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Don't leave smoking out of the treatment equation

January 23, 2017
by Alison Knopf, Contributing Writer
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For patients in treatment for addiction to substances, telling them to stop smoking to avoid cancer, for example, might not work. They already have engaged in risky substance use, with adverse effects on their bodies. However, nicotine addiction is very real, and smoking when combined with alcoholism leads to an increase in head and neck cancers, as well as esophageal cancer, explains Neal L. Benowitz, MD, professor of medicine and bioengineering and therapeutic sciences and chief of the division of clinical pharmacology at the University of California San Francisco.

“Every psychiatric patient who is a smoker needs to be treated,” Benowitz tells Addiction Professional. “We all know that patients with mental illness don’t live as long as other people. This is true for substance use disorder as well.”

In addition to quitting “cold turkey,” which is not really a treatment, popular approaches for smoking cessation include nicotine replacement therapy (NRT), such as the nicotine patch, and the drug varenicline (Chantix). Varenicline, as of the end of 2016, no longer requires a “black box” label warning about neuropsychiatric effects. This could make it even more attractive as an aid in smoking cessation, and one of several potentially useful tools for addiction treatment centers.

Part of recovery

There should be no question about treating a patient who comes into a program for a substance use disorder and is also a smoker, says Brian Coon, clinical director of Pavillon in Mill Spring, N.C. But this is not looked at as “quitting” smoking or smoking “cessation” at the North Carolina treatment center. Rather, it is seen as part of recovery, and this means tapering from nicotine using NRT.

“The negative physical impacts of smoking and tobacco use are well known,” says Coon. Compromised respiratory function, at the least, can impede well-being.

“We address this from a recovery framework,” Coon tells Addiction Professional. “We’re promoting recovery with respect to health and wellness. So we help our patients understand that, and we add the tobacco issue into their whole recovery.”

Coon adds, “We like to have the whole nicotine taper completed” during treatment. Nicotine withdrawal symptoms are greatly alleviated by tapering. It’s similar to using benzodiazepines for detoxification from alcohol, or buprenorphine to detox from opioids.

“We do have a detox here, so we can manage alcohol withdrawal with benzodiazepines and opioid withdrawal with opioids,” says Coon. Nicotine withdrawal, treated with NRT such as the patch, can be done at the same time, he says, although it might take a few more days than alcohol or opioid withdrawal.

The conventional wisdom used to state that it’s harder to quit smoking and other substances at the same time. “That’s false,” says Coon. “Recovery rates are higher when you include all substances, including tobacco.”1,2

For someone who is still dependent on nicotine, additional counseling, support, craving management and fellowship are necessary, says Coon. “Wouldn’t it be strange to ignore one addiction while treating another?” he says.

Smoking is unique in some ways. While many alcoholics do not say they want to stop drinking, the vast majority of smokers do want to stop smoking, says Coon. “The willingness to quit is there,” he says. “So it’s valuable for the person who comes for addiction treatment to include recovery from nicotine, as well.”

Indeed, quitting smoking does improve recovery rates, something that treatment providers should endorse, says Philip T. McCabe, a health educator at the Rutgers School of Public Health.

“People need to change the behavioral pattern of, ‘I need something in order to feel better,’” McCabe says. “You can feel good from exercise, from laughing with a friend. But if the mindset says, ‘I’m feeling agitated, I should reach for a cigarette,’ that makes it easier for them to want to reach for something else.”

Research has shown that relapse rates are 50% greater for individuals who continue to smoke in recovery, McCabe says.3 In addition, 50% of those in recovery from alcoholism die from smoking-related illnesses, he says.

“Withdrawing from nicotine is not easy,” says McCabe. “But if they’re going to be withdrawing from many substances, why not have them withdraw at the same time while they can be monitored in your facility? Why withdraw from alcohol and opioids and have them leave your program with an addictive substance?”

Use of NRT

The first line of defense involves using nicotine replacement therapy, says McCabe. NRT can be in the form of a patch, gum, or an inhaler.

“Patients taper down from the level they’re using,” he says. “The counselor can discuss the tobacco level—if it's a pack a day, that’s about 20 milligrams of nicotine a day, so these patients would start with the higher patch level (21 milligrams) and then taper down.”

Some people question the philosophy, as they do with use of methadone and buprenorphine for opioid addiction, questionting why clinicians are treating one drug with another, says McCabe. “The distinction is that [smoked] nicotine has many toxins,” he says. Nicotine, while addicting, is not the cause of the harm that results from smoking, he says. And by gradually reducing the nicotine dose, NRT makes it possible to stop smoking.

Giving doses of nicotine that are too low will be counterproductive, says McCabe. “NRT is most successful when it is used at the correct dose and for a longer amount of time,” he says. Low doses will result in more craving, which will counteract the work being done in the recovery program, he explains.

Progress with Chantix