#TEACHwebinar
Educational Rounds 2017-2018 1
TEACH Educational Rounds
Relapse Prevention in Tobacco Dependence
Treatment
Faculty Presenter(s): Dr. Sarah Dermody PhD
CAMH, CIHR Postdoctoral Fellow Oregon State University, Courtesy Faculty
Appointment
Date: April 12, 2017
#TEACHwebinar
Educational Rounds 2017-2018 2
Requirements:
1. Registered for the webinar & complete Pre- Learning Assessment
2. Sign-in to view/participant in the live webinar session using your FIRST and LAST name.
3. Complete Evaluation and Post- Learning Assessment
Interested in Obtaining a Letter of Completion for this TEACH Educational Rounds?
#TEACHwebinar
Educational Rounds 2017-2018 3
• These webinars are being live tweeted on Twitter
• Follow the CAMH Nicotine Dependence Service on Twitter:
@PSQuitSmoking
• To follow the live tweeting or to post your questions or comments using Twitter follow: #TEACHwebinar
#TEACHwebinar
Educational Rounds 2017-2018 4
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.
#TEACHwebinar
Educational Rounds 2017-2018 5
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.
Disclosures
#TEACHwebinar
Educational Rounds 2017-2018 6
No disclosures to report
Dr. Sarah Dermody
Disclosures
#TEACHwebinar
Educational Rounds 2017-2018 7
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.
TEACH Curriculum Development
#TEACHwebinar
Educational Rounds 2017-2018 8
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.
Disclaimer
#TEACHwebinar
Educational Rounds 2017-2018 9
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
#TEACHwebinar
Educational Rounds 2017-2018 10
Stages of Change
#TEACHwebinar
Educational Rounds 2017-2018 11
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
#TEACHwebinar
Educational Rounds 2017-2018 12
• 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
What is a smoking relapse?
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.
#TEACHwebinar
Educational Rounds 2017-2018 13
• Referred to as a “slip” or “lapse”
• Lapse vs relapse distinction
– Promotes continuous vs binary model
– Behavior change is a continuous process
What about “just one puff”?
#TEACHwebinar
Educational Rounds 2017-2018 14
• 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
Why care about relapse?
So why is this so important?!?
#TEACHwebinar
Educational Rounds 2017-2018 15
• High relapse rates common – particularly in 1st week – 12-month relapse rates following unaided tobacco cessation: ~90%
Relapse is Prevalent
Hughes JR, Naud S. (2004) Shape of the relapse curve and long-term outcomes among untreated smokers. Addiction, 99: 29-33.
#TEACHwebinar
Educational Rounds 2017-2018 16
• 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
Tobacco use disorder
#TEACHwebinar
Educational Rounds 2017-2018 17
• Tolerance
• Withdrawal – tobacco or nicotine is taken to relieve or avoid symptoms – Irritability, frustration, anger
– Anxiety
– Difficulty concentrating
– Increased appetite
– Restlessness
– Depressed mood
– Insomnia
Tobacco use disorder
#TEACHwebinar
Educational Rounds 2017-2018 18
• 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
Tobacco use disorder
#TEACHwebinar
Educational Rounds 2017-2018 19
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!”
#TEACHwebinar
Educational Rounds 2017-2018 20
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
#TEACHwebinar
Educational Rounds 2017-2018 21
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
#TEACHwebinar
Educational Rounds 2017-2018 22
Cognitive-Behavioral Model of Relapse
Larimer, Palmer, & Marlatt, 1999
#TEACHwebinar
Educational Rounds 2017-2018 23
Global risk factors
#TEACHwebinar
Educational Rounds 2017-2018 24
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)
#TEACHwebinar
Educational Rounds 2017-2018 25
• Goals: – Anticipate when lapses are likely to occur and
avoid them
– Learn to cope with a lapse to prevent relapse
RP Treatment
#TEACHwebinar
Educational Rounds 2017-2018 26
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
#TEACHwebinar
Educational Rounds 2017-2018 27
• 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
Behavioral skills training
#TEACHwebinar
Educational Rounds 2017-2018 28
• Help cope with lapse to prevent further relapse
– Relaxation techniques
– Problem solving skills
– Social support
Behavioural skills training
#TEACHwebinar
Educational Rounds 2017-2018 29
• 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
Exposure therapy
#TEACHwebinar
Educational Rounds 2017-2018 30
Exposure therapy
#TEACHwebinar
Educational Rounds 2017-2018 31
• 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
Exposure therapy
#TEACHwebinar
Educational Rounds 2017-2018 32
• 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
Implementing RP Implementing RP
#TEACHwebinar
Educational Rounds 2017-2018 33
• 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
Implementing RP
#TEACHwebinar
Educational Rounds 2017-2018 34
• 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
Family involvement
#TEACHwebinar
Educational Rounds 2017-2018 35
• Limitations
– Family members need to be willing to be involved
– Smoking family members can be triggers
Family involvement
#TEACHwebinar
Educational Rounds 2017-2018 36
• 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
So… how do we put this together??
#TEACHwebinar
Educational Rounds 2017-2018 37
• 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
Conclusions
#TEACHwebinar
Educational Rounds 2017-2018 38
Questions?
#TEACHwebinar
Educational Rounds 2017-2018 39
• 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.
Case Example 1
#TEACHwebinar
Educational Rounds 2017-2018 40
• 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
Case 1: approach
#TEACHwebinar
Educational Rounds 2017-2018 41
• 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.”
Case 1: approach
#TEACHwebinar
Educational Rounds 2017-2018 42
• Stopped smoking entirely
• Reported greater confidence to remain smoke-free
• Referral for treatment for depression
Case 1: outcome
#TEACHwebinar
Educational Rounds 2017-2018 43
• 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.
Case Example 2
#TEACHwebinar
Educational Rounds 2017-2018 44
• 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
Case 2: approach
#TEACHwebinar
Educational Rounds 2017-2018 45
#TEACHwebinar
Educational Rounds 2017-2018 46
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.
#TEACHwebinar
Educational Rounds 2017-2018 47
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**
#TEACHwebinar
Educational Rounds 2017-2018 48
TEACH Educational Rounds Archives:
Missed the beginning of today’s presentation?
Want to view it again?
Interested in seeing previous TEACH webinars?
No problem! View the archived webinar links on our website! How do you access the archives?
The TEACH Project records all Educational Rounds webinars for later viewing, in case you are not able to attend the live session.
In order to access the archived webinars please visit our website
www.teachproject.ca “TEACH Educational Rounds” “Archive and Self Study” (here).
#TEACHwebinar
Educational Rounds 2017-2018 49
#TEACHwebinar
Educational Rounds 2017-2018 50
Copyright
Copying or distribution of these materials is
permitted providing the following is noted on
all electronic or print versions:
© CAMH/TEACH
No modification of these materials can be
made without prior written permission of
CAMH/TEACH.