Treating Tobacco Use Disorder and Managing Other Toxic Exposures

Question 1

What is the single largest preventable cause of morbidity and mortality in the US?

Answer 1

Tobacco

Question 2

Smokers have a life expectancy at least home years shorter than for non smokers?

Answer 2

10 year

Question 3

How many deaths annually are due to smoking?

Answer 3

480,000- this includes deaths from second hand smoking

Question 4

The greatest annual mortality numbers in the US related to smoking are caused by what?

Answer 4

cancer
cardiovascular disease
respiratory disease

Question 5

List 13 health risks of smoking

Answer 5

1. Diabetes ( smokers are at 30-40% increased risk of developing diabetes compared to nonsmokers)
2. Rheumatoid arthritis
3. impaired immune system/immune function, due to high levels of tar
4. Reduced quality of life
5. problems with reproduction in men and women
6. poorer quality, slower wound healing
7. TB
8. ectopic pregnancy, preterm delivery, stillbirth, low birth weight, SIDS
9. cleft lip and cleft palate
10. ED
11. age- related macular degeneration
12. failure rate of treatment for all cancers
13. bone fractures

Question 6

What is the most common form of chemical dependence in the US?

Answer 6

Nicotine

Question 7

What % of smokers desire to quit?

Answer 7

70%

Question 8

which cancers have the clearest link to alcohol use?

Answer 8

head and neck
esophagus
liver
breast
colon/rectum

Question 9

What can excessive alcohol use increase the risk of?

Answer 9

high blood pressure
stroke
unintentional injuries
OB complications

Question 10

What does the USPHS recommend when it comes to screening for tobacco use?

Answer 10

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

Question 11

What is the criteria for lung cancer screening?

Answer 11

greater or equal to 20 pack year smoking hx
current smoker or quit in the last 15 years
btwn the ages of 50-80

Question 12

What is the Fagerstrom Test for Nicotine Dependence?

Answer 12

10 item self-report questionnaire specifically designed to measure tobacco dependence
7-10 high dependence
4-6 moderate dependence
< 4 minimal dependence

Question 13

What is the heaviness of Smoking index?

Answer 13

It is a 2 question test derived from the Fagerstrom test.

Question 14

What are the 2 questions on the Heaviness of smoking index?

Answer 14

1. Time to first cigarette after waking
2. number of cigarettes per day.

Question 15

What is considered a standard drink?

Answer 15

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

Question 15

what are the recommended limits on drinking?

Answer 15

2 or less drinks a day for men and one drink or less a day for women

Question 16

what is the definition of binge drinking?

Answer 16

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

Question 17

what is the definition of heavy alcohol use?

Answer 17

binge drinking 5 or more drinks on at least 5 days in the past month.

Question 18

what is at risk drinking?

Answer 18

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.

Question 19

What is the definition of alcohol use disorder?

Answer 19

a pattern of use that leads to impairment or distress
meets at least 2/11 criteria for a substance use disorder

Question 20

What are the different screening tools that can be used to screen for unhealthy alcohol use?

Answer 20

CAGE
AUDIT
NMASSIST
CRAFFT
TAPS
MSASQ

Question 21

when should ppl be screened for unhealthy alcohol use?

Answer 21

Annual prevention examination
family planning visits
prenatal visits
problem oriented visits
high risk groups

Question 22

What health problems does alcohol misuse put patients at?

Answer 22

anemia
osteoporosis
cognitive decline
live disease
cardiac disease
HTN

Question 23

What is TAPS?

Answer 23

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

Question 24

Vareniciline

Answer 24

1. most effective mono-therapy for patients attempting to quit smoking 2. Acts as a nicotine receptor partial agonist, meaning the medication binds to the same receptors as nicotine but less strongly pregnancy category C

Question 25

Bupropion SR

Answer 25

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

Question 26

second line medications for tobacco cessation

Answer 26

clonidine and nortriptyline

Question 27

Contraindications to Bupropion

Answer 27

use of MAOIs seizure disorder bulimia/anorexia abrupt discontinuation of ethanol or sedatives.

Question 28

Contraindications to varenicline

Answer 28

known hx of serious hypersensitivity or skin reactions to vareniciline

Question 29

What is considered first line for adolescents trying to quit smoking?

Answer 29

Counseling

Question 30

what are treatments that have not demonstrated effectiveness for smoking cessation?

Answer 30

acupunture hypnosis

Question 31

Follow up schedule for someone trying to quit smoking

Answer 31

2 weeks prior to quit date 1 week after quit date 3 months after quit date 6 months after quit date

Question 32

what are medications available for alcohol use?

Answer 32

Naltrexon Acamprosate Dilsulfiram

Question 33

Naltrexone

Answer 33

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

Question 34

Acamprosate

Answer 34

modulates glutamate neurotransmission. 2nd line medication due to dosing, 2 tablets 3 times a day most beneficial when not drinking

Question 35

Disulfiram

Answer 35

250mg PO daily aversion agent. high rates of noncompliance

Question 36

off label medications for alcohol use

Answer 36

gabapentin 300-600mg PO 2-3x/day Topiramate 100-150 mg PO BID

Question 37

Medications for opioid use

Answer 37

naltrexone Buprenorphine Methadone

Question 38

Naltrexone when using for opioid use disorder

Answer 38

50mg PO daily to transition to naltrexone 380mg injections every 4 weeks. blocks euphoric and sedating effects of opioids, can reduce cravings

Question 39

buprenorphine when using for opioid use disorder

Answer 39

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

Question 40

methadone

Answer 40

full opioid agonist with long 1/2 life. must be dispensed through an opioid treatment program when used for opioid use disorder

Question 41

5 As of behavioral change

Answer 41

Assess Advise Agree Assist Arrange

Question 42

5A of tobacco cessation

Answer 42

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

Question 43

motivational interviewing to help with tobacco cessation

Answer 43

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

Question 44

5Rs of motivational interviewing

Answer 44

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.

Question 45

When to refer to specialist for addition medicine

Answer 45

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.

Question 46

Grade A recommendations for tobacco use

Answer 46

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.

Question 47

Grade B recommendations for unhealthy drug use

Answer 47

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.

Question 48

Grade B recommendations for alcohol use

Answer 48

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