Nancy A. Melville

December 12, 2017

SAN DIEGO, California ― Headway is being made in the treatment of tobacco dependence in psychiatric and substance abuse patients, owing to a better understanding of the safety and efficacy of therapeutic strategies.

Even so, the problem of tobacco dependence is often omitted from psychiatric evaluations, experts say.

"Despite substantial reductions of tobacco consumption in the general population over the last decades, similar changes have not occurred in patients with mental illness," Maher Karam-Hage, MD, of the University of Texas MD Anderson Cancer Center, Houston, Texas, told delegates here at the American Academy of Addiction Psychiatry (AAAP) 28th Annual Meeting.

"For many years, smoking was tolerated and even encouraged in psychiatric settings. However, [psychiatric patients] may be as interested in quitting as the general population."

Cessation Rates Higher Than Expected

An intensive tobacco treatment program developed by Dr Karam-Hage and colleagues at the MD Anderson Cancer Center's Tobacco Treatment Center has tackled the problem head-on.

An initial report on 600 smokers with psychiatric comorbidities who participated in the program from 2016 to 2017 showed impressive results.

All of the participants had cancer or had recently recovered from cancer. The patients had various psychiatric comorbidities, including depression, anxiety, posttraumatic stress disorder, and insomnia. They received simultaneous treatment for smoking and psychiatric comorbidities unless they requested treatment of their psychiatric symptoms first.

In initial findings, the smoking abstinence rate was 49% after 8 to 10 weeks of treatment; it was 45% after 6 months. These rates are significantly higher than is typical in the psychiatric population.

"[The rate] is much higher than what is expected, as we are treating those psychiatric comorbidities and therefore we diminish their impact on the ability to quit," Dr Karam-Hage told Medscape Medical News.

"Usually among patients without psychiatric comorbidities, the 6-month quit rates hover around 25%, and those with psychiatric comorbidities, around 10% to 15%, not including schizophrenia or bipolar disorder, as those have dismal rates of quitting and staying quit," he added.

Importantly, there were no significant differences in abstinence levels between those without psychiatric diagnoses and those with a single psychiatric disorder.

The abstinence rate was somewhat lower among those with two or more psychiatric disorders (35%); the rate increased to 45% after treatment and stabilization of patients' psychiatric disorders.

The Tobacco Treatment Program includes a combination of intensive counseling, eight 30-minute sessions; proactive medication management with first- and second-line medications for 6 months; and nicotine replacement therapy (NRT), administered for longer than the standard 3 months, if needed.

Contrary to common concerns that treatment of tobacco dependency may exacerbate psychiatric symptoms, patients showed improvement, Dr Karam-Hage reported.

"The majority of our patients are treated simultaneously, and it's very rare that their psychiatric symptoms worsen. In fact, both bupropion and varenicline had a positive impact on anxiety and depressive symptoms," he said.

These findings are consistent with those of other studies. Dr Karam-Hage noted one meta-analysis of 26 observational studies that showed the effect sizes of smoking cessation in patients either with or without psychiatric disorders to be equal to or larger than the effect sizes observed with antidepressant treatment for mood and anxiety disorders.

Dr Karam-Hage noted that the decision of whether to treat psychiatric illness and tobacco dependence simultaneously should be decided on the basis of patients' needs and preferences.

"The bottom line is you do what works best for the patient. If they're not ready to take on both challenges, then start with the psychiatric treatment and begin the tobacco treatment when they feel ready," he said.

The counseling sessions at the MD Anderson program include motivational interviewing with social support, skill building, and problem solving. The center uses a multidisciplinary team approach to address the full range of patient needs, including treatment of psychiatric comorbidities, if needed.

The program includes follow-up every 3 months. Patients who do not successfully quit smoking or who experience relapse are invited to return for additional therapy.

Although the program largely involves the center's cancer patients, noncancer patients are also included.

"In our program, we have participants including employees and significant others of patients who do not have cancer, and we get very similar rates. We think this is because we are minimizing all the other aspects that may interfere with someone's ability to quit, such as psychiatric comorbidities and the combination of medications, etc," said Dr Karam-Hage.

Black Box Warnings

Concerns about adverse effects associated with the use of drugs for tobacco cessation by individuals with psychiatric disorders were amplified when the US Food and Drug Administration issued a black box warning for both varenicline and bupropion.

These warnings were lifted in 2016, largely as the result of findings from the landmark EAGLES trial, which found that patients who had a single stable psychiatric disorder did not experience an increase in symptoms.

"Neither varenicline nor bupropion increased serious neuropsychological adverse events compared with NRT or placebo in smokers with or without psychiatric disease," said the study's senior investigator, Robert M. Anthenelli, MD, director of the Pacific Treatment and Research Center in the Department of Psychiatry, University of California, San Diego, who discussed the study at the meeting.

He noted that in a follow-up analysis, other pretreatment factors associated with neuropsychiatric serious adverse events included a prior history of suicidal ideation, current symptoms of anxiety, and white race.

The findings help establish an important role for medications in the treatment of tobacco dependence in patients with mental illness, Dr Anthenelli said.

"The study showed that all three first-line smoking cessation medications [varenicline, bupropion, and NRT] can be used safely and effectively in smokers with stable psychiatric disorders," he said.

"When combined with other studies, there is abundant evidence that their benefits outweigh the risks."

However, adverse psychiatric events are more common in psychiatric patients who attempt to quit smoking, regardless of the cessation strategy, and clinicians should more closely monitor those patients, Dr Anthenelli said.

Do Doctors Ask?

With research increasingly showing clear benefits of treating tobacco addiction in psychiatric patients, researchers at the Medical University of South Carolina (MUSC), in Charleston, researched how often medical professionals address the issue.

In a poster presented at the meeting, they described a review of 100 randomly selected medical records in three different clinical settings in the Ralph H. Johnson VA Medical Center, Charleston. Those settings included primary care, substance treatment and recovery (STAR), and mental health clinics.

The reported rates of smoking were 41.9% in primary care clinics, 38.4% in mental health clinics, and 81.6% among STAR patients.

Identification of patients as smokers or nonsmokers differed significantly among the three types of clinics. The identification was made in 98% of primary care clinics, 86% of mental health clinics, and 87.5% of STAR patients ( P < .001).

Interestingly, smokers were far more likely to be advised to quit in the primary care setting (92.7%) compared to the mental health (34.6%) and STAR settings (35.2%; P < .001).

Pharmacotherapy for smoking cessation was prescribed in only 6.6% of clinics; there were no significant differences between the three treatment groups.

Study investigator James Walker, MD, of MUSC, noted that the psychiatric problems that bring patients to the mental health and STAR clinics may simply take precedent over tobacco use.

"I think in a lot of psychiatric cases, people clearly aren't coming in for smoking, so it may just get overlooked. But I think the argument should be made to document whether or not the patient smokes in the initial evaluation," Dr Walker told Medscape Medical News.

Addiction specialist James Rotchford, MD, MPH, an attendee at the session, said that at the initial contact with patients who present with psychiatric or substance use disorders, clinicians may often need to proceed with caution and to prioritize the patient's needs.

"I think if you're going to help someone stop smoking, you need to first establish a relationship. [Smoking cessation] may not be something the patient wants to talk about at first," he told Medscape Medical News.

Dr Walker agreed, noting, "It's important to have a relationship with them, and you don't want to push someone too hard to quit at first if they're not ready. But I think the argument can be made that it is still is important to keep tobacco dependency on your radar," he said.

Dr Karam-Hage's study was funded by the National Institutes of Health through a National Cancer Institute Cancer Center grant to the University of Texas MD Anderson Cancer Center. The Tobacco Treatment Program is supported by the state of Texas' tobacco settlement funds. Dr Anthenelli has received research funding from Alkermes and Pfizer and has had consulting agreements with Arena Pharmaceuticals, Cerecor, and Pfizer. His research is supported by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Dr Walker's study received funding from DART.

American Academy of Addiction Psychiatry (AAAP) 28th Annual Meeting. Abstracts B65 and 41, presented December 9 and 10, 2017.

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