angina

$ 42,500

In summaryIn summary

• Residential treatment patients are more severely dependenty p

• Strongly believe they need this level of intensityintensity

• Have better outcomes• Why are they not offered as a component of a broad spectrum of care?broad spectrum of care?


Added value:Three Shields

Hong Kong within five hour flight for 1/3 world population

Not a cost – an investment

ReferencesReferencesJT Ha s* DR Schroeder IT Croghan MV B rke JO Ebbert RD H rt Residential tobacco dependenceJT Hays*, DR Schroeder, IT Croghan, MV Burke, JO Ebbert, RD Hurt. Residential tobacco dependence

treatment compared to outpatient treatment. Poster presentation: SRNT Dublin Ireland April, 2009.

JT Hays, TD Wolder, KM Eberman, IT Croghan, KP Offord, RD Hurt. Residential (inpatient) treatment compared with outpatient treatment for nicotine dependence Mayo Clinic Proceedings Vol 79 Issue 2 124compared with outpatient treatment for nicotine dependence. Mayo Clinic Proceedings Vol 79 Issue 2 124-33. 2001.

BM Sundblad, K Larsson, L Nathell. High rate of smoking abstinence in COPD patients: Smoking cessation by hospitalization Nicotine and Tobacco Research/ 10 (5) : 883 90 2008hospitalization. Nicotine and Tobacco Research/ 10 (5).: 883-90. 2008.

WR Miller and RK Hester. The effectiveness of alcoholism What the research reveals. In Miller and Heather (eds) Treating Addictive Behaviors the Process of Change. Pp 121-74, New York Plenum Press, 1986,

Project MATCH Research Group. Matching alcoholism treatments to client heterog3eneity: Project MATCH post-treatment drinking outcomes. Journal of Studies on Alcohol 58, 7-29. 1997

RG Rychtarik, GJ Connors, RB Whitney et. al. Treatment settings for persons with alcoholism: Evidence for matching clients to inpatient vs. outpatient care. Journal of Consulting and Clinical Psychology,68(2), 277-89, 2000.


residential treatment for tobacco dependence · residential treatment for tobacco dependence 3. ......

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