Treating Tobacco Use Disorder and Managing Other Toxic Exposures Flashcards
What is the single largest preventable cause of morbidity and mortality in the US?
Tobacco
Smokers have a life expectancy at least home years shorter than for non smokers?
10 year
How many deaths annually are due to smoking?
480,000- this includes deaths from second hand smoking
The greatest annual mortality numbers in the US related to smoking are caused by what?
cancer
cardiovascular disease
respiratory disease
List 13 health risks of smoking
- Diabetes ( smokers are at 30-40% increased risk of developing diabetes compared to nonsmokers)
- Rheumatoid arthritis
- impaired immune system/immune function, due to high levels of tar
- Reduced quality of life
- problems with reproduction in men and women
- poorer quality, slower wound healing
- TB
- ectopic pregnancy, preterm delivery, stillbirth, low birth weight, SIDS
- cleft lip and cleft palate
- ED
- age- related macular degeneration
- failure rate of treatment for all cancers
- bone fractures
What is the most common form of chemical dependence in the US?
Nicotine
What % of smokers desire to quit?
70%
which cancers have the clearest link to alcohol use?
head and neck
esophagus
liver
breast
colon/rectum
What can excessive alcohol use increase the risk of?
high blood pressure
stroke
unintentional injuries
OB complications
What does the USPHS recommend when it comes to screening for tobacco use?
1.Clinicians need to recognize that tobacco dependence is a chronic disease and should be treated appropriately.
2. should consistently assess and document tobacco use
3.tobacco use treatments are effective across a broad range of populations
4. brief tobacco dependence treatment is effective
5. individual, group, and telephone counseling is effective
6. if a tobacco user is not ready to quit, clinicians should use MI
What is the criteria for lung cancer screening?
greater or equal to 20 pack year smoking hx
current smoker or quit in the last 15 years
btwn the ages of 50-80
What is the Fagerstrom Test for Nicotine Dependence?
10 item self-report questionnaire specifically designed to measure tobacco dependence
7-10 high dependence
4-6 moderate dependence
< 4 minimal dependence
What is the heaviness of Smoking index?
It is a 2 question test derived from the Fagerstrom test.
What are the 2 questions on the Heaviness of smoking index?
- Time to first cigarette after waking
- number of cigarettes per day.
What is considered a standard drink?
14 grams of alcohol
12 oz of 5% alcohol by volume
5 oz of 12 ABV wine
1.5 oz of 40% ABV 80 proof spirits
what are the recommended limits on drinking?
2 or less drinks a day for men and one drink or less a day for women
what is the definition of binge drinking?
drinking enough that BAC increases to 0.08mg/L
typical amounts are 5 drinks in 2 hours for men, 4 drinks in 2 hours for women
what is the definition of heavy alcohol use?
binge drinking 5 or more drinks on at least 5 days in the past month.
what is at risk drinking?
1.exceeds the levels above for any day of the week
2.binge drinking at least once a month
3. drinking that increases the risk of future problems, even thought there are no current symptoms.
What is the definition of alcohol use disorder?
a pattern of use that leads to impairment or distress
meets at least 2/11 criteria for a substance use disorder
What are the different screening tools that can be used to screen for unhealthy alcohol use?
CAGE
AUDIT
NMASSIST
CRAFFT
TAPS
MSASQ
when should ppl be screened for unhealthy alcohol use?
Annual prevention examination
family planning visits
prenatal visits
problem oriented visits
high risk groups
What health problems does alcohol misuse put patients at?
anemia
osteoporosis
cognitive decline
live disease
cardiac disease
HTN
What is TAPS?
TAPS is an assessment to be administered by the patient or the clinician
TAPS-1 : 4 questions regarding tobacco, alcohol use above the recommended limits, prescription medication in a non-medical fashion and use of illicit substances
TAPS-2: a longer more in depth tool
Has > 70% sensitivity for identifying a substance use disorder at a score of 2 or higher
Vareniciline
- most effective mono-therapy for patients attempting to quit smoking
- Acts as a nicotine receptor partial agonist, meaning the medication binds to the same receptors as nicotine but less strongly
pregnancy category C
Bupropion SR
inhibits the re-uptake of Norepinephrine and dopamine at the nerve synapse so that norephrine and dopamine are available to attach to the corresponding receptors and stimulate the postsynaptic neuron
pregnancy category C
second line medications for tobacco cessation
clonidine and nortriptyline
Contraindications to Bupropion
use of MAOIs
seizure disorder
bulimia/anorexia
abrupt discontinuation of ethanol or sedatives.
Contraindications to varenicline
known hx of serious hypersensitivity or skin reactions to vareniciline
What is considered first line for adolescents trying to quit smoking?
Counseling
what are treatments that have not demonstrated effectiveness for smoking cessation?
acupunture
hypnosis
Follow up schedule for someone trying to quit smoking
2 weeks prior to quit date
1 week after quit date
3 months after quit date
6 months after quit date
what are medications available for alcohol use?
Naltrexon
Acamprosate
Dilsulfiram
Naltrexone
50mg PO daily
blocks mu-receptor
can begin during alcohol abstinence or during alcohol use to help modulate use.
meant to be taken daily
modest improvements in relapse, # of drinking days, and alcohol craving
Acamprosate
modulates glutamate neurotransmission.
2nd line medication due to dosing, 2 tablets 3 times a day
most beneficial when not drinking
Disulfiram
250mg PO daily
aversion agent.
high rates of noncompliance
off label medications for alcohol use
gabapentin 300-600mg PO 2-3x/day
Topiramate 100-150 mg PO BID
Medications for opioid use
naltrexone
Buprenorphine
Methadone
Naltrexone when using for opioid use disorder
50mg PO daily to transition to naltrexone 380mg injections every 4 weeks.
blocks euphoric and sedating effects of opioids, can reduce cravings
buprenorphine when using for opioid use disorder
partial agonist with high affinity for opioid receptor.
allows mitigation of withdrawal and manages cravings by occupying the opioid receptor.
can precipitate withdrawal if full agonist are present
methadone
full opioid agonist with long 1/2 life.
must be dispensed through an opioid treatment program when used for opioid use disorder
5 As of behavioral change
Assess
Advise
Agree
Assist
Arrange
5A of tobacco cessation
Ask- identify tobacco use and document
Advise- use a clear, strong, and personalized manner when you advise quitting
Assess- is the tobacco user ready to quit
Assist- provide counseling or pharmacotherapy
Arrange- schedule follow-up
motivational interviewing to help with tobacco cessation
Express empathy- open ended questions, reflective listening, normalize feelings and concerns, support autonomy
Develop discrepancy- highlight discrepancy btwn the patient’s values, goals and priorities, reinforce and support change talk, build and deepen a commitment to change
Roll with resistance: back off and use reflection when the patient expresses resistance, express empathy, as permission to provide information
Support self -efficacy- help the patient build on past successes
5Rs of motivational interviewing
Relevance: ask the patient to identify the negative consequences of use
Risk of use: acute risks, long-term risks, environmental risks of second hand smoke in spouses
Rewards of quitting: have the patient list potential benefits
Roadblocks to quitting: patient’s identified barriers
Repetition: repeat the steps above at every visit.
When to refer to specialist for addition medicine
Unsuccessful attempts at moderating substance use
co-occuring psychiatric and physical disorders in which medication choice is complicated
concern for significant withdrawal with cessation or modulation of current use
evaluation for levels of care higher than episodic outpatient visits.
Grade A recommendations for tobacco use
Providers should ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA approved pharmacotherapy for cessation to non-pregnant adults who use tobacco.
provider should ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco.
Grade B recommendations for unhealthy drug use
screening should occur by asking questions about unhealthy drug use in adults age 18 and older. it should be implements when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.
Grade B recommendations for alcohol use
clinicians should screen for unhealthy alcohol use in primary care settings in adults 18 and older, including pregnant patients and provider persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use
