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Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician

4.1.4 Implications for management

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The World Health Organization (WHO) has recommended three broad strategies for assisting people to quit or reduce tobacco use⁽¹⁰⁸⁾:

1. The routine delivery for all smokers of brief opportunistic intervention by health professionals.
2. Intensive support provided as a backup for brief intervention, including quit/reduce groups, coping skills information and support.
3. Pharmacological aids.

These three strategies are discussed in the following paragraphs.

All forms of treatment may require a degree of modification to accommodate those with mental disorders who have impaired cognitive ability.

1. Brief intervention

All smokers should be asked regularly about their tobacco use and offered at least brief intervention.

The Smoking cessation guidelines for Australian general practice (2004) recommended the 5As model for brief intervention⁽⁶⁶⁾:

• Ask about smoking and keep an up-to-date record of smoking status.
• Advise smokers to stop smoking in a clear, straightforward and non-judgemental manner.
• Assess motivation to quit or reduce tobacco use.
• Assist the smoker by offering support and information about ways to quit/reduce, withdrawal symptoms, coping strategies, pharmacotherapy aids and other supports.
• Arrange follow-up if possible.

2. Support

Smokers need a range of cognitive and behavioural strategies to address their tobacco use. They may require:

• Support to plan their quitting attempt.
• Information regarding trigger situations and how to cope with them.
• Information regarding withdrawal symptoms and cravings.
• Help to identify and work through barriers to quitting.
• Relapse prevention skills.
• Coping skills.

Motivational interviewing is an effective way to help increase commitment to quitting.

The Stages of Change Model is a valuable model for assessing a person's readiness to change and suggests interventions targeted to the person's current stage in the Stage of Change. In the model the patient is at one of several stages relevant to changing their behaviour. The stages are:

• Precontemplation: the patient is not intending to change.
• Contemplation: the patient is thinking about changing.
• Determination: the patient has decided to change.
• Action: the patient is taking active steps towards changing.
• Maintenance: the changed behaviour has been established.
• Relapse: the patient has reverted to the previous behaviour.

Each stage requires a different intervention from the clinician.

For further information concerning motivational interviewing and stages of change models, please refer to:

Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting⁽¹¹⁶⁾:

http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/TheGreenBook/RACGPgreenbook2nd.pdf

3. Pharmacological aids

Nicotine replacement therapy

Nicotine replacement therapy (NRT) aims to replace some of the nicotine obtained from cigarettes. This reduces physical withdrawal symptoms when stopping smoking, helps the person resist the urge to smoke⁽⁸⁴⁾ and is acceptable in those with mental disorders****^{(93, 96)}:

• It is available in patches, lozenges, inhalers, sublingual tablets and gum.
• It does not contain other toxic substances found in cigarettes, such as tar and carbon monoxide.
• It does not produce the dramatic surges of plasma nicotine concentrations.
• It does not produce dependence.
• It has been shown to increase quit rates by approximately 1.5-2 times, regardless of the setting⁽¹¹⁷⁾.

Combination NRT or high dose NRT

People who are heavy smokers (smoke more than 20 cigarettes a day) can use combined treatments if they are still experiencing withdrawal symptoms and are unable to quit using a single type of NRT. For example, using a combination of a patch with gum, lozenge or inhaler may be more effective.

NRT is contraindicated and medical advice is recommended for people who;

• Have had a recent heart attack or stroke.
• Have ischaemic heart disease with current active angina.
• Experience cardiac arrhythmias.
• Are under the age of 12 years.

In addition, specific products are not recommended for some people, including:

• Patches: for those with severe skin disease or an allergy to the patch.
• Lozenges: for those with phenylketonuria.
• Inhalers: for those who are hypersensitive to menthol.
• Gum: for those who have difficulties chewing gum⁽⁸⁴⁾.

NRT for pregnant women and nursing mothers is indicated with precaution and medical advice should be sought regarding the appropriate product and dosage.

Bupropion (Zyban)

Bupropion is a non-nicotine oral therapy to assist smoking cessation. Its mechanisms of action are still unclear; however, it is thought to inhibit the reuptake of noradrenaline and dopamine. It has been shown to reduce the withdrawal symptoms associated with stopping smoking. In a number of clinical trials, bupropion demonstrated a significant effect in increasing long-term abstinence from smoking⁽⁶⁶⁾ as well as proving its effectiveness and acceptability for use in those with mental disorders****^{(94-97, 99)}.

The greatest risk associated with bupropion use is the lowering of the seizure threshold. Therefore, it should not be used by people with a predisposing risk factor for seizures unless the potential benefit of smoking cessation outweighs the increased risk of seizure^{(66, 108)}. Predisposing risk factors for seizure include:

• Any seizure disorder, past or current.
• Concomitant use of medications known to lower seizure threshold, for example, antipsychotics, antidepressants (including SSRIs and tricyclics), antimalarials, tramadol, theophylline, systemic steroids, quinolones, sedating antihistamines^x.
• Excessive alcohol or benzodiazepine consumption^x.
• Withdrawal from alcohol or benzodiazepines.
• History of recent head injury.
• Diabetes treated with oral hypoglycaemics or insulin.
• Use of stimulants or anorectic products.
• Known central nervous system tumours.

In addition, major drug interactions occur with monoamine oxidase inhibitors (MAO-I) (both reversible and non-reversible). Therefore, bupropion should be avoided if these have been taken within the last 14 days.

Bupropion is further contraindicated, or its use needs be taken under strict consideration, in the following situations:

• Allergy to bupropion.
• Current or previous history of anorexia nervosa.
• Pregnant or breast-feeding women.
• Opioid dependence.
• Bipolar affective disorder, psychosis.
• Cardiac disease, hypertension.
• Renal disease.
• Liver disease.

For full prescribing information on bupropion, please see the Pharmaceutical Benefit Scheme (PBS) website:

http://www.pbs.gov.au/html/healthpro/home

Varenicline (Chantix/Champix)

Varenicline is a new non-nicotine oral therapy to assist smoking cessation and is the first approved nicotinic receptor partial agonist. It has been shown to be an efficacious and well-tolerated smokingcessation pharmacotherapy that is superior to both placebo and bupropion in helping to maintain longterm abstinence from cigarettes***⁽¹¹⁸⁾.

Varenicline interactions with other drugs appear to be minimal. However, the safety of the combination of varenicline and buproprion has not been established. The combination of varenicline and NRT has caused the discontinuation of treatment due to side effects such as nausea, headache, vomiting, dizziness dyspepsia and fatigue and should not be used.

The most common side effect of varenicline is nausea. This has been described as mild to moderate and often transient.

Varenicline is contraindicated, or its use needs be taken under strict consideration, in the following situations:

• Renal disease.
• Pregnant or breast-feeding women.

For full prescribing information on varenicline, please see the PBS website:

http://www.pbs.gov.au/html/healthpro/home

Complementary therapies

There is little evidence to suggest that complementary or alternative therapies such as acupuncture or hypnotherapy are effective in the management of smoking cessation.

There is no consistent evidence that shows that acupuncture (or any particular acupuncture technique) is superior in comparison to no treatment, other anti-smoking interventions, or sham acupuncture in the prevention of smoking⁽⁸¹⁾.

Different types of hypnotherapy are used to try and help people quit smoking. Some methods try to weaken people's desire to smoke, strengthen their will to quit, or help them concentrate on a quit program. There are conflicting results for the effectiveness of hypnotherapy compared to no treatment or to advice against smoking. Hypnotherapy has not been shown to have a greater effect on quit rates than other interventions or no treatment at all.

For further information please consult:

Smoking cessation guidelines for Australian general practice⁽⁶⁶⁾:

http://www.quitsa.org.au/cms_resources/documents/AustralianGeneralPracticeGuidelineHandbook.pdf

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