Nicotine Dependence: a Chronic Disease

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Nicotine Dependence a Chronic Disease

• Chronic Disease Epidemiology, Room 115
• November 25, 2008
• Catherine A. Martin, MD
• cmartin_at_uky.edu

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Outline

• Scope of the problem
• Primary secondary and tertiary prevention
• Understanding Nicotine Dependence as a Chronic
  Disease
• Applications to Tobacco Smoking Prevention and
  Cessation
• Additional thoughts on other substance use

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Importance in Kentucky

• Cigarette smoking is the greatest cause of
  preventable death and disability in the United
  States Centers for Disease Control and
  Prevention, 1993
• Kentucky has the highest lung cancer death rate
  in the U.S. Expected lung cancer deaths in
  Kentucky in 2006 (3,500) rival that of
  Massachusetts (3,790), a state with more than 50
  percent more residents (American Cancer Society,
  2006).

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A Pediatric Epidemic

• The modal age for starting tobacco use is between
  11 and 15.
• Early initiation of cigarette smoking is
  associated with increased frequency and
  persistence of use even in the case of early,
  very light, experimental use1.
• 80 of adult smokers started smoking in early and
  mid adolescence.
• Only 5 of adolescent smokers view themselves as
  smokers in 5 years, while 75 are actually
  smoking 8 years later2.

1 Chassin et al., 1990 2 Sussman et al.,1999
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Significance of Adolescent Tobacco Use

• Adolescents smoke about 1.1 billion packs of
  cigarettes a year
• 200 billion dollars in future healthcare costs
• For example, the onset of smoking in adolescence
  is associated with increased risk of lung cancer
  because of physiological changes that are not
  seen in later onset smokers1.
• Nicotine has been identified as a potential
  gateway to other drug use

• 1 Doll Peto, 1976 Hegmann et al., 1993 and
  Wiencke et al., 1999

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Primary Prevention

• Primary prevention avoids the development of a
  disease. Most population-based health promotion
  activities are primary preventive measures.

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Secondary Prevention

• Secondary prevention activities are aimed at
  early disease detection, thereby increasing
  opportunities for interventions to prevent
  progression of the disease and emergence of
  symptoms.

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Tertiary Prevention

• Tertiary prevention reduces the negative impact
  of an already established disease by restoring
  function and reducing disease-related
  complications.

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A Child Psychiatrist's Perspective

• Individual
• Family
• Peers
• School
• Community

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What is addiction

• Genetic
• Learned
• Brain disease

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Drug Addiction Is Learned

• Explicit Memory
• consciously recalled memories
• Implicit Memory
• Operant conditioning can be defined as a type of
  learning in which voluntary (controllable
  non-reflexive) behavior is strengthened if it is
  reinforced and weakened if it is punished (or not
  reinforced).
• Classical conditioning a stimulus acquires the
  capacity to evoke a reflexive response that was
  originally evoked by a different stimulus.

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• Drug Addiction
• A Brain Disease

• Addicts are
• Tolerant
• physically dependent
• psychologically dependent
• Addiction is a chronic, relapsing disorder
• Relapse can occur long after drugs are gone from
  the body
• Loss of control of drug-taking behavior
• Overwhelming compulsion to take drugs
• Craving when drugs not available

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Psychoactive Effects of Nicotine

• Increase in dopamine release in the CNS
• Stimulates the pleasure and reward centers
• Increase in Glutamate, GABA, ß-Endorphin
• Reduces anxiety, enhances concentration, reduces
  appetite, activates pleasure and reward centers

Arizona Smokers HelplineASHLine.org
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• Activation of the Brain Reward Pathway

• Teaches us to repeat the behavior that
  activated it
• i.e., its reinforcing
• Release of the neurotransmitter dopamine
  is an essential step

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• Withdrawal

• Behavioral and physiological signs produced
  when a physically dependent person stops taking
  drugs
• Withdrawal signs vary across drug classes
• Symptoms are often the opposite of a drugs
  effects
• Craving is a symptom produced by the brain of
  an addict in withdrawal

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Nicotine Withdrawal

• Peak 3 -5 days after you quit and may disappear
  after 2 weeks,some may persist for several
  months.
• Headaches
• Sore throat, coughing, and signs of a cold
• Tension and craving
• Tingling in the hands and feet
• Sweating
• Abdominal cramps, nausea
• Inattention
• Weight gain

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A Pathway for Reward
Prefrontal cortex
Nucleus accumbens
Ventral tegmental area
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The reward pathway

• ventral tegmental area
• the nucleus accumbens, and
• the prefrontal cortex.
• The neurons of the VTA contain dopamine, which is
  released in the nucleus accumbens and in the
  prefrontal cortex

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Effects of Nicotine on Dopamine Levels
Source Di Chiara and Imperato
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And Food and Methamphetamine
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Addiction Is Like Many Common Chronic Diseases

• Begins with voluntary behaviors
• Results in biological changes
• There is no cure
• Medications can be useful treatments
• Requires lifestyle changes to control

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Primary Prevention

• Population-based health promotion activities
• School based
• Community

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A Comprehensive Community Approach

• Adopt and enforce local and statewide policies
• School policies
• Tobacco tax increases
• Restrictions on commercial access to tobacco by
  youth
• Smoke-free public places

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A Comprehensive Community Approach

• Use evidence-based anti-tobacco curricula in
  grades K-12
• Counter pro-tobacco norms through a high-quality
  media campaign
• (do not lecturethis is your brain on drugs vs
  high sensation seekinghike with the youth
  groupdont smoke

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Center for Tobacco-Free Kids, 2001
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Secondary Prevention

• Screen
• Self-report
• Biological measures

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Adolescent Fagerstrom
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piCo Smokerlyzer Breath Carbon Monoxide
Monitor
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Semi-Quantitative Urine Cotinine Test NicAlertTM
in vitro diagnostic semi-quantitative
determination of cotinine in urine to determine
if an individual has been exposed to tobacco
products
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Treatment Overview

• Individual
• Counseling
• Pharmacotherapy
• Choosing a quit date
• High relapse periods 2 weeks and 2 months
• Slip get back on track, relapse- try again
• Regular monitoring
• Work with the family
• Impacting the community
• What is primary, secondary and tertiary
  prevention?

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Tertiary Prevention

• Medication
• Behavioral Management

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Tobacco Treatment Menu

• NRT
• Primary Care Referral
• Cooper Clayton at Health Department or you could
  become a trainer
• 1-800-QUIT-NOW
• UK Health Care is supporting vouchers for NRT for
  UK Employees and their families
• One of the hardest disorders to treat

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Treatment Strategies In the Clinic Setting

• AMA-CDC protocol for healthcare settings
• 4 brief, clinic-based, 1-on-1 sessions with
  health professional
• Coping skills, awareness of tobacco use, quit
  date
• Not evaluated in adolescents

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Treatment Strategies Five As
Fiore et al., 2000
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Treatment Strategies 5 Rs
Fiore et al., 2000
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Treatment Strategies A Family Involvement

• Encourage parents to establish no-smoking
  expectations and home policies
• Parental disapproval of smoking was more
  effective in discouraging progression to
  established smoking than parental non-smoking and
  even attenuated the effect of peer smoking.
• If adolescents perceived parents becoming more
  lenient toward smoking, they were more likely to
  progress to become established smokers .

Sargent Dalton, 2001
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Family

• BTC video

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Treatment Strategies Medications (Adults)

• FDA approved medications
• Nicotine replacement therapies
• (e.g., gum, lozenge, patch)
• Bupropion SR
• Varenicline
• Effective but not FDA approved
• Nortriptyline
• Clonidine most efficacy in women

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Nicotine Replacement (NRT) Administration

• Nicotine patch
• 7, 14 to 21 mg patch (can go higher with
  physician guidance)
• Patient smokes 10 cpd 21 mg daily for 6 weeks,
  then 14 mg daily for 2 weeks, then 7 mg daily for
  2 weeks, then discontinue
• Patient smokes lt10 cpd14 mg/d for 6 weeks, then
  7 mg/d for 2 weeks, then discontinue
• Watch for skin irritation
• Nicotine gum
• 2 to 4 mg
• 1 piece every 1-2 hours up to 9 per day
• Watch for irritation of oral mucosa
• Slow taper to decrease chance of relapse

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Special Populations

• Adolescents
• Psychiatric Patients
• Women
• Pregnant Women
• Rural
• Do not know enough

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Smoking Cessation in Psychiatric Patients

• 40 of adult psychiatric patients smoke
• Anxiety, mood and personality disorders have 3-6
  X smoking rate of general population
• Smoking rates are highest among schizophrenics,
  agoraphobics, panic disorder, major depression,
  PTSD
• Schizophrenics more likely to smoke high-tar
  cigarettes

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Tailor treatment

• CBT
• Tailored, intensive, therapy
• Bupropion and effect related to improvement in
  depression
• Bupropion associated with reduced relapse
• Nortriptyline
• SSRIs do not help with smoking behaviors

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Adolescent Alcohol Use

• Higher levels of use are associated with the 3
  most frequent forms of mortality among
  adolescents
• Fatal automobile or boating crashes
• Homicides
• Suicides
• 9 out of 10 adolescent automobile accidents
  involve use of alcohol

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Alcohol and Driving
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Also higher levels of adolescent alcohol use are
associated with

• Increased risk of sexually transmitted diseases
  including HIV
• Adolescent pregnancy
• Poor school performance
• Gateway to illegal drug use

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CRAFFT

• C Have you ever ridden in a Car driven by
  someone (including yourself) who was high or had
  been using alcohol or drugs?
• R DO you ever use alcohol or drugs to Relax, feel
  better about yourself, or fit in?
• A Do you ever use alcohol or drugs whie you are
  by yourself Alone?
• F Do you ever Forget things you did while using
  alcohol or drugs?
• F Do your Family or Friends ever tell you that
  you should cut down on your drinking or drug use?
• T Have you ever gotten in Trouble while you are
  using alcohol or drugs?
• What kind of prevention???

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Addiction is a Disease That Starts in Childhood
Adolescence
Percent in each age group who develop first-time
cannabis use disorder
Age at 1st diagnosis of cannabis use disorder
NIAAA National Epidemiologic Survey on Alcohol
and Related Conditions, 2003
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Treatment

• Suggests long-term Prosthetic Environment with
  continuing clear rewards/punishments for behavior
• Crowley AACAP 2002
• Emphasize trust, alliance
• Reduce anxiety not confrontational
• This is a chronic, relapsing illness

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Treatment of Substance Abuse

• Motivational Interview teachable moment
• Family-based Multisystemic multidimensional is
  working
• School, family
• Housing, transportation, psychiatric F/U,
  case-management
• Re-enforce competing, incompatible behaviors-
  school, sports, church, time with family,
  volunteer work back to the protective factors

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Can psychotropics be an adjunct?