The Relationship between Alcohol Use Disorders and Nicotine Dependence[1]

The Relationships Between Alcohol Use Disorders and Nicotine Dependence Margaret Rukstalis, M.D. University of Pennsylvania School of Medicine April 26, 2002 Copyright Alcohol Medical Scholars Program 1 INTRODUCTION • Material is relevant to health professionals – Medical Students – Nurses – Staff • Goal: To place alcohol use disorders and nicotine dependence into clinical perspective Copyright Alcohol Medical Scholars Program 2 OVERVIEW • Introduction to substance use disorders • Application to alcohol use disorders • Relevance to nicotine use disorders • Relationships among the two substance use disorders Copyright Alcohol Medical Scholars Program 3 CRITERIA FOR DEPENDENCE • Pattern of 3+ repetitive problems occurring together as a syndrome • International Classification of Diseases (ICD) and American Psychiatric Classification-Diagnostic and Statistical Manual (DSM) are similar Copyright Alcohol Medical Scholars Program 4 DSM IV DEPENDENCE Tolerance Withdrawal-usually the opposite of acute effects Using more than intended or more often Persistent desire to cut back Lots of time using or recovering Decreased function: social/occupational/recreational 7. Continued use despite physical/psychological problems (lung disease, cancer, depression, etc.) Copyright Alcohol Medical Scholars Program 5 1. 2. 3. 4. 5. 6. DSM IV ABUSE • • Only diagnose if no history of dependence Criteria: repetitive problems in any one of four areas 1. Failure to fulfill major role obligations 2. Use in hazardous situation 3. Legal problems 4. Use despite problems Applies to most drugs--but not nicotine Copyright Alcohol Medical Scholars Program 6 • CLINICAL COURSE OF DEPENDENCE • • • • • Age of onset use, early problems similar to population Repetitive problems in late teens (for nicotine) or 20’s (for alcohol) Dependence/abuse risk for serious problems Course usually fluctuates (problems, abstinence, controlled use, relapse to problems High rate of spontaneous remission Copyright Alcohol Medical Scholars Program 7 GENETIC INFLUENCE: DRUG DEPENDENCIES • Familial • Similarity identical > fraternal twins • Adopted away offspring have high risks • Genetics explain 50%+ of risk for alcohol use disorders, nicotine dependence Copyright Alcohol Medical Scholars Program 8 ALCOHOL INTOXICATION • • • • • Problems thinking clearly while drunk Impaired motor skills Impaired judgment Blackouts Hangovers Copyright Alcohol Medical Scholars Program 9 Epidemiology of Lifetime Risk: ALCOHOL USE DISORDERS • Alcohol Dependence: 15% in males, 8% in females • Alcohol Abuse: 5-10% • Majority (80+%) alcohol dependent, also nicotine dependent Copyright Alcohol Medical Scholars Program 10 ALCOHOL USE DISORDERS: CAUSES OF DEATH 1. Heart disease: high blood pressure, high blood fats, cardiomyopathy 2. All cancers, including lung 3. Accidents 4. Suicide Copyright Alcohol Medical Scholars Program 11 GENETICS: ALCOHOL DEPENDENCE • 60% risk for alcohol dependence is genetic • 4X risk in children of alcoholics • Complex genetically-influenced disorder – Both genes and environment – Multiple inherited characteristics: alcohol metabolizing enzymes high impulsivity, low response to alcohol Copyright Alcohol Medical Scholars Program 12 DSM IV: NICOTINE DEPENDENCE Tolerance Withdrawal-irritability, anxiety, insomnia Using more than intended or more often Persistent desire to cut back Lots of time using (NOT recovering) Decreased function: social/occupational/recreational functioning 7. Continued use despite physical/psychological problems (lung disease, cancer, depression, etc.) Copyright Alcohol Medical Scholars Program 13 1. 2. 3. 4. 5. 6. ACUTE NICOTINE EFFECTS • • • • Feeling energized Enhanced concentration Improved performance May decrease some effects of alcohol Copyright Alcohol Medical Scholars Program 14 EPIDEMIOLOGY: NICOTINE Use • 72% men, 61% women ever smoked • 33% men, 6% women ever chewed tobacco Daily smoking ~50% • males> females; whites>non-whites Nicotine dependence • 24% in the National Co-morbidity Survey • Majority (90%) nicotine dependent, also drink alcohol Copyright Alcohol Medical Scholars Program 15 CLINICAL COURSE: NICOTINE DEPENDENCE • • • • • • Risk for dependence increases after 4+ cigs Daily smoking onset: age 15-20 years Dependence lags 1+ yr behind daily smoking risk for serious health problems Multiple quit attempts 35-50% smokers achieve long term remission Copyright Alcohol Medical Scholars Program 16 GENETICS: NICOTINE DEPENDENCE • 60-70% risk for dependence is genetic • 2-4X risk for close relatives – identical twins> fraternal twins • Complex genetically-influenced disorder – Both genes and environment – Multiple inherited characteristics Copyright Alcohol Medical Scholars Program 17 ACUTE EFFECTS OF ALCOHOL NICOTINE • Decreased concentration • Sedation • Impaired motor function • Increased energy • Improved concentration • Heightened performance Copyright Alcohol Medical Scholars Program 18 EPIDEMIOLOGY • Non-alcoholics who drink are twice as likely to smoke • 80%+ alcoholics smoke cigarettes • Alcohol dependent smokers smoke more cigarettes/day vs. nonalcoholics Copyright Alcohol Medical Scholars Program 19 NATURAL HISTORY • Continued combined use reflects reinforcing effects • Using one drug may use of other • Co-use progresses to avoid discomfort Copyright Alcohol Medical Scholars Program 20 GENETIC vs. ENVIRONMENT Alcohol Dependence Nicotine Dependence Environment Genetics Environment Environment Genetic Genetic R= 0.23 (90.140.3) R= 0.68 (0.61-0.74) 21 Copyright Alcohol Medical Scholars Program TREATMENT ISSUES • Cognitive behavioral approach • Medications • Groups Copyright Alcohol Medical Scholars Program 22 COGNITIVE BEHAVIORAL THERAPY • Increase motivation for abstinence • Re-establish life style conducive to abstinence • Optimize physical functioning • Relapse Prevention Copyright Alcohol Medical Scholars Program 23 MEDICATIONS FOR RELAPSE PREVENTION ALCOHOL NICOTINE DEPENDENCE DEPENDENCE • Naltrexone • Nicotine Replacement (Trexan, Revia) • Buproprion • Acamprosate (Zyban, Wellbutrin) (Campral) Copyright Alcohol Medical Scholars Program 24 NALTREXONE • Oral, long acting, opiate antagonist • FDA approved: opiate and alcohol dependence • Blocks craving +/- pleasurable alcohol effects • Prolongs time to first drink, to first relapse Copyright Alcohol Medical Scholars Program 25 ACAMPROSATE • Calcium acetylhomotaurinate • GABA, NMDA action • Acamprosate vs. placebo – Greater completion rates – Longer time to first drink – Higher abstinence • FDA approval pending Copyright Alcohol Medical Scholars Program 26 SMOKING CESSATION • Cognitive Behavioral Therapy – Group or individual – Homework assignments – Set a quit date – Relapse Prevention • Nicotine Replacement • Buproprion Copyright Alcohol Medical Scholars Program 27 NICOTINE REPLACEMENT • Most widely used/accepted • Agonist therapy to reduce withdrawal • Best results when combined with counseling • 4 different products: gum, patch, nasal spray and oral inhaler Copyright Alcohol Medical Scholars Program 28 BUPROPRION • FDA approved for smoking cessation • Antidepressant • Mechanism involves serotonin, norepinephrine, dopamine • Increased quit rates, abstinence • Risk for seizures above 450 mg/day Copyright Alcohol Medical Scholars Program 29 TREAT BOTH DEPENDENCIES Voluntary smoking cessation DOES NOT IMPAIR alcohol dependence treatment Copyright Alcohol Medical Scholars Program 30 KEY POINTS • Alcohol and nicotine are commonly used together • The use of both drugs is associated with health risks • Future directions include exploring treatment for both dependencies Copyright Alcohol Medical Scholars Program 31