What is the best management approach for a 59-year-old man with a history of substance abuse on Suboxone (buprenorphine/naloxone) treatment, myocardial infarction (MI), possible diabetes, chronic obstructive pulmonary disease (COPD), and impaired renal function, who is a current cigarette smoker?

Management of Tobacco Use in a Patient with Complex Medical History

For this 59-year-old man with substance abuse history on Suboxone, previous MI, possible diabetes, COPD, and current smoking, varenicline should be initiated as first-line pharmacotherapy for smoking cessation along with behavioral counseling.

Smoking Cessation as Primary Intervention

Smoking cessation is the most critical intervention for this patient given his complex medical history:

• History of MI (cardiovascular disease)
• Possible COPD (respiratory disease)
• Current substance abuse treatment (on Suboxone)
• Possible diabetes

Pharmacotherapy Options

1. First-line option: Varenicline (Chantix)

   • Recommended as the preferred treatment due to superior efficacy 1
   • Dosing:
     • Begin 1 week before target quit date
     • Days 1-3: 0.5 mg once daily
     • Days 4-7: 0.5 mg twice daily
     • Week 2-12: 1 mg twice daily 2
   • Consider dose reduction if patient experiences adverse effects 3
   • Monitor for neuropsychiatric symptoms given history of substance abuse 2

2. Alternative options if varenicline is not tolerated:

   • Bupropion SR (may be particularly useful given substance abuse history) 1
   • Nicotine replacement therapy (NRT) options:
     • Patch plus short-acting NRT (gum or lozenge) for breakthrough cravings 3
     • Consider longer course of NRT (>14 weeks) for better efficacy 3

Behavioral Support Components

• Implement the 5 A's approach: Ask, Advise, Assess, Assist, Arrange 1
• Provide motivational interviewing focused on:
  • Benefits of quitting for cardiovascular health (post-MI)
  • Benefits for respiratory symptoms (COPD)
  • How quitting supports recovery from substance abuse
• Schedule regular follow-up appointments to monitor progress 1
• Refer to specialized counseling services or quitline (1-800-QUIT-NOW) 1

Management of Comorbid Conditions

COPD Management

• Optimize bronchodilator therapy based on symptom severity:
  • For moderate disease: Regular short-acting β2 agonist and/or anticholinergic 3
  • For severe disease: Combination therapy with regular β2 agonist and anticholinergic 3
• Consider corticosteroid trial to assess response 3
• Assess inhaler technique and select appropriate device 3
• Consider pulmonary rehabilitation program 3

Cardiovascular Risk Management

• Continue appropriate post-MI medications (not mentioned in history)
• Beta-blockers should be continued despite COPD history, as they are associated with improved mortality in post-MI patients with COPD 4
• Monitor blood pressure and lipids
• Address other cardiovascular risk factors (weight, nutrition)

Substance Abuse Treatment

• Continue Suboxone (buprenorphine/naloxone) treatment
• Buprenorphine is associated with lower cardiac risks compared to methadone 5
• Recognize that substance dependence requires chronic disease management approach 6
• Be aware that many patients with substance use disorders perceive smoking as less serious than other substances 7

Implementation and Follow-up

1. Initial visit:

   • Start varenicline with dosing schedule as outlined above
   • Set a quit date within 1-2 weeks
   • Provide behavioral counseling
   • Optimize COPD treatment

2. Follow-up within 1-2 weeks:

   • Assess for medication side effects
   • Reinforce quit attempt
   • Address withdrawal symptoms

3. Regular monitoring:

   • Continue follow-up appointments to support cessation
   • Monitor for neuropsychiatric symptoms with varenicline
   • Assess COPD symptoms and adjust treatment as needed
   • Monitor cardiovascular risk factors

Important Considerations

• Patients with substance use disorders often have high smoking rates and unique barriers to quitting 7
• Smoking cessation is particularly important after MI - it's potentially the most effective preventive measure 3
• Recognize tobacco dependence as a chronic condition requiring ongoing support 1
• Consider the interaction between smoking cessation efforts and substance abuse recovery 7

By implementing this comprehensive approach focusing on smoking cessation with varenicline as the primary pharmacotherapy along with behavioral support, while managing comorbid conditions, this patient has the best chance of improving morbidity, mortality, and quality of life outcomes.