Review Paper
a) Treatment combined modalities for individuals with Nicotine Addiction
At present, Tobacco use is a global pandemic that is nonnegligible. With 5 million tobaccorelated deaths annually, which are mainly caused by lung cancer, stroke, coronary heart
disease, and chronic obstructive pulmonary disease (Casella et al., 2010). The modalities for
treating nicotine addiction in tobacco users includes numerous methods such as
pharmacotherapy (Nicotine Replacement therapy, Bupropion, and Varenicline) and evidencebased recommendation such as cognitive-behavioral therapy (CBT), or a combination of both
methods.
A study conducted by Evins et al., (2014) showed that the combined modality treatment for
nicotine addiction patients including maintenance pharmacotherapy with varenicline and
cognitive behavioral therapy is effective in improving prolonged tobacco abstinence rates. As
a result, researchers found that participants who involved in the combination of maintenance
therapy and cognitive behavioral therapy for one year showed a less relapse rate of 35% after
the termination of a 12-week intervention, suggesting that this approach is effective and
feasible in patients with nicotine addiction (Evins et al., 2014). Other than that, another study
conducted by Pachas et al., (2012) showed a result that the combination of varenicline and
cognitive behavioral therapy had an observed significant improvement from baseline to week
12 or early termination in terms of nicotine withdrawal symptoms (individual subscales of
urge to smoke, anxiety, depression, irritability, and concentration). Moreover, according to
Fouz-Rosón and colleagues (2017), their study showed that a high intensity cognitive
behavioral therapy is believed to significantly contribute to the success of the pharmacologic
therapy with varenicline in balancing the efficacy and low adherence rates effectively.
Another recent study conducted by Arslan et al., (2021) found a significantly high number
and percentage of quitting smoking rate in participants who received combined treatment of
varenicline and CBT.
Although many recent studies showed the effectiveness of combined modality treatment for
treating nicotine addiction including varenicline and cognitive behavioral therapy, a study
conducted by Laude and colleagues (2017) has underpinned the controversy. Results of the
study showed that there was a lack of effectiveness of extended-CBT treatment combined
with varenicline in a smoking cessation program for patients with nicotine addiction. It might
be due to the intensive, regular, in-person CBT over six months produced treatment fatigue
and declined returns of the on-going treatment (Laude et al., 2017). Laude and colleagues
(2017) were then concluded that CBT treatment which combined with pharmacologic
treatment such as varenicline exceeded 26 weeks does not escalate long-term abstinence
rates, could be explicated by declined commitment caused by treatment fatigue. Similarly,
Windle et al., (2016) reviewed that higher-intensity CBT (i.e., individual, group, or telephone
therapy) do not improve the abstinence in individuals prescribed varenicline as compared to
minimal clinical intervention. Hence, the researchers did not find strong evidence that CBT is
necessary to attach with pharmacotherapy (Windle et al., 2016). Nonetheless, García-Gómez
et al., (2019) concluded that combined treatment for smoking cessation might be quite
effective in the short term, but the abstinence rates are disappointing in the following year.
b) Prescription privileges to clinical psychologists
Ever since psychology became a scientific profession, it continues to evolve and grow. Over
the past decade, arguments exist in the clinician's community regarding the prescription
privileges of clinical psychologists (Whitaker, 2016). The researcher stated that if clinical
psychologists were given the privileges in prescribing medications, the behavioral problems
of patients will be less overlooked, and physicians would also benefit by prescribing fewer
psychoactive medications that they are not adequately trained to prescribe (Whitaker, 2016).
Other than that, a comparison review by Muse and McGrath (2010) stated that
pharmacologically trained psychologists are better prepared than practitioners in other
prescribing professions, which could benefit the clients or patients as pharmacologically
trained psychologists would handle their patients with all the behavioral, mental, and
emotional conditions. Similarly, McGrath (2010) also stated that prescriptive authority for
clinical psychologists could increase access to appropriate care for the patients. Moreover,
evidence that prescribing clinical psychologists tend to prescribe medication at a low rate
than physicians do, in a way, reducing the chances of overmedication and polypharmacy
(McGrath, 2010). A study result from Linda and McGrath (2017) indicated that prescriptive
privilege of clinical psychologists is offering benefits both in the field of psychology and the
patients as the prescribing psychologists reported increased services to patients of minority
background, lower socioeconomic status, and patients from the rural area, which psychiatric
service is scarce.
In contrast, there are also controversies against the prescriptive privilege of clinical
psychologists over the debate. The major concern of the argument is that the combination of
psychotherapy medications would have harmed the patients (Whitaker, 2016). As a result,
patients might be very dependent on medications, and it could reduce patients' ability to
obtain effective adaptive behavioral and thinking patterns which they could access through
psychotherapy (Whitaker, 2016). To support the argument, the American Psychiatric
Association is concerning the patient's safety in providing prescriptive privileges for clinical
psychologists who did not go through proper training to prescribe medicine (Levin, 2017).
Furthermore, to protect patients' safety, prescribing law of the United State of America
restricted psychologists' scope of practice (Moran, 2014). Due to the lack of relevant
educational background in prescribing medications, psychologists are restricted in
prescribing medicines unless they completing minimum educational and training
requirements. Prescribing psychologists are also required to collaborate with a physician in
treating patients with mental illness (Moran, 2014).
c) Personal stance on prescription privilege of clinical psychologists
As for my stance towards the prescription privilege of clinical psychologists, I am supporting
this issue as it may aid in treating patients from minority backgrounds where psychiatric
service is meager and insufficient. Like a shred of evidence, few studies reported the
reduction of psychiatrists when patients are desperate to seek psychoactive medication
consultants (McGrath, 2010; Linda & McGrath, 2017; Shafron, 2014).
Other than that, I think that clinical psychologists should be providing prescriptive privilege
if they were completing relevant educational and training requirements regarding
pharmacology. It is believed that pharmacologic training and didactic materials are sufficient
for clinical psychologists to gain the prescriptive privilege. To support the statement, the
result of a comparison review by Muse and McGrath (2010) showed that pharmacologically
trained psychologists are exposed to an intensive pedagogic material that is relevant to the
incorporation of pharmacotherapy in the clinical treatment of mental, behavioral, and
emotional conditions. Hence, the researchers think that there is nothing to prevent a clinical
psychologist with well-trained in pharmacology to prescribe psychoactive medications.
However, clinical psychologists could obtain prescriptive privileges with conditions, such as
completing the doctorate program. This is to ensure and beneficiating the treatment process
of the patients.
Research questions
1. Is combined modalities treatment effective in treating patients with nicotine addiction in
the Malaysian context?
2. What are the advantages and disadvantages of the prescriptive privilege of clinical
psychologists in Malaysia?
3. Is Malaysia's clinical psychology education requirements sufficient for the practitioners to
obtain prescriptive privilege?
Conclusion
To summarize this assignment, it is a review paper discussing the effectiveness of combined
modality treatment in treating nicotine addiction patients. As studies reported, combined
therapy is effective to treat patients with nicotine addiction as compared to pharmacologic
and evidence-based treatment alone. However, in my humble opinion, I think that we should
consider the uniqueness of different patients before the treatment plans can be written out. As
therapies are not a one-size-fits-all theory, we should be more aware of the different
conditions of the patients.
Lastly, this review paper also discussed the controversies of the prescriptive privilege of
clinical psychologists in pharmacotherapy. Psychologists need to receive appropriate training
and educational study before even talked about the prescriptive privilege. The authorities
should be more careful in the decision-making as it will be affecting the effectiveness of
patients' treatment process.
References
Arslan, Y., Öcal, N., Çağın, A., Doğan, D., & Taşçı, C. (2021). The success of smoking
cessation treatments: The Gulhane experience. Addicta: The Turkish Journal on
Addictions, 8(1), 8-15. doi: 10.5152/ADDICTA.2021.21041
Evins, A. E., Cather, C., Pratt, S. A., Pachas, G. N., Hoeppner, S. S., Goff, D. C., Achtyes, E.
D., Ayer, D., & Schoenfeld, D. A. (2014). Maintenance treatment with varenicline for
smoking cessation in patients with schizophrenia and bipolar disorder. JAMA, 311(2),
145-154. doi: 10.1001/jama.2013.285113
Fouz-Rosón, N., Montemayor-Rubio, T., Almadana-Pacheco, V., Montserrat-García, S.,
Gómez-Bastero, A. P., Romero-Muñoz, C., & Polo-Padillo, J. (2017). Effect of 0.5
mg versus 1 mg varenicline for smoking cessation: a randomized controlled trial.
Addiction, 112(9), 1610–1619. doi:10.1111/add.13855
García-Gómez, L., Hernández-Pérez, A., Noé-Díaz, V., Riesco-Miranda, J. A., & JiménezRuiz, C. (2019). Smoking cessation treatment: Current psychological and
pharmacological options. Rev Invest Clin, 71, 7-16.
Heiby, E. M. (2010). Concerns about substandard training for prescription privileges for
psychologists. Journal of Clinical Psychology, 66(1), 104-111.
doi:10.1002/jclp.20650
Laude, J. R., Bailey, S. R., Crew, E., Varady, A., Lembke, A., McFall, D., … David, S. P.
(2017). Extended treatment for cigarette smoking cessation: a randomized control
trial. Addiction, 112(8), 1451–1459. doi:10.1111/add.13806
Levin, A. (2017). Psychologist prescribing bills defeated in many states. Psychiatric News.
https://doi.org/10.1176/appi.pn.2017.8a2
Linda, W. P., & McGrath, R. E. (2017). The current status of prescribing psychologists:
Practice patterns and medical professional evaluations. Professional Psychology:
Research and Practice, 48(1), 38-45. http://dx.doi.org/10.1037/pro000011838
McGrath, R. E. (2010). Prescriptive authority for psychologists. Annual Review of Clinical
Psychology, 6(1), 21–47. doi:10.1146/annurev-clinpsy-090209-151448
Moran, M. (2014). Prescribing law tightly restricts psychologists’ scope of practice.
Psychiatric News. https://doi.org/10.1176/appi.pn.2014.8a2
Muse, M., & McGrath, R. E. (2010). Training comparison among three professions
prescribing psychoactive medications: psychiatric nurse practitioners, physicians, and
pharmacologically trained psychologists. Journal of Clinical Psychology, 66(1), 96103. doi:10.1002/jclp.20623
Pachas, G. N., Cather, C., Pratt, S. I., Hoeppner, B., Nino, J., Carlini, S. V., … Evins, A. E.
(2012). Varenicline for smoking cessation in schizophrenia: Safety and
effectiveness in a 12-week open-label trial. Journal of Dual Diagnosis, 8(2), 117–
125. doi:10.1080/15504263.2012.663675
Shafron, G. R. (2014). Prescription privileges and the ethics code: A modern look into the
right to prescribe among applied psychologists. Graduate Student Journal of
Psychology, 15, 95-102.
Windle, S. B., Filion, K. B., Mancini, J. G., Adye-White, L., Joseph, L., Gore, G. C., …
Eisenberg, M. J. (2016). Combination therapies for smoking cessation. American
Journal of Preventive Medicine, 51(6), 1060–1071. doi:10.1016/j.amepre.2016.07.0