Don`t leave smoking out of the treatment equation

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

“The recent paper in Lancet, which was the basis for pulling the black box warning on [varenicline], was pretty convincing that there was no increase in risk [of neuropsychiatric effects],” says Benowitz, a co-author of that study.⁴

The black box warning was introduced in 2009, and indicated that use of the medication could result in suicidal thoughts and other problems. The warning was ordered removed Dec. 19, 2016. A similar warning was also removed from bupropion (Zyban), also used in smoking cessation treatment.

Varenicline is a partial agonist, Benowitz says, so it has some nicotinelike effects. At the same time, it also “blocks any kind of reward that comes from smoking a cigarette,” he says. For patients willing to participate in a smoking cessation program, [varenicline] has better efficacy than nicotine replacement alone, he says.

“When they leave treatment, smoking quit rates are better on [varenicline]” than on nicotine replacement, Benowitz says. But whether nicotine replacement or varenicline is used, it is very important to “motivate people to quit smoking when they leave treatment,” he says.

“[Varenicline] is a better choice because it won’t sustain your addiction,” says Benowitz. However, it’s more difficult to titrate the dose for varenicline than for nicotine replacement, which can even be given in double patches, as the Mayo Clinic does, for very heavy smokers, says Benowitz. Higher doses of varenicline might cause nausea, he says.

That said, however, varenicline and nicotine replacement can be used together. Typically, a patient could start on the nicotine replacement, while being treated for other substance use disorders. Once the patient is stabilized, the switch to varenicline could occur, says Benowitz.

Bupropion is also used for smoking cessation, but is not recommended for people withdrawing from benzodiazepine or alcohol use disorders.

Missing nicotine, at some level of craving, can go on for months and months after use has stopped, says Pavillon's Coon. In this way, long-term withdrawal from smoking is a reality, just as it is for alcohol and opioids. “Certain cues or environmental triggers can provoke a strong craving” for smoking, he says.

Supportive family members

Sometimes, patients may not be happy to hear that addressing their tobacco addiction will be a component of their recovery plan, Coon admits. But family members are “overwhelmingly delighted,” he says. “We hear this at the front door and in admission phone calls,” he says.

The way a program discusses smoking is important, says Coon. “We present it in an affirmative way,” he says. “We’re not sheepishly asking permission—we’re confident and hopeful.”

The bottom line, says Rutgers' McCabe, is that patients need to make behavioral changes. “Facilities that have smoke-free policies are creating a safer environment for their clients,” he says. And that doesn’t mean letting patients go outside to smoke. “What good is it to have someone not smoking in your facility, but letting them use cigarettes anyway?”

Smokers often want to stop smoking, but are scared of what it will do to them, McCabe says. He and others urge addiction treatment programs to help these individuals quit while helping them quit other substances. It will benefit their health and their overall recovery from addiction.

Alison Knopf is a freelance writer based in New York.

References

1. Knudsen HK, White WL. Smoking cessation services in addiction treatment: Challenges for organizations and the counseling workforce. Counselor 2012;13:10-14.

2. Cavazos-Rehg PA, Breslau N, Hatsukami D, et al. Smoking cessation is associated with lower rates of mood/anxiety and alcohol ue disorder. Psychol Med 2014 September;44:2523-35.

3. Hurt RD, et al. Treating nicotine addiction in patients with other addictive diseases. In Orleans CT, Slade J (eds.). Nicotine Addiction: Principles and Management. New York City: Oxford University Press; 1993.

4. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, buproprion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): A double-blind, randomized, placebo-controlled clinical trial. Lancet 2016 Jun 18; 387(10037):2507-20.

What about e-cigarettes instead?

“We don’t have vaping or e-cigarettes here,” says Brian Coon, clinical director of the smoke-free Pavillon facility. “The reason is that we want a total recovery. We don’t want someone to be engaged with a substance or behavior that promotes the addiction disease.”

Philip McCabe of the Rutgers School of Public Health agrees. “We cannot say that vaping is a safe alternative because it is not being regulated by the FDA,” he says. “Most of the materials come from the vape shops where you have a young person mixing something up in the back, with a lot of toxins and chemicals.”

In addition, for other patients who are quitting smoking using nicotine replacement therapy and/or varenicline, vaping becomes a “visual trigger,” McCabe explains. Finally, there are states that don’t allow vaping even indoors. “People misunderstand, they think you can use this product anywhere. You can’t,” he says.

Young people are very vulnerable in early recovery and they may start vaping if they see others doing it, says McCabe. Treatment center policy needs to address the issue so that all clients and staff are informed of the risks, and it is not ignored or seen as a personal choice to use e-cigarettes.

The surgeon general's warning on the dangers of vaping for young people can be found here.

However, University of California San Francisco professor Neal L. Benowitz thinks that vaping is a good way to reduce smoking. “If you were to ask the question in Europe, they use vaping very successfully in smoking cessation,” he says. “It’s much less hazardous than cigarette smoking. The only question is whether over time they can get off all cigarettes including e-cigarettes. If people fail at other treatments and are willing to use e-cigarettes, I would support that.”