Transcript Alcoholism and Smoking Background

Treating Tobacco Dependence in
Patients with Other Addictions
Richard D. Hurt, M.D.
Professor of Medicine, Mayo Clinic College of
Medicine
Director, Nicotine Dependence Center
http://ndc.mayo.edu
Smoking and Mental Illness
• 22% of people who have never been
diagnosed with a mental illness currently
smoke.
• 34.8% of people who have had been
diagnosed with a mental illness sometime
in their life currently smoke.
• 41% of people who have been diagnosed
with a mental illness In the past month
currently smoke
• 44% of all cigarettes smoked are by people
with a ‘past-month’ mental health
diagnosis.
Lasser et. Al. 2000
Nicotine Dependence and Psychiatric Disorders
U.S. Adults
• National Epidemiologic Survey on Alcohol and
Related Conditions
• Face-to-face interviews (N=43,093) to
determine co-occurrence of DSM-IV nicotine
dependence and Axis I & II psychiatric
disorders
• NIAAA Alcohol Use Disorder and Associated
Disabilities Interview Schedule – DSM-IV
• Current cigarette use = any use in past year.
Characterized on days smoked and cigarettes
usually smoked
Grant BF. Arch Gen Psychiatry 61:1107, 2004
Nicotine Dependence and Psychiatric Disorders
U.S. Adults
Total
Current smokers
Males
Females
24.9%
Nicotine dependence
13%
14%
11%
Alcohol abuse
5%
7%
3%
Alcohol dependence
3%
5%
2%
Grant BF. Arch Gen Psychiatry 61:1107, 2004
Prevalence of Psychiatric Disorders Among
Respondents with Nicotine Dependence
Alcohol use disorder
23%
Alcohol abuse
9%
Alcohol dependence
13%
Major depression
17%
Anxiety disorder
22%
Personality disorder
32%
Grant BF. Arch Gen Psychiatry 61:1107, 2004
Prevalence of Nicotine Dependence
Among Psychiatric Disorders
Alcohol use disorder
Alcohol abuse
Alcohol dependence
Drug use disorder
Drug abuse
Drug dependence
Major depression
Anxiety disorder
Personality disorder
Grant BF. Arch Gen Psychiatry 61:1107, 2004
34%
25%
45%
52%
45%
69%
30%
25%
27%
Alcoholism and Smoking
Background
• Regular smoking usually precedes
development of alcoholism
• 2-3x  in prevalence of smoking among
substance abusers
• 10x  in prevalence of alcoholism
among heavy smokers vs. nonsmokers
• Smoking alcoholics constitute 26% of
all smokers
Alcoholism and Tobacco Dependence
Bill Wilson, AA Co-founder
“A heavy, sloppy smoker all his life, he
developed emphysema in the 1960s. It
killed him. He gave his last speech to
the International AA Convention in
Miami in 1970, lifted to the platform in a
wheelchair, gasping for breath and
sucking oxygen from the tank that was
always with him.”
Robertson: Inside Alcoholics Anonymous
Mortality Following Inpatient
Addictions Treatment
Study Design
• Olmsted County patients admitted for
inpatient addictions treatment 1972-1983
• Follow-up through 1994 – Rochester
Epidemiology Project
• Vital status and death certificates
• CDC classification of alcohol or tobaccorelated cause of death
Hurt RD, et al. JAMA 275:1097, 1996
Mortality Following Inpatient
Addictions Treatment
Patient Demographics
• n=845 (65% men, 35% women)
• Mean age at admission – 41.4 years
• 78% alcohol only, 18% alcohol and
other drugs
• 75% current and 8% former smokers
• Length of follow-up/patient – 10.55.6
years (8913 pt/yrs)
Hurt RD, et al. JAMA 275:1097, 1996
Hurt RD, et al. JAMA 275:1097, 1996
Mortality Following Inpatient
Addictions Treatment
Tobacco or Alcohol Cause of Death
Percent Observed Expected
RR
Alcohol
34
73
18
4.1
Tobacco
51
109
53
2.0
Hurt RD, et al. JAMA 275:1097, 1996
Mortality Following Inpatient
Addictions Treatment
Conclusions
• High risk for premature mortality
• Tobacco-related diseases leading
cause of death
• Treating tobacco dependence is
imperative in this high risk group
Hurt RD, et al. JAMA 275:1097, 1996
Treating Alcohol and Tobacco Dependence
Simultaneously
Design
• Prospective nonrandomized controlled
trial with 1 year abstinence outcomes
• Inpatient addictions treatment unit
• Control group (n=50) – usual care
• Intervention group (n=51)
• Consultation
• Group sessions (5)
• Education sessions (5)
• Telephone follow-up
Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994
Treating Alcohol and Tobacco Dependence
Simultaneously
Substance Use History
Intervention
Control
N=51
N=50
74.5
54.0
0.031
Smoking rate
(CPD)
25.08.7
21.310.7
0.052
Smoking onset
(age)
14.63.7
16.65.6
NS
Year smoked
26.612.4
19.910.8
0.012
Alcohol only (%)
Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994
P
Treating Alcohol and Tobacco Dependence
Simultaneously
Abstinence Outcomes
Intervention
Control
N=51
N=50
No alcohol/drugs
at 1 year
68.6
66
NS
Not smoking at
dismissal
21.6
10.0
NS
Not smoking at
1 year
11.8
0
0.027
Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994
P
Treating Alcohol and Tobacco Dependence
Simultaneously
Conclusions
• 11.8% tobacco abstinence rate
acceptable but can be improved
• Study run in less than optimal
environment
• Perception that it is hard is real
• No apparent negative effect on
abstinence from alcohol or other drugs
• Unit became tobacco-free after study
Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994
Nicotine Patch Therapy in Recovering
Alcoholic Smokers
Baseline Characteristics
Recovering
Nonalcoholic
Alcoholics
(n=314)
(n=43)
P value
CPD
34.19.6
28.010.4
<0.001
FTQ
9.13.2
8.13.3
0.022
22.810.7
18.912.1
0.007
Baseline
nicotine (ng/mL)
Baseline
cotinine (ng/mL)
305.5126.7 261.28 118.8
Hurt RD, et al. Addiction 90:1541, 1995
0.049
Nicotine Patch Therapy in Recovering
Alcoholic Smokers
Conclusions
• More nicotine dependent than
nonalcoholics
• Can achieve short-term tobacco abstinence
with nicotine patch therapy
• May require more intensive intervention:
• Dose matching
• Longer treatment
•  behavioral intervention
•  relapse prevention
Hurt RD, et al. Addiction 90:1541, 1995
Nicotine Patch Therapy in Alcoholic Smokers
Demographics
Nonalcoholic Recovering
(n=281)
(n=53)
Age
Active
(n=48)
P
45.21.3
43.810.8
42.811.2
NS
% female
61
42
37
0.001
Smoking
rate (CPD)
26.49.1
30.612.1
29.811.3
0.004
FTQ
6.91.8
8.41.7
7.81.9
<0.001
Hays JT, et al. Ann Behav Med 21:244, 1999
Nicotine Patch Therapy in Alcoholic Smokers
Tobacco Abstinence Rates
70
no alcohol problem (n=281)
62.6
active alcohol problem (n=48)
58
60
54.2
past alcohol problem (n=53)
% not smoking
50
43.4
41.7
40
34
30
26.7
20
25
15.1
10
0
week 4
Hays JT, et al. Ann Behav Med 21:244, 1999
week 8
week 26
High Dose Nicotine Patch Therapy
in Heavy Smokers
Methods
• Post hoc analysis of 1039 heavy smokers (30 cpd)
• Screened for current alcohol problem with short
alcohol dependence data questionnaire
• Smokers with alcohol problems in past year were
excluded
• Nicotine patch dose – placebo, 21 mg, 35 mg, or 42
mg
• Higher nicotine patch doses were “slightly more
efficacious”
Hughes, JR, et al. Drug Alcohol Depend 71:269, 2003
High Dose Nicotine Patch Therapy
in Heavy Smokers
Past History
No problems
(n=879)
Alcohol Problems
(n=160)
Age
44
42
% men
47
66
Cigs/day
38
38
CO (ppm)
33
34
FTQ
7.9
8.3
Years smoked
26
26
Hughes, JR, et al. Drug Alcohol Depend 71:269, 2003
High Dose Nicotine Patch Therapy
in Heavy Smokers
Conclusions
• In heavy smokers with or without past
history of alcohol problems, no
difference in:
• time to lapse
• prolonged tobacco abstinence
• Thus, past history of alcohol problems
does not predict a worse outcome
Hughes, JR, et al. Drug Alcohol Depend 71:269, 2003
Bupropion for Smokers with past History of
Alcoholism or Depression
Results
• Neither PHMDD nor alcoholism
associated with abstinence at EOT
(p=0.93) or 1 year (p=0.23)
• Dose response effect for bupropion
at EOT (p<0.001) and 1 year (p=0.02)
Hayford KE, et al. Br J Psychiatry 174:173, 1999
Pharmacologic Relapse Prevention for
Recovering Alcoholic Smokers
Weeks 1-8
Open label tailored
nicotine patch therapy
(n=195)
Bupropion 300 mg/d
(n=56)
Week
76
Follow-up
Placebo
(n=54)
R01 AA-11219
Week
52
Nicotine Patch Dose Based on
Serum Cotinine
Baseline Serum
Cotinine
Initial Nicotine Patch
Dose, mg/d
 200
22
201-300
33
> 301
44
Hurt RD, et al. J Stud Alcohol 66:506-516, 2005.
Tailored Nicotine Patch Therapy for
Recovering Alcoholic Smokers
Serum Cotinine
Week 2
Patch dose
n
Baseline
n
Abstinent
subjects
n
Smoking
subjects
25
165
18
125
7
178
22 mg
Cotinine
% of baseline
77%
113%
33 mg
Cotinine
49
257
31
% of baseline
233
18
92%
291
112%
44 mg
Cotinine
% of baseline
63
403
36
366
93%
27
405
101%
Tailored Nicotine Patch Therapy for
Recovering Alcoholic Smokers
Not Smoking, %
Smoking Abstinence Rates
100
90
80
70
60
50
40
30
20
10
0
96/195
94/195
94/195
95/195
93/195
94/195
100/195
2
3
4
5
6
7
8
75/195
1
Hurt RD, et al. J Stud Alcohol 66:506-516, 2005.
Visit Number
Tailored Nicotine Patch Therapy for
Recovering Alcoholic Smokers
Smoking Abstinence
100
7-day point prevalence
Continuous
Abstinent (%)
80
60
40
20
0
1
2
3
4
5
6
7
8
Visit number
Hurt RD, et al. J Stud on Alcohol, 66:506, 2005
CP1120196B-1
Tailored Nicotine Patch Therapy for
Recovering Alcoholic Smokers
Conclusions
• Excellent 8 week smoking
abstinence rate (51%) with tailored
nicotine patch therapy
• Dosing algorithm works
• No evidence of nicotine toxicity
• Very low rate of relapse to drinking
Hurt RD, et al. J Stud Alcohol 66:506-516, 2005.
Nicotine Patch Therapy in Alcoholics
• Efficacy of 21 or 42 mg x 4 wk (then taper)
•
•
•
nicotine patch doses in heavy smokers
(N=130) with PH alcoholism
FTND score 7.7, mean smoking rate 31.5 cpd
Median alcohol abstinence 4 months (69%
receiving alcoholism treatment at the time of
enrollment)
Longer alcohol abstinence predicted better
smoking abstinence outcome
Kalman D, et al. Psychol Addict Behav 18:78-82, 2004
Nicotine Patch Therapy in Alcoholics
Smoking Abstinence Rates
Initial Nicotine
Patch Dose
Wk 1
Wk 4
Wk 12
21 mg/d
35.4%
30.7%
20.0%
42 mg/d
30.8%
20.0%
9.2%
Kalman D, et al. Psychol Addict Behav 18:78-82, 2004
Treating Alcohol and Tobacco Dependence
Rationale to Initiate Treatment
During Treatment of other Dependencies
•
•
•
•
•
•
•
Serious cause of morbidity/mortality
Closely related behaviors
Eliminates a cue to drink
Common message
Apply same treatment philosophy
Protected milieu to initiate an attempt
Many patients in CD programs express
interest in stopping tobacco (46-70%)
Treating Tobacco Dependence in
Alcoholics in Treatment or Recovery
• Meta-analysis of 19 randomized controlled
trials
• Post-treatment intervention effects (but not
long-term) were significant and comparable
for patients in addictions treatment or
recovery
• Tobacco dependence interventions provided
during addictions treatment  (25%) longterm alcohol and/or drug abstinence
Prochaska JJ, et al. J Consult Clin Psychol 72:1144-1156, 2004
Timing of Alcohol and Smoking
Cessation (TASC)
• Smokers in treatment for alcohol
dependence willing to consider stopping
smoking
• Randomized to concurrent treatment or
delayed treatment 6 months after alcohol
dependence treatment
• N=499, mean age 39.2, mean CPD 25.5,
FTND 6.0, 47% previously used NRT or
bupropion
Joseph AM. J Addict Dis 22:87-107, 2003
Timing of Alcohol and Smoking
Cessation (TASC)
Smoking Abstinence
ITT
Concurrent Delayed
(N=251)
(N=248)
P
7 day PP smoking
abstinence
3 months
15.5%
4.4%
<0.0001
6 months
10.8%
5.2%
0.2
12 months
12.8%
10.1%
NS
18 months
12.4%
13.7%
NS
Joseph AM. J Stud Alcohol 65:681, 2004
Timing of Alcohol and Smoking
Cessation (TASC)
Alcohol Abstinence
ITT
Concurrent
Delayed
(N=251)
(N=248)
30 day alcohol abstinence
6 months
12 months
18 months
6 month alcohol abstinence
6 months
12 months
18 months
Joseph AM. J Stud Alcohol 65:681, 2004
P
51%
46%
48%
64%
53%
60%
0.004
0.11
0.01
41%
33%
56%
42%
0.001
0.06
41%
48%
0.14
Does Smoking Abstinence Threaten
Sobriety?
• 10% of recovering
alcoholics state it
does
• 16% report
increased craving
• 18% relapse to
alcohol/drug use
during tobacco
abstinence
Adapted from John Hughes, 2004
• 90% state it
DOES NOT
threaten sobriety
• 84% report NO
increase in craving
• 82% DO NOT
relapse to
alcohol/drug use
during tobacco
abstinence
Concurrent vs Delayed Treatment for
Smoking
Kalman
Joseph
N=36
N=499
Delayed less likely to
enter smoking tx
Delayed less likely to
enter smoking tx
No difference in
smoking outcomes
No difference in
smoking outcomes
Delayed had worse
alcohol outcomes
(p=.07)
Concurrent had worse
alcohol outcomes
(p <.01)
Kalman D. J Subst Abuse Treat. 2001;20:233
Joseph AM. J Stud Alcohol. 2004;65:681
Unanswered Questions
•
•
•
•
•
Adequacy of brief treatments?
Concurrent vs. delayed treatment?
Integrating 12 step and behavioral therapies?
Interventions for peer resistance?
Prophylactic treatment to prevent alcohol
remission?
BUT . . .
Postponing treatment means potentially never
Treating Tobacco Dependence in
Recovering Alcoholics
• Keep tobacco use on the problem list
• Motivate every few months using
personal risks and discussing
barriers
• Utilize past success strategies
• Associate with non-tobacco using
friends
• Consider an ex-tobacco user as a
“sponsor”
Treating Tobacco Dependence in
Recovering Alcoholics
• Recommend proven therapies
• NRT
• Bupropion
• Varenicline
• Behavior Therapy
• Social Support
• Monitor frequently for relapse
• Let patient decide the timing