Changing organisational systems to address tobacco dependence in drug and alcohol treatment centres

1
Changing organisational systems to address
tobacco dependence in drug and alcohol treatment
centres

• Billie Bonevski
• Cancer Institute NSW
• Research Fellow
• University of Newcastle, Australia

2
The team

• University of Newcastle Amanda Wilson, Flora
  Tzelepis, Chris Paul, Jamie Bryant, Andrew Searle
• Hunter New England Health Adrian Dunlop
• National Drug and Alcohol Research Centre
  (NDARC) Anthony Shakeshaft, Michael Farrell,
  Richard Mattick
• Cancer Council NSW Scott Walsberger, Phil Hull,
  Jon OBrien
• University of Wollongong Pete Kelly
• London John Strang, Ann McNeill
• US Judith Prochaska

3
Overview

• Part 1 Myth Busting
• Part 2 What is current practice
• Part 3 What can we do
• Part 4 How do we do it

4
Why address smoking amongst drug and alcohol
(DA) treatment clients?
5
Myth No 1

• Tobacco is not a health priority for this
  population. Other drugs are more
  important/deadly/more harmful

6
Hospital admissions in Canada
Single et al, 2000
7
Annual drug-related deaths in the US
Centre for Disease Control, 2008, 2004, 2007
8
Tobacco-related deaths within Australia compared
with other causes
Begg et al, 2007
Begg et al., 2007
9
Drug related deaths in Australia (2004/05)
Collins DJ, Lapsley HM. DoHA 2008.
Begg et al., 2007
10
Smoking rates in DA treatment populations
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Myth No 2

• Tobacco smoking is a necessary self-medication

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Tobacco is part of the problem not the solution

• Perpetuated by the tobacco industry
• Mental illness
• Stress, coping, stabilise mood etc
• Nicotine reward system

13
Nicotine dependence
Physiological addiction Behavioural habit
Triggers the release of dopamine Frequency and immediacy of reinforcement firmly cements a behavioural cluster
Positive affect brain reward system 1 pack/day 200/day hand to mouth rituals
De-activation leads to withdrawal (cravings) Social acceptability increases range and number of triggers
Limited effect on lifestyle
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Myth No 3

• Addicts are not interested in quitting smoking

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Australian DA clients are interested to quit

• N 228 smokers in residential DA treatment
• 75 had tried quitting in the past
• 67 were seriously thinking about quitting
• Kelly et al, 2012

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Methadone maintained clients interest in quitting

• N 103 OTP clients in two clinics in Australia
• 84 current smokers
• 56 previous quit attempt
• 38 thinking of quitting next 6 months
• Would like help with quitting 36 said Yes and
  31 were Unsure
• 80 were heavy nicotine dependence

Bowman et al 2011
17
Myth No 4

• Drug and alcohol clients are unable to quit
  smoking

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Smoking cessation offered during DA treatment is
effective
A Meta-Analysis of Smoking Cessation
Interventions With Individuals in Substance Abuse
Treatment or Recovery. Prochaska, Judith
Delucchi, Kevin Hall, Sharon Journal of
Consulting Clinical Psychology.
72(6)1144-1156, December 2004.
Significant two-fold increase in the likelihood
of smoking abstinence among intervention versus
control participants
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Myth No 5

• Addressing smoking compromises other treatment
  outcomes

20
Alcohol and illicit drug abstinence following
smoking cessation intervention
A Meta-Analysis of Smoking Cessation
Interventions With Individuals in Substance Abuse
Treatment or Recovery. Prochaska, Judith
Delucchi, Kevin Hall, Sharon Journal of
Consulting Clinical Psychology.
72(6)1144-1156, December 2004.
Significant increase of 25 in the likelihood of
abstinence from drugs and alcohol among
participants receiving a smoking cessation
intervention relative to participants in the
control condition.
21
How is smoking currently treated within the drug
and alcohol sector?
22
Clinically recommended

• Tobacco dependence is a chronic disease with
  remission and relapseNicotine dependence
  warrants medical treatment as does any drug
  dependence disorder or chronic disease
• Fiore et al, U.S. Dept of Health and Human
  Services, June 2000

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(No Transcript)
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Is smoking cessation care provided to DA
treatment clients?

• National survey of DA agencies (n 260 agencies
  213 managers and/or 204 other staff)
• 23-25 said they had a written smoke-free policy
• 80-83 indicated delivery of smoking support was
  left to the discretion of individual staff -
  ie, not routinely and systematically provided

Walsh et al, 2006
25
DA treatment centres smoking cessation care
practices
Statement of clients receiving
Smoking status recorded 65
Recommendation to quit 36
Counselling on behavioural methods 26
Attempt to negotiate quit date 17
Recommendation to use NRT 20
Referral to stop smoking group 16
Follow-up discussion 27
Walsh et al, 2006
Bonevski et al., 2012, under review
26
Barriers to the provision of smoking cessation
care in DA setting

• Staff smoking status1
• Lack of training1,2,3
• Resistance to smoke-free policies1,3
• Limited resources, eg, cost of NRT1
• Lack of coordinated staff approach (no system!)2
• Lack of staff time2
• Lack of confidence2,3
• Pessimism regarding effectiveness of smoking
  cessation interventions2
• Misperceptions eg, tobacco is not a real
  drug, its too difficult to address tobacco and
  other dependencies, clients dont want to
  quit1,2,3

1 Zeidonis, Guydish, 2006 2 Walsh, Bowman et al
2005 3 Baca et al, 2008
27
Attitudes of managers and staff toward smoking
interventions (strongly agree/agree) Walsh et al
2006

Provision of smoking cessation interventions should be an integral function of this agency 65
Smoking clients of this agency should receive smoking cessation interventions tailored to their readiness to quit 86
Smoking cessation counselling is as important as counselling about other drugs for clients of this agency 53
Increasing restrictions on smoking and greater provision of smoking interventions would have very little impact on client attendance at this agency 47
Most drug and alcohol clients who smoke are not interested in doing anything about their smoking 64
Clients of this agency usually have enough other problems without worrying about smoking 58
Occasionally it is useful for staff to smoke with a client in an effort to build rapport/trust 15
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What can we do - Menu of support

Brief Advice 5As (ASK, ADVISE, ASSESS, ASSIST, ARRANGE)
Motivational Interviewing
Behavioural Counselling
Pharmacotherapy (NRT gum, patches, inhaler, lozenges), buproprion
Quitline
Follow-up
Referral to other stop smoking services
Heavily addicted!! Best to throw everything at
them!
29
How to integrate this into usual care provision
in drug and alcohol services?
30
What is a systems based strategy?

• Six Core Components
• Implement a system of identifying and recording
  smoking status
• Equip staff with education, resources and
  feedback
• Dedicate staff to tobacco dependence treatment
• Organisational policies
• Provide tobacco dependence treatments as part of
  service (pharmaco and behavioural)
• Defined duties of care

(Fiore et al, Zeidonis et al)
31
How technology can be used

• Touchscreen computers
• Highly acceptable to clients
• Accurate
• Assesses smoking status, nicotine
• dependence, quit attempts
• Print-out for client files
• Education for staff and clients
• Ongoing monitoring and improvement

Shakeshaft et al, 1999, Bonevski et al, 2010,
Bryant et al 2012
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Advantages of a systems based strategy

• Integration of smoking cessation support
  provision in routine care
• Aim to build capacity of the organisation to
  address smoking
• De-normalisation of smoking within the setting
• Based on systems - sustainable model in the long
  term

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Is it effective at reducing smoking?

• Pilot studies have found
• Improves staff attitudes score regarding smoking
• Increases distribution of NRT
• Increases provision of behavioural cessation
  support
• The potential is evident
• Well designed trials needed

Guydish, 2010, 2012 Zeidonis 2007
34
Trial of system change intervention in drug and
alcohol setting (NHMRC2013-16)
30 Drug Alcohol Treatment Centres in QLD, NSW
Vic randomised to
15 Drug Alcohol centres in control group
usual care

• 15 Drug Alcohol centres in intervention group
• Touchscreen survey and print out
• Staff training
• Organisational policies
• NRT
• Follow-up

• Outcomes at 6 months
• Cessation
• Quit attempts
• Smoking care provision

35

• THANK YOU
• Funding
• Cancer Council NSW
• Cancer Institute NSW
• NHMRC
• University of Newcastle
• HMRI
• Contact me on
• Billie.bonevski_at_newcastle.edu.au
• or ph 02 40335710

CRICOS Provider 00109J www.newcastle.edu.au