11-17-11 Training

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D O T A ALCOHOL TOBACCO & OTHER DRUGS ALL B A R C TREATS Tobacco Addiction Training Nov 16-17, 2011

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in the room of addiction treatment is there still another presence ? ….after all these years? can you spot it ?

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"Cigarette smoking is the chief, single avoidable cause of death in our society U.S. Surgeon General 1981-1989 and the most important public health issue of our time." C. Everett Koop, M.D.

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illicit drugs cause less than 1% of deaths in this country tobacco use causes 20% of the deaths in this country homicides cause less than 3%

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William White, historian of the recovery field keynote speaker at workshops co-sponsored by BARC in 2006 and 2009 : “Moving forward to address nicotine addiction within the larger rubric of addiction treatment is no longer a question of inadequate research, it is a question of honesty, courage and leadership.”

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“Every day, addictions professionals who have been addicted to nicotine are shedding that addiction I choose to : …and embracing a personal manifesto with one or more of the following: * help hasten the end of the addiction field’s enabling of tobacco addiction among our clients and our workers. * forever sever my personal relationship with nicotine; it no longer has a place in my life. * offer assistance to those seeking to recover from nicotine addiction. * not model a behavior (smoking) that could take years from my own life and the lives of those who could be influenced by my example. * no longer remain silent about the tobacco industry’s targeted marketing to women, children, communities of color, and citizens of developing countries, * not live the hypocrisy of being addicted while working as an addictions professional.”

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… this really matters to BARC’s clients : … which leads directly to this next stunning statistic: People with substance-abuse and/or mental-health diagnoses consume 44 % of all the cigarettes smoked in the USA

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How can we accept a 25 year gap like that ? of the 435,000 people who die every year from tobacco use People with substance-abuse and mental-health diagnoses who smoke live 25 years less than non-smokers in the general population 200,000 are people like our clients

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Smoking nicotine is like a train wreck for the body in very slow motion

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a heavy smoker aged 25 can expect to lose 25 % of his life due to smoking

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Causes of Early Death fires ( 1%) illicit drugs ( 1%) homicide ( 3%) car accidents ( 4%) suicide ( 4%) AIDS ( 4%) alcohol (15%) tobacco (68%) combination of tobacco use (61%) + second-hand smoke (7%) * * About 200,000 of these victims also suffered from mental illness and/or substance abuse

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so what can we do at BARC to make a difference ? # 1 : “De-Normalize” tobacco use within treatment and recovery # 2 : Assist our clients to get free from tobacco as part of their day-at-a-time recovery using Motivational Interviewing approaches ( people who smoke tend to think that most other people smoke as well)

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… a network of agencies trying to treat tobacco addiction “ 100 Pioneers ” program In 2009, BARC was accepted as one of the founding members of the along with other addictions and psychiatric diagnoses We now have access to national “Webinar” trainings and new materials – including some used in this presentation

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Since then, BARC has been recognized as one of the 25 best programs in the United States ( and the only one in Florida ) for bringing together the treatment of tobacco addiction with the treatment of addiction to all other drugs.

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Survey of Staff Knowledge & Beliefs regarding Tobacco Addiction Treatment Summary of results from survey given September 2011 to employees of Broward Addiction Recovery Center * with comparisons to 2003, 2005 2007, 2009, 2010, & 2011 surveys

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Do you believe that nicotine is : O An addictive drug that is more addictive than other drugs of dependence. O An addictive drug that is just as addictive as other drugs of dependence. O An addictive drug, but not as addictive as other drugs of dependence. O A drug, but not addictive. O Not really a drug. How important is treating clients’ tobacco addiction in their overall medical health? O Extremely important O Very important O Somewhat important O Not at all important How will tobacco dependence treatment (including tobacco abstinence) affect a client’s overall recovery? O It is essential for healthy recovery O It will help the client’s recovery a lot O It may help the client’s recovery a little bit O It will not have any effect (either way) O It will harm a client’s overall recovery O Not sure Do you think that treating tobacco addiction along with other addictions is a good idea? O Absolutely – a drug is a drug is a drug! O Yes, but we need to allow clients to choose their own time-line for stopping their tobacco use O Maybe – we need to examine this matter on a case-by-case basis O No. Tobacco addiction has little relevance to other addictions O Definitely not! Addressing tobacco addiction while a client is in treatment for other addictions would be damaging to clients. If you have face-to-face contact with clients, how many of them do you ask about their tobacco use? O 1 in 10 O 2 in 10 O 3 in 10 O 4 in 10 O 5 in 10 O 6 in 10 O 7 in 10 O 8 in 10 O 9 in 10 O 10 in 10 What is your own personal relationship with tobacco? O Never used O Tried, but never any regular use O Former user O Current user Do you support tobacco-free grounds for the entire agency? O Fully supportive. O Supportive, but not in certain areas. O Smoking for staff should be allowed, but not for clients O Smoking should be allowed, for staff and clients. Violations of tobacco-free grounds policy should be confronted by: O Security O Clinical staff O Support staff O Administrative staff O All employees *Adapted from Michigan Smoke Free Hospital Development Plan SURVEY of STAFF KNOWLEDGE & BELIEFS Regarding TOBACCO ADDICTION TREATMENT

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We can do even more by lowering definition of “success” making the goal-posts wider and easier instead of: “getting Joe-Bob to quit smoking” ( not so easy ) try: “getting some information to Joe-Bob” ( not so hard )

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there are existing, effective interventions clients fear and resist stopping it you are here the most lethal and prevalent drug in the world clinicians disinclined to intervene

Health Consequences of Smoking:

Health Consequences of Smoking Cancers in many parts of the body Acute leukemia Bladder Kidney Cervix Oral cavity, esophagus, throat Stomach Lung Pancreas Pulmonary diseases Acute (like pneumonia) Chronic (like COPD) Cardiovascular diseases Disease related to the heart, arteries, and blood vessels Circulation problems in hands and feet Reproductive effects Lower fertility in women Low birth weight Preterm birth Infant mortality Other effects: Cataracts (eyes) Osteoporosis (bones) Periodontitis (teeth and gums) Poor surgical outcomes

The Dangers of Second-Hand Smoke:

There is no safe level of second-hand smoke. Second-hand smoke is bad for health; being around tobacco smoke can cause disease and death in nonsmokers Serious health effects from second-hand smoke on children and adults include sudden infant death syndrome (SIDS), lung and ear problems, and asthma The Dangers of Second-Hand Smoke Millions of people in the U.S. smoke in their homes, at work, and places where they socialize ( especially including AA/NA meetings )

Quitting Smoking Lowers Risk of Death:

Quitting Smoking Lowers Risk of Death Years of life gained Age at cessation (years) Quitting smoking at any age can make a person healthier and allow for longer life. Among those who keep smoking, at least half will die from a tobacco-related disease.

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besides having more money ($2,500 a year for pack-a-day smoker) many things get better very soon .... 20 minutes after your last cigarette : blood pressure drops toward normal heart rate slows temperature of hands and feet rises to normal 8 to 12 hours after quitting : carbon monoxide level in blood drops to normal oxygen level in blood increases to normal 24 hours after quitting : risk of heart attack begins to decrease ( by the end of a year, it’s half the risk of a smoker ! )

Smoking Prevalence Among Those with Mental Illness:

Smoking Prevalence Among Those with Mental Illness Prevalence is 75%+ for those with either addictions and/or mental illness, as opposed to 18.2% for the general population In mental health settings, about 30-35% of the staff smoke – though not at BARC! ( only 8 % !)

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Neurotransmitter Brain Region Localization PD/SUD Involved Dopamine (DA) VTA, NAc , SNc , PFC, ACC Schizophrenia, bipolar disorder, alcohol and drug addiction Norepinephrine (NE) LC, PFC Bipolar disorder, major depressive disorder, cocaine dependence Serotonin (5-HT) RN, PFC, OFC Major depression, PTSD Acetylcholine ( ACh ) NBM, PPN, HIPP, PFC Schizophrenia, major depression, nicotine dependence Endogenous opioid peptides (EOPs) PAG, VTA Opioid and alcohol dependence Glutamate PFC, NAc, VTA, THAL Schizophrenia, bipolar disorder, major depression γ-aminobutyric acid (GABA) PFC, NAc, VTA, THAL Schizophrenia, major depressive disorder, cocaine dependence Endocannabinoids (ECBs) VTA, NAc, HIPP, CEREB Cannabis and opioid dependence Neurotransmitter Systems Affected by Cigarette Smoking in PD and SUD Abbreviations: VTA, ventral tegemental area; NAc, nucleus accumbens; SN, substantia nigra; PFC, prefrontal cortex; ACC, anterior cingulated cortex; LC, locus ceruleus; RN, raphe nucleus; OFC, orbitofrontal cortex; NBM, nucleus basalis of Meynert; PPN, pedunculopontine nucleus; HIPP, hippocampus; PAG, periaquaductal gray; THAL, thalamus; CEREB, cerebellum. Am J Addict.2005

Tobacco Use Impacts Mental Health Treatment:

Tobacco Use Impacts Mental Health Treatment Amount of medications Smoking can make people need more of some medications Any client who begins smoking, quits smoking, or changes the amount that they smoke should talk with a doctor about any medication they’ve been taking. Quitting smoking also improves mental health treatment by improving self-esteem and self-confidence and promoting recovery

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What are the odds that regular smoking will cause terminal disease ? Florida Lottery Grand Prize: 23 million to 1 The Powerball Lottery: 146 million to 1 odds of smoking-related death ? 1 to 1 that would be 50 % odds

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an average smoker…. one pack a day…. takes in 73,000 drags in a year 7 3, 0 0 0 little hits every year

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73,000 drags in a year brings in about a pint of tar….

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how much of the tar and other chemicals goes back out ? all of it ? most of it ? where does the residue go ? how would you know ?

What’s in Tobacco Smoke ?:

What’s in Tobacco Smoke ? Nicotine does NOT cause the ill heath effects of tobacco use. Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde Nicotine Nitrosamines Lead Cadmium Polonium-210 An estimated 4,800 compounds are in tobacco smoke, including many proven to cause cancer in humans

over 40 known carcinogens:

Ammonia Tars and ash u r e a toluene Butane acetone Acrolein hydrogen cyanide over 40 known carcinogens Cadmium

vaporized , free-base nicotine:

vaporized , free-base nicotine P l u s : Acetaldehyde Nitrosamines Lead Nickel Zinc Radioactive Polonium 210

Lots of Others ::

Lots of Others : PROPYLENE GLYCOL TOLUENE PHENOL EUGENOL ARSENIC BENZOPYRENE DIOXIN PESTICIDE RESIDUES COCOA CAFFEINE GLYCEROL SUGAR

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while the disease and death caused by nicotine use are staggering is it connected with addiction to and recovery from other drugs ?

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instead of bashing smokers with sermons… …or with shocking pictures… can we show evidence of the extreme drug-nature of nicotine ?

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are there statistical or scientific associations … of “smoking gun” quality ? here are 3 such connections : showing the interaction with recovery from other drugs ?

One of the first studies of concurrent tobacco-addiction treatment was done by Elizabeth Stuyt, MD, at Texas Tech University Hospital residential treatment unit::

One of the first studies of concurrent tobacco-addiction treatment was done by Elizabeth Stuyt, MD, at Texas Tech University Hospital residential treatment unit: Dr Stuyt followed up on clients to see how many were clean from drug-of-choice, one year later. clients were divided into those who were using tobacco , at the end of that year, and those who were not using tobacco . Results : Smoking Gun # 1

Short, purple column: # of smoking clients clean from drug-of-choice, after one year ( 14%) Tall, green column: # of non-smoking clients clean from drug-of-choice, after one year ( 48% ) :

Short, purple column: # of smoking clients clean from drug-of-choice, after one year ( 14%) Tall, green column: # of non-smoking clients clean from drug-of-choice, after one year ( 48% ) that’s 48% without smoke 14% with smoke

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In research done in 2004, by Judith Prochaska , looking at 19 different studies, treatment of tobacco addiction was associated with an average of 25% better long-term recovery from alcohol and other drugs !

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Just as people who don’t drink – not even a little bit – are more likely to stay in recovery, People who don’t smoke anything at all are more likely to stay in recovery from alcohol and all other drugs !

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Recent research with laboratory rats showed that exposure to nicotine increased appetite for alcohol. New research ( Nov 2011 ) shows lab rats given nicotine for 7 days in drinking water had an increased physiological response …. to cocaine ! This “priming” effect comes from nicotine’s altering DNA in a gene (FosB) that’s involved in addiction

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evidence that nicotine is, “ounce-for-ounce” as powerful in the brain as any other drug of addiction Smoking Gun # 2 here’s the power of nicotine in the brain : …and coming up, the power of nicotine compared to cocaine :

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Nicotine : if you saw it like this, in a syringe: maybe it would look like what it really is : one of the most destructive, addictive drugs in the world !

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what if ... people were given injections of cocaine or of nicotine .... Could they tell the difference ?

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such a study was done ….at Johns Hopkins University ….in 1999 subjects were current users of cocaine ( IV or crack ), who also smoked at least one pack of cigarettes a day neither subjects nor injectors knew which drug was given, or how strong a dosage, or if a placebo was used … subjects were then asked questions about how they felt … “Do you feel a drug effect?” “Does the drug have any good effects?” ( subjects had been told they might get any of a wide range of drugs, from uppers to downers ) “Do you feel a rush?”

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To the question : COCAINE NICOTINE question : “Do you feel a rush ?” “Do you feel a drug effect ?” COCAINE NICOTINE

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question : “Does the drug have any good effects ?” COCAINE NICOTINE “Does the drug have any bad effects ?” COCAINE NICOTINE

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question : “Do you like the drug ?” COCAINE NICOTINE “How high are you ?” COCAINE NICOTINE 75% of subjects getting nicotine guessed they were getting cocaine

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the 2 drug types : Nicotine … and Opiates have an almost identical effect in the VTA and nucleus accumbens area of the brain where both drugs stimulate production of dopamine

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0 100 150 200 250 0 1 2 3 hr Time After Nicotine % of Basal Release Accumbens Caudate NICOTINE Effect of Nicotine on Dopamine Levels

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Smoking Gun # 3 what does nicotine do in the addictive brain ? …how does it affect the recovering brain ?

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enters the bloodstream in the lungs vaporized nicotine

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in less than 6 seconds neurons spread it all thru the brain quickly filling nicotine receptors nicotine is carried to the brain

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Smokers develop many more nicotine receptors When they stop smoking, those receptors are hungry (withdrawal) But over time those cells are no longer needed and fade away, after about 4 weeks

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synapse ¼ milligram dose of nicotine delivered 73,000 times per year

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neurons and their connections get stronger grey matter becomes white matter as it’s covered with myelin

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Knowing about the brain actually changes the brain …like thinking about our thoughts changes how we think. Neuro-plasticity

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Prenatal injuries – including smoke Lack of sleep Concussions and other brain injuries Lack of exercise Excessive use of alcohol or other drugs Poor diet …. Especially smoking ! Excessive caffeine Chronic stress Factors that reduce brain functioning Negative thinking

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Positive social connections Fish Oil New learning … especially music Regular exercise Gratitude Healthy diet Meditation Daily multiple vitamins Positive thinking Factors that improve brain functioning Dancing ( without drinking )

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Meditation….Prayer….Gratitude….Positive Affirmations strengthen the left front part of the brain….

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Neurogenesis Adult Neural Stem Cells Your brain produces a “fertilizer” for new cell growth B D N F ( Brain – Derived Neurotrophic Factor ) this “fertilizer” gets eaten away by the chemicals produced with stress including the stress caused by smoking

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Alcohol-Induced Brain Injury Cortical gray matter and white matter atrophy, especially in frontal lobes Enlarged sulci and ventricles Reduced volume of subcortical structures Brain changes from long-term use of alcohol and tobacco Dieter Meyerhoff , 2008

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with even smaller cortical volumes in smoking heavy drinkers (HD) ( “light” drinkers: 13 drinks/month; “heavy” drinkers: 170/month )

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Smoking-induced Brain Injury (no history of alcohol dx ) Greater brain atrophy after age 50 Smaller cortical gray matter volume and density in prefrontal cortex Smaller left anterior cingulate volume Lower gray matter densities in right cerebellum Same areas affected by alcoholism

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Brain Deficits in Chronic Smokers Memory (Hill et al., 2003) Working memory (Ernst, 2001) Executive functions ( Razani et al., 2004) Psychomotor speed & cognitive flexibility ( Kalmjn et al., 2002) General intellectual abilities ( Deary et al., 2003) Abnormal decline in cognition ( Ott et al., 2004) Increased risk for various forms of dementia ( Launer et al., 1999) Greater incidence of mood disorders (Gilman & Abraham, 2001)

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The Big Question … according to Meyerhoff : Does chronic cigarette smoking contribute to the brain deficits linked to chronic alcohol-dependence ?

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with one week abstinence Frontal Gray Matter Perfusion (blood flow) non-smoking light drinker smoking recovering alcoholic non-smoking recovering alcoholic

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Brain Matter Volume Affects Cognition Differently for non-smoking recovering alcoholics for smoking recovering alcoholics Visuospatial learning and memory have positive correlation in temporal and occipital lobes there’s no such positive correlation with white matter volume over 1-month abstinence over 1-month abstinence

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Smoking Affects Recovery of PreFrontal “Executive” Skills in testing over a period of 8 months : non-smoking recovering alcoholics showed improvements in : executive skills processing speed working memory visuospatial learning memory smoking recovering alcoholics did not show those improvements … and there’s less recovery of executive skills when nicotine dependence was stronger :

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Brain Changes in Early Sobriety : blood oxygen levels rise, as carbon monoxide is replaced by O₂ important brain metabolites recover with no smoking : choline and myo-inositol completely normal in 5 weeks NAA (n- acetylaspartate ) close to normal smoking in early abstinence slows down or arrests almost all metabolite recovery Meyerhoff’s Conclusions to This Study ◊ Chronic smoking affects the brain ! ◊ Chronic smoking contributes to brain injury and compounds alcohol-related injury.

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◊ Chronic smoking hampers recovery from alcohol-related brain injury and cognitive deficits. ◊ Smokers may be less able to integrate treatment ◊ Smokers may respond differently than non-smokers to pharmacological interventions. ◊ Any intervention should target smoking and drinking, with concurrent smoking cessation advised. during early recovery.

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(Ventral Tegmental Area) so ... how does this work ? what does the brain really look like ?

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an actual brain : just 2% of body weight weighs about 3 pounds but uses 20% of body’s oxygen and energy …and 70% of all the body’s genes are working in the brain

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conditioned and unconditioned also with aggressive, sexual, maternal, and eating behaviors the Amygdala participates in emotional memory mediates anxiety (including panic attacks) with declarative memory laid down in the Hippocampus and sadness involved with attention Amygdala processes fear ~ one on each side of the brain almond-shaped structure

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take 2 paths : signals from the sensory systems a slower “high road” to the Cortex (consciousness) then on to the Amygdala …and a much faster “low road” to the Thalamus Amygdala the Amygdala compares that info with previous dangers sending commands to the autonomic nervous system and up to the Cortex – including inhibition of cortical functioning leading to “ acting without thinking ”

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the limbic surge – automatically triggered – lasts only 90 seconds then the released chemicals dissipate… and are sustained only if we hook into negative loops we must use the pre-frontal brain to talk to this part of the brain about what we need and want and don’t want like talking to bad parents

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Addiction involves the imbalance of the “GO” system and the “STOP” system the “GO” is the ancient and powerful mesolimbic system it’s the brain area focused on survival developing early in childhood and adolescence fed by dopamine never “maturing”

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the “STOP” system, with its inhibitions, recollecting, forecasting develops up through the early 20’s …unless it’s impaired or its dopamine reward pathways are hijacked and over-ridden by surges of drugs and other intense experiences

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the “STOP” system pushes back against the limbic signals created even by visual cues : but may be overwhelmed by an energized “GO” system …and this is what a brain looks like on cocaine :

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more research published by Childress in 2008 but the “unseen” pictures with drug or sexual content images seen by subjects shows the effects on the limbic system of cues outside of awareness ! for only 33 milliseconds were not remembered or “seen” lit up the limbic system

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the cerebral cortex needs 500 to 600 milliseconds the “ GO ” system is going the Limbic System needs less than 50 milliseconds to process an experience and to register it in conscious awareness to react to potential threat …or to drug cues before the “ STOP ” system knows anything’s happening …or to sexual images …or to food

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If you’re an addict in early recovery what‘s your brain seeing ?

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so…are clients secretly thinking about quitting ? are they afraid of the withdrawal ? what helps people stop smoking?

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“They often speak of my drinking…” an old British saying : “….but never of my thirst.”

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Brief Interventions Can be done by anyone and everyone Who talks with clients It’s having a conversation about smoking, Using open-ended questions Not aggressive Not confrontive But instead … Respectful ….Compassionate If we don’t look at smokers like this : They won’t look at us like this :

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Even very brief interventions, given By doctors, of less than 3 minutes : produced quit rates of 13.4% ! ( “will-power”, “cold-turkey” rates are less than 5%) Interventions lasting 3 to 10 minutes each, delivered in 2 to 3 sessions : Quit Rates of 16 % Interventions of 15 to 45 minutes each, delivered in 4 or more sessions : Quit Rates of 22.1 %

WHY USE a MEDICATION FOR QUITTING?:

WHY USE a MEDICATION FOR QUITTING? Medications help by making people more comfortable while quitting Reduces withdrawal symptoms Allows clients to focus on changing their behavior The medications do not have the harmful ingredients found in cigarettes Nicotine replacement therapy (NRT) products provide a clean form of nicotine Other medications that do not include nicotine are available with a doctor’s prescription Medications improve chances of quitting

MEDICATIONS for SMOKING CESSATION:

Nicotine gum Nicorette ( OTC) Generic nicotine gum (OTC) Nicotine lozenge Commit (OTC) Generic nicotine lozenge (OTC) Nicotine patch Nicoderm CQ (OTC) Generic nicotine patches (OTC, Rx) Nicotine nasal spray Nicotrol NS (Rx) Nicotine inhaler Nicotrol (Rx) Bupropion SR tablets Zyban (Rx) Generic (Rx) Varenicline tablets Chantix (Rx) These are the only medications approved by the Food and Drug Administration (FDA) for smoking cessation. MEDICATIONS for SMOKING CESSATION OTC = over-the-counter / no prescription needed

NICOTINE GUM :

NICOTINE GUM Sugar-free chewing gum Absorbed through the lining of the mouth Available in two strengths (2mg and 4mg) Available flavors are: Original, cinnamon, fruit, mint (various), and orange Sold without a prescription as Nicorette or as a generic Some find the gum difficult to chew May not be a good choice for people with jaw problems, braces, retainers, or significant dental work Nicorette gum (shown here) is manufactured by GlaxoSmithKline.

NICOTINE LOZENGE:

NICOTINE LOZENGE Absorbed through the lining of the mouth Available OTC in two strengths 2mg and 4mg Available sugar-free flavors include: Mint Cappuccino Cherry Commit lozenges (shown here) are manufactured by GlaxoSmithKline.

NICOTINE PATCH:

NICOTINE PATCH Nicotine is absorbed through the skin Sold without a prescription as Nicoderm CQ or as a generic Wear on upper part of the body, in a place with little hair such as the upper back or outside of the arm Do not cut in half Apply a new patch every 24 hours Nicoderm CQ patches (shown here) are manufactured by GlaxoSmithKline.

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Not approved by FDA …early research shows widely-varying levels of nicotine

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“ E “ cigarettes … safety update FDA has moved to block imports tests show presence of nitrosamines and other carcinogens and the “water vapor” in the fake smoke ? – propylene glycol and diethylene glycol ( key ingredients in antifreeze )

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nor are hookahs a safe way to smoke…. the smoke is cooler, and therefore better tolerated but still just as full of toxins ! especially carbon monoxide

BUPROPION SR TABLETS:

BUPROPION SR TABLETS Does not contain nicotine Tablet that is swallowed whole, and the medication is released over time Same medication as Wellbutrin, which is used to treat depression Sold with a prescription as Zyban or generic Zyban (shown here) is manufactured by GlaxoSmithKline.

VARENICLINE ( Chantix ):

VARENICLINE ( Chantix ) Does not contain nicotine Tablet that is swallowed whole Sold with a prescription only as Chantix People who take Chantix should be in regular contact with their doctor Chantix (shown here) is manufactured by Pfizer. NOTE : Some people who used varenicline have reported experiencing changes in behavior, agitation, depressed mood, suicidal thoughts or actions. Clients should talk to their doctor before taking this medication.

DAILY COSTS of TREATMENT versus SMOKING CIGARETTES:

DAILY COSTS of TREATMENT versus SMOKING CIGARETTES Cost per day in U.S. dollars $6.07 $5.81 $5.73 $5.26 $3.91 $3.67 $4.22 $4.26

LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS:

LONG-TERM (  6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev Percent quit 18.0 15.8 11.3 9.9 16.1 8.1 23.9 11.8 17.1 9.1 19.0 10.3 11.2 20.2

The CHALLENGES of QUITTING :

The CHALLENGES of QUITTING People smoke in many different situations: Quitting requires coping – changing how you think and what you do – in these situations Quitting requires motivation – thinking about a more positive life outlook and other meaningful reasons to quit Talking with someone who knows about quitting can help people learn to cope and get motivated to quit without having a cigarette or using tobacco When drinking coffee While driving in the car When bored While stressed While at 12-step meetings After meals During breaks at work While on the telephone When spending time with family or friends who use tobacco While drinking alcohol or using drugs

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Tobacco-Free-Grounds at our Residential Treatment Center since July 5, 2005 S E R E N I T Y G A R D E N

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tobacco aware treatment Increase in quit rate A totally tobacco-free treatment environment Brief intervention Moderate intervention Intense intervention >5 mins <1 mins 2-5 mins 2 fold 3 fold 4 fold 5-7 fold

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smoking aware environment A ‘no-smoking practice’.... 2 fold Display no smoking posters. Ban smoking on treatment premises Routinely identify the smoking status of clients Flag the records of smokers. Promote self-help materials, leaflets, Display QuitLine numbers in the waiting room. Videotaped presentations in public areas ... can double the quit rate

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Ask about smoking status at all opportunities Involve all members of the treatment team Assess desire to quit, Provide self-help materials Refer to Quit-Line Brief intervention .... tobacco aware treatment <1 min ... can triple the quit rate 3 fold

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4 fold tobacco aware treatment 2-5 mins Moderate intervention .... ... four times the quit rate Ask about smoking status at all contacts Assess desire to quit, dependence and barriers to quitting Provide self-help materials Advise on strategies to overcome barriers Set a quit date Assist by offering pharmacotherapy through QuitLine Arrange follow-up (or refer to smoking cessation services)

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tobacco aware treatment >5 mins 5-7 fold Intense intervention .... ... five times the quit rate Ask about smoking status at all opportunities Assess desire to quit, dependence and barriers to quitting, Discuss high risk situations, explore confidence Advise on strategies to overcome barriers. Address dependence, habit, triggers, negative emotions. Brainstorm solutions and develop a quit plan. Assist by offering pharmacotherapy and follow-up counseling via Quit-Line

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Motivational interviewing Key principles Regard the person’s behaviour as their personal choice Encourage the patient to discuss the advantages and disadvantages of making a quit attempt Let the patient decide how much of a problem they have Avoid argumentation and confrontation

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Motivational tension Worry about health Dislike of financial cost Guilt or shame Disgust with smoking Hope for success Decreasing chances of recovery from other drugs Enjoyment of smoking Need for cigarette Fear of failure Concern about withdrawal Perceived benefits Offering treatment can influence the choice

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Express Empathy Roll with Resistance Develop Discrepancy Support Self-efficacy Avoid Argumentation Confrontation as Goal - not Style Principles of Motivational Interviewing

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Accurate empathy conveys understanding of the client through the skill of reflective listening. It clarifies and mirrors back the meaning of client communication without distorting the message. Counselor empathy is highly correlated with successful treatment outcome. Principle #1 : Express Empathy

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In Motivational Interviewing, “Resistance” is defined as a misalliance in the counselor-client relationship and not an inherent “symptom” of addiction. Client ambivalence is accepted as a natural part of the change process. Client “resistance” is decreased through the use of non-confrontational methods. MI advocates “rolling with” and accepting client statements of resistance rather than confronting them directly. Therapists adopting a hostile-confrontational style tend to elicit more withdrawal, lower involvement, distancing, and resistance. Principle #2 : Roll with Resistance

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• Arguments clients themselves make for change are more effective than arguments offered by others. It is the counselor’s role to elicit these arguments by exploring client values and goals. Discrepancies identified between the client goals, values and current behavior are reflected and explored. The counselor focuses on the pros and cons of the problem behavior and differentially responds to emphasize discrepancies identified by the client. Principle #3: Develop Discrepancy

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• Key to behavior change is the expectation that one can succeed. Motivational Interviewing seeks to increase client perception about their skills, resources and abilities that they may access to achieve their desired goal. Principle #4 : Support Self- Efficacy

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It is easy to fall into an argument trap when a client makes a statement that the counselor believes to be inaccurate or wrong. MI takes a supportive and strength-based approach. Client opinions, thoughts and beliefs are explored, reflected and clarified, but not directly contradicted. Goal of MI is to increase ambivalence about smoking not to force change process. Principle #5 : Avoid Argumentation

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• Motivational Interviewing, like client -centered counseling has been described as a “way of being” with a client. The “spirit” in which it is delivered is as important as the techniques that are used. The spirit of MI is characterized by a warm, genuine, respectful and egalitarian stance that is supportive of client self-determination and autonomy. The quality of the therapeutic relationship accounts for up to 30% of client improvement in outcome studies Spirit of Motivational Interviewing

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Ask all clients about tobacco use “Do you, or does anyone in your household, ever smoke or use any type of tobacco?” “We ask our clients about tobacco use, because it can affect their recovery from other drugs, and interact with many medications.” “We ask our clients about tobacco use, because it can cause many medical conditions.” “We ask our clients about tobacco use because it can harm their mental and physical health.” , Step 1: Ask Research shows that treatment providers simply ASKING about smoking leads to a 30% increase inpatients attempts to quit.

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A S K “What are your thoughts about smoking? (not: “ do you want to quit?” “Has your doctor ever said anything about smoking and your…. .......asthma ……heart condition …..bronchitis ….children’s illness ….diabetes ….pregnancy ….stroke, etc, etc “Do you ever wish you’d never started smoking in the first place ?” A S K

Step 2: Advise:

people who use tobacco to quit (use a clear, strong, and personalized message) “Quitting smoking is very important for improving your overall health and recovery. I can refer you to people who can help you.” ADVISE Step 2: Advise

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A D V I S E “When you quit….. (not: “ if you quit”) “you will increase your chances of staying free of all drugs.” “Stopping your smoking is the single best thing you can do for your health, and for the health of everyone who lives near you…. babies, children, partners, family, pets…” “When you quit, they won’t get sick from your smoke.”

Step 3: Refer:

people who use tobacco to other resources: Referral options: The toll-free telephone Quit-Line: A local group program, such as Nicotine Anonymous The support program provided free with each smoking cessation medication REFER Step 3: Refer

Refer to : toll-free telephone Quit-Line:

Refer to : toll-free telephone Quit-Line Referring clients to a tobacco quitline is simple People who call the Quit-Line receive one-on-one advice from trained counselors Free nicotine patches and gum are available Follow-up counseling is provided by the quitline Quit-Lines are free, and they work! Sample cards, for distribution to clients.

Power of Intervention:

Power of Intervention ⅓ to ½ of the 44.5 million smokers will die from the habit. Of the 31 million who want to quit, 10 to 15.5 million will die from smoking. Increasing the 2.5% cessation rate to 10% would save 1.2 million additional lives. If cessation rates rose to 15%, 1.9 million additional lives would be saved. No other health intervention could make such a difference!

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