Relapse Prevention in Tobacco Dependence Treatment

#TEACHwebinar

TEACH Educational Rounds

Faculty Presenter(s): Dr. Sarah Dermody PhD CAMH, CIHR Postdoctoral Fellow Oregon State University, Courtesy Faculty Appointment

Date: April 12, 2017

Educational Rounds 2017-2018 1 #TEACHwebinar Interested in Obtaining a Letter of Completion for this TEACH Educational Rounds?

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3. Complete Evaluation and Post- Learning Assessment

Educational Rounds 2017-2018 2 #TEACHwebinar

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Educational Rounds 2017-2018 3 #TEACHwebinar Presenters

Dr. Sarah Dermody PhD Dr. Sarah Dermody, PhD, is a Canadian Institute of Health Research Postdoctoral Fellow at the Centre for Addiction and Mental Health. She received her PhD in Clinical Psychology and Biological and Health Psychology from the University of Pittsburgh and completed a one-year clinical residency at CAMH, including a rotation at the Nicotine Dependence Clinic. Her clinical work and research has emphasized applying and refining interventions for smoking cessation and related outcomes like alcohol use. Presently, she is conducting research at CAMH to investigate how smoking and drinking go hand-in-hand, and thus can be targeted together by treatment approaches.

Educational Rounds 2017-2018 4 #TEACHwebinar Disclosures

Potential sources of bias outlined on the following slide have been mitigated by making this information accessible and available to all participants at the time of registration and the presentation date.

Educational Rounds 2017-2018 5 #TEACHwebinar Disclosures

Dr. Sarah Dermody

No disclosures to report

Educational Rounds 2017-2018 6 #TEACHwebinar TEACH Curriculum Development

The TEACH Curriculum and slides were developed and compiled with funding from the Government of Ontario, Ministry of Health and Long Term Care. Content of slides are primarily based on evidence based guidelines including:

• CAN-ADAPTT Canadian Practice Guidelines Initiative – developed in collaboration with national experts in tobacco cessation and health behaviour change (www.can-adaptt.net) • US Guidelines Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 Update. US Department of Health and Human Services, Public Health Service • Rethinking Stop-Smoking Medications: Treatment Myths and Medical Realities OMA Position Paper, January 2008.

The development and delivery of the TEACH curriculum is not influenced or funded in any part by tobacco industry. TEACH has not received funding from the tobacco industry. The development of the TEACH curriculum has not been influenced by pharmaceutical industry. Information presented on pharmacotherapy refers to generic products only, and recommendations are based on existing research, including the CAN-ADAPTT and US guidelines.

Educational Rounds 2017-2018 7 #TEACHwebinar Disclaimer

These materials (and any other materials provided in connection with this presentation) as well as the verbal presentation and any discussions, set out only general principles and approaches to assessment and treatment pertaining to tobacco cessation interventions, but do not constitute clinical or other advice as to any particular situations and do not replace the need for individualized clinical assessment and treatment plans by health care professionals with knowledge of the specific circumstances.

All materials, including without limitation all intellectual property, data, information and all other materials (e.g. PPT slides and pictures) performed and prepared by the Faculty are property of the Faculty, and the Faculty hereby grants to CAMH an unconditional and irrevocable license to use the Work in connection with the TEACH Educational Rounds.

Educational Rounds 2017-2018 8 #TEACHwebinar Learning Objectives

1. Learn terms and principles associated with relapse prevention; 2. Articulate common relapse warning signs and triggers 3. Identify evidence-based interventions for relapse prevention in tobacco dependence treatment

Educational Rounds 2017-2018 9 #TEACHwebinar Stages of Change

Educational Rounds 2017-2018 10 #TEACHwebinar What is smoking relapse?

• There is no consensus definition of the term “relapse” – Setback in the behavior change process – Resumption of target behavior (e.g., drug use)

Hendershot et al., 2011

Educational Rounds 2017-2018 11 #TEACHwebinar What is a smoking relapse?

• Resuming smoking after a quit attempt – “smoking 7 or more consecutive days or more than once/week for 2 or more weeks”1 • includes non-cigarette tobacco use, but not nicotine medications in definitions of relapse – Russell Standard Clinical definition: smoke at least 5 cigarettes after quit attempt2

1Hughes JR, Keely JP, Niaura RS, Ossip-Klein DJ, Richmond RL, Swan GE. Measures of abstinence in clinical trials: issues and recommendations. 2West, R., et al., Outcome criteria in smoking cessation trials: proposal for the common standard. Addiction, 2005. 100, 299-303. Educational Rounds 2017-2018 12 #TEACHwebinar What about “just one puff”?

• Referred to as a “slip” or “lapse” • Lapse vs relapse distinction – Promotes continuous vs binary model – Behavior change is a continuous process

Educational Rounds 2017-2018 13 #TEACHwebinar Why care about relapse?

• Serves no useful diagnostic purpose – Reinforces binary view of addiction (e.g., addict vs. non-addict, recovered vs. relapsed) – The term “relapsed” conveys failure, shame

So why is this so important?!?

Educational Rounds 2017-2018 14 #TEACHwebinar Relapse is Prevalent • High relapse rates common – particularly in 1st week – 12-month relapse rates following unaided tobacco cessation: ~90%

Hughes JR, Naud S. (2004) Shape of the relapse curve and long-term outcomes among untreated smokers. Addiction, 99: 29-33.

Educational Rounds 2017-2018 15 #TEACHwebinar Tobacco use disorder

• Maladaptive pattern of substance use leading to significant impairment or distress

• Maladaptive pattern of use – Tobacco taken in larger amounts or for longer than intended – Difficulty cutting down or stopping – Spending a lot of time getting, using, or recovering from use – Use in physically hazardous situations – Craving or strong desire or urge to use

Educational Rounds 2017-2018 16 #TEACHwebinar Tobacco use disorder

• Tolerance • Withdrawal – tobacco or nicotine is taken to relieve or avoid symptoms – Irritability, frustration, anger – Anxiety – Difficulty concentrating – Increased appetite – Restlessness – Depressed mood – Insomnia

Educational Rounds 2017-2018 17 #TEACHwebinar Tobacco use disorder

• Significant impairment due to continued use – Not managing responsibilities at work, home, or school – Relationship difficulties – Giving up important activities – Physical or psychological problems from use

Educational Rounds 2017-2018 18 #TEACHwebinar Consequences of Relapse

• Return to regular smoking • The Abstinence Violation Effect – Post-lapse reaction – Emotional- guilt, blame, failure, etc. – Cognitive - Internal, stable, global, uncontrollable – Behavioral Reaction- return to habitual response of smoking – Cognitive Reaction- resolve discrepancy • “I will always be a smoker!” • “I cannot live without smoking!”

Educational Rounds 2017-2018 19 #TEACHwebinar Cognitive behavioral theories

• Emphasis on contextual determinants • Cognitive (e.g., drug expectancies) and motivational processes • Substance use as a learned behavior • Biological processes are acknowledged

• Potential targets for reducing substance use – Enhancing motivation – Altering environmental contingencies – Learning coping skills

Educational Rounds 2017-2018 20 #TEACHwebinar Marlatt’s Relapse Prevention Model

• Based upon cognitive-behavioral model • First fully articulated CBT model of addictive behavior • Initiation versus maintenance of behavior change as separate processes • From a CBT perspective, relapse is a temporary setback during the behavior change process

Educational Rounds 2017-2018 21 #TEACHwebinar Cognitive-Behavioral Model of Relapse

Larimer, Palmer, & Marlatt, 1999

Educational Rounds 2017-2018 22 #TEACHwebinar Global risk factors

Educational Rounds 2017-2018 23 #TEACHwebinar Relapse Prevention Treatment

• Important premises – Teaching behavioral/coping skills can reduce relapse risk • Understand and deal with – Pressures to smoke – Smoking cues and cravings

– Distinction of lapse vs. relapse • Address expectations about success

– Lapse provides learning opportunity (Prolapse)

Educational Rounds 2017-2018 24 #TEACHwebinar RP Treatment

• Goals: – Anticipate when lapses are likely to occur and avoid them

– Learn to cope with a lapse to prevent relapse

Educational Rounds 2017-2018 25 #TEACHwebinar Implementing RP

• Assessment – Assess client’s potential relapse precipitants (high risk situations) and coping skills

• Behavioral methods (e.g., drug refusal skills, changing one’s environment, cue-exposure training)

• Cognitive methods (e.g., enhance self-efficacy, address expectancies)

• Address lifestyle factors (e.g., stress)

• Family involvement

Educational Rounds 2017-2018 26 #TEACHwebinar Behavioral skills training • Relapse prevention – Prevent initial lapse and maintain abstinence (or reduction) goals • Identify and eliminate risky situations and triggers – “people, places, and things” » E.g., drug using friends, places where drugs are obtained, reminders of drug use – physical and emotional triggers • Increase time spent in safe activities and contexts

Educational Rounds 2017-2018 27 #TEACHwebinar Behavioural skills training

• Help cope with lapse to prevent further relapse – Relaxation techniques – Problem solving skills – Social support

Educational Rounds 2017-2018 28 #TEACHwebinar Exposure therapy

• Attempt to extinguish relationship between drug cues and craving (and ultimately use)

• Based in classical conditioning – Repeated pairing of drug cues (conditioned stimuli) with drug (unconditioned stimuli) leads to desire to use (conditioned response) the drug when presented with cues – Need to “unlearn” association

Educational Rounds 2017-2018 29 #TEACHwebinar Exposure therapy

Educational Rounds 2017-2018 30 #TEACHwebinar Exposure therapy

• Fairly new approach for smoking – Primarily laboratory studies of smokers – Not a lot of empirical evidence yet

• Limitations – Craving-use link is debated – Ethical concerns

Educational Rounds 2017-2018 31 #TEACHwebinar

ImplementingImplementing RP RP

• Cognitive methods – Enhance self-efficacy • Identify and utilize personal strengths • E.g., address giving up (“I will always be a smoker”) – Address outcome expectancies • Rationalizing smoking (“one cigarette won’t hurt”) • Fear of failure • Beliefs that drug helps problem(s) in life

• Relapse management plans

Educational Rounds 2017-2018 32 #TEACHwebinar Implementing RP

• Lifestyle balance – Manage stress and negative emotions – Issue of boredom and rewards from non-drug activities • Former addicts struggle with lack of euphoria from natural rewards, which may promote relapse • Promote engagement in other pleasurable activities

Educational Rounds 2017-2018 33 #TEACHwebinar Family involvement

• Establish a home environment that facilitates cessation

• Several family factors linked to addiction and relapse – Family disruption, stress, loss – Environmental trigger – partners who smoke – Enabling behaviors

• Family can help motivate recovery

Educational Rounds 2017-2018 34 #TEACHwebinar Family involvement

• Limitations – Family members need to be willing to be involved – Smoking family members can be triggers

Educational Rounds 2017-2018 35 #TEACHwebinar So… how do we put this together??

• Multimodal approach is most common • Patient-centered practices are important – Tailor approach based on • Past experiences and beliefs about the future • Relevant triggers • Patient strengths and weaknesses

Educational Rounds 2017-2018 36 #TEACHwebinar Conclusions

• Relapse is common in smoking cessation • Relapse prevention is critical part of SC programs • RP interventions help clients maintain smoking cessation over time and address vulnerabilities to relapse • RP approaches are diverse and can be individualized

Educational Rounds 2017-2018 37 #TEACHwebinar Questions?

Educational Rounds 2017-2018 38 #TEACHwebinar Case Example 1

• Bob (70 y.o.) has been trying to quit smoking for 20 years. He has had several long period of abstinence (longest for 10 years), but reports resuming smoking “out of the blue” and “for no apparent reason.” He reports not having smoked any cigarettes for the past year. Bob states that he wants to stop smoking but that he thinks it is impossible because he has no control over his smoking behavior.

Educational Rounds 2017-2018 39 #TEACHwebinar Case 1: approach

• Introduce monitoring and stimulus control – Goal: identify triggers and instances of craving • Teach coping skills for triggers – Avoid or alter – 4 Ds: Delay, distraction, drink water, deep breaths • Enhance motivation – Review short-term and long-term benefits of quitting – Increase compliance with NRT

Educational Rounds 2017-2018 40 #TEACHwebinar Case 1: approach

• Pleasant activities scheduling – Goal: self-care, alternate pleasurable activities, distraction for craving • Address “resumption thoughts” – Testing control: “I bet I can smoke just one cigarette when with friends then put them down.” – Crisis: “Ordinarily I wouldn’t smoke, but I’m under so much pressure right now.”

Educational Rounds 2017-2018 41 #TEACHwebinar Case 1: outcome

• Stopped smoking entirely

• Reported greater confidence to remain smoke-free

• Referral for treatment for depression

Educational Rounds 2017-2018 42 #TEACHwebinar Case Example 2

• Shirley (65 y.o.) presented as being highly motivated to quit smoking, but had been receiving support for smoking cessation at CAMH for 2 years and has continued to smoke 3-5 CPD. After 4 sessions motivation enhancement, Shirley quit smoking and wanted to stop treatment immediately because she achieved her goal. She agreed to attend a final session, but resisted discussing relapse prevention.

Educational Rounds 2017-2018 43 #TEACHwebinar Case 2: approach

• Psychoeducation about importance of relapse prevention

• Introduce coping strategies in case of lapse – Stop, look, and listen – Stay relaxed and calm – Renew commitment to quitting – Review situation leading up to lapse – Make recovery plan – Ask for help

Educational Rounds 2017-2018 44 #TEACHwebinar

Educational Rounds 2017-2018 45 #TEACHwebinar Remember …

• A link to the Evaluation and Post- Learning Assessment will be sent by e-mail today by 4pm EST. You will have one week to complete this Post-Learning Assessment in order to receive your Letter of Completion.

• If you participated as a group, make sure to email [email protected] with a complete list of participants by 2:00 PM EST today.

Educational Rounds 2017-2018 46 #TEACHwebinar Remember …

Next Educational Rounds Webinar:

Mindfulness Based Relapse Prevention: What is it? And why should we use it?

Wednesday, May 24, 2017 | 12:00-1:00pm EST

**Registration opening soon**

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