Smoking Cessation with Psychiatric Patients

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Smoking Cessation with Psychiatric Patients

• Mark Publicker, MD FASAM
• Medical Director
• Mercy Recovery Center

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Addiction

• Addiction is a cycle of spiraling dysregulation
  of brain reward systems that progressively
  increases, resulting in compulsive drug use and a
  loss of control over drug taking George Koob

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Neuroadaptation

• Drugs change the brains balance
• The brain has mechanisms to oppose this change
• The balancing action overshoots
• The stronger the drug, the higher the dosage and
  the longer the use, the more the opposing change

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Allostasis

• Change to new, vulnerable state
• Deficit states inhibition of brain reward
  circuitry
• Altered hedonic tone (Koob)
• Reward thresholds increase
• Opponent process theory
• Counteradaptive hedonic dysregulation

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Opponent process theory
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Nicotine pharmacology

• Broad distribution of receptors
• Highly lipophilic
• Nicotinic receptors - cholingergic family
• Repeated administration leads to sensitization
• Non-nicotine substances inhibit MAO-B

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Nicotine pharmacology

• Receptors located at pre-synaptic membrane
• Regulate release of neurotransmitters
• acetylcholine
• serotonin
• norepinephrine
• dopamine

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Nicotine and sleep

• Promotes increased wake time
• reduces total sleep time
• reduces REM sleep

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Nicotine and cognitive function

• Increases attention
• Increases concentration
• Increases memory
• Increases visual attention, decreases sensitivity
  to auditory stimuli

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Nicotine addiction

• Single largest cause of preventable illness and
  death
• Significant cause of increased mortality rates
  for chronically hospitalized psychiatric patients

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Nicotine addiction

• Nicotine binds to
• mesolimbic dopaminergic reward circuitry
• locus ceruleus, regulating vigilance, arousal,
  concentration and stress reactions

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Nicotine addiction

• Dopaminergic activation creates powerful pleasure
  reinforcement
• Heightened arousal with a pleasure trigger
  creates a sense of cyclical satisfaction
• Only drug used to feel normal

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Nicotine SPECT Scan
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Chronic brain adaptations
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Epidemiology

• Persons with primary psychiatric and substance
  abuse disorders 2-3 times more likely to smoke
  than general population
• They consume half of all cigarettes in US
• 2-3 times more likely to develop tobacco-related
  medical consequences

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Smoking and risk of psychiatric disorders

• Smokers at elevated risk of depression,
  alcoholism, drug addiction, panic disorder
  schizophrenia, ADHD
• National Co-morbidity Survey
• Effects of smoking vary by disorder
• Current daily smoking predicts onset of major
  depressive disorder
• no variation by intensity of smoking

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Smoking and risk of psychiatric disorders

• Current smoking predicted onset of panic disorder
  and agoraphobia
• Risk of onset decreases with time for ex-smokers
• Current (but not past) smoking predicts onset of
  substance abuse disorders

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Smoking and risk of psychiatric disorders

• No increased risk for current smokers for Post
  Traumatic Stress Disorder

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Suicide

• Smoking associated with higher risk
• May be related to lower brain serotonin
• Acute smoking increases release serotonin and
  dopamine
• Chronic smoking decreases serotonin synthesis

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Suicide

• Post-mortem studies smokers vs non-smokers
• Less serotonin and 5-HIAA and higher serotonin
  receptor density in smokers
• Findings of suicide completers and suggest
  vulnerability to suicide independent of
  psychiatric diagnosis
• Smoking lowers serotonin and increases
  depresseion depression lowers serotonin and
  increases smoking

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Adolescent psychiatric co-morbidity

• Early onset (under 13) robust predictor of
  substance abuse and psychopathology
• Parental history of substance abuse disorders
  predictive
• Disruptive behavior disorders
• ODD, CD, ADD/ADHD

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Effects prenatal exposure

• 25 of all pregnancies
• Increase in disruptive behaviors in toddlers
• Increase in teen smoking
• Dose response relationship
• Dysregulation of neurodevelopment
• Higher risk for psychiatric and substance abuse
  disorders

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First line pharmacotherapies

• Reliably increase long-term abstinence
• Bupropion SR
• Nicotine gum
• Nicotine inhaler
• Nicotine patch
• Nicotine nasal spray

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Second line medication

• Identified as effective
• Can be used if first-line drugs not effective
• Nortriptyline (Pamelor)
• Clonidine (Catapres)

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Nicotine replacement products

• Stimulation of nicotinic receptors VTA leading to
  increased dopamine release
• Cochrane review doubling of cessation rates

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Nicotine replacement therapy

• In smokers, tobacco deprivation can impair
  cognitive performance
• And subsequent nicotine administration or smoking
  can reverse these deficits

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Bupropion

• Atypical antidepressant
• Effective independent of antidepressant effect
• Decreases craving
• Decreases withdrawal
• Can increase abstinence rates

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Abstinence rates bupropion /- nicotine patch
Jorenby et al. N Engl J Med 1999340 685-91
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Schizophrenia bupropion

• George Biological Psychiatry July 2002
• Decreased smoking rates vs placebo
• Positive symptoms not effected
• Negative symptoms significantly reduced
• Atypicals enhanced smoking cessation response to
  bupropion
• Well-tolerated and safe

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Adolescent ADHD and bupropion

• J Am Academy Child Adolescent Psychiatry
  February 2004
• Open label study
• Significant decrease in cigarettes smoked and 31
  completely abstinent
• No change in ADHD symptoms

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Clonidine

• Alpha-2 agonist blocks noradrenergic
  hyperactivity of locus ceruleus
• 8/9 trials showed improved cessation rates
• Blocks withdrawal syndromes
• Alcohol
• Opioids
• Nicotine

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Nortriptyline

• Tricyclic antidepressant
• Similar magnitude of effectiveness to bupropion
• Effectiveness independent of antidepressant effect

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Tobacco and psychiatric medication metabolism

• Tars metabolized in liver potent inducers of CYP
  1A2 isoenzyme
• Increases metabolism of anti-psychotics,
  antidepressants and anti-anxiety medications

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Does cessation worsen outcomes?

• No evidence of worsened outcomes in hospitalized
  psychiatric and chemically dependent patients
• Best outcomes when prohibition is coupled with
  effective pharmacotherapy

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Treatment

• Assess readiness and motivation to quit
• Promote self-responsibility and self-efficacy
• Provide a menu of choices
• Explain the role and value of pharmacotherapy
• Advise and coach in their effective use

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Zyban (bupropion)

• Antidepressant
• decreases craving
• decreases withdrawal
• can increase abstinence rates
• side effects GI, anxiety, headaches

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