Tobacco, Mental Health and Substance Abuse Disorders

1
Tobacco, Mental Health and Substance Abuse
Disorders

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

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Key issues for tobacco interventions in
co-occurring disorders

• Prevalence rates in mental disorders and
  substance abuse disorders
• Sleep
• Pharmacology metabolism, drug interactions

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Nicotine pharmacology

• Induces metabolism of drugs metabolized by
  CYP1A2-
• Clozapine
• Imipramine
• Haloperidol
• Oxazepam
• During hospitalization, smoking cessation my
  result in increased toxicity
• Smoking may lessen opioid analgesia and
  benzodiazepine sedation

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Nicotine pharmacology

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

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Nicotine pharmacology

• Primary CNS effects
• Arousal
• Relaxation in stressful situations
• Enhancement of mood, attention, reaction time
• Improvement in performance behavioral tasks
• These may be related to relief of withdrawal
  state
• Subtle modulation vs.. flagrant intoxication with
  other drugs

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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 (P50 auditory gating)

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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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Substance abuse and mental health screening

• Understand higher prevalence rates for mental
  illness and substance abusers in smokers
• T-ACE, CAGE

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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 other SUDs

• Alcohol 6.4 odds ratio
• Prevalence 85-95 abstinent or not
• Any drug dependence 15.9 OR

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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

• Schizophrenia
• increase in P50 auditory gating
• Reverses haloperidol dose-related cognitive
  impairments
• Relieves some negative symptoms - blunted affect,
  emotional withdrawal, lack of spontaneity

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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
• Depression
• Smoking prevalence doubled
• Progression to dependence more rapid

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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
  depression 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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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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Treatment

• Motivational Interviewing with personalized
  feedback with schizophrenic patients (Steinberg
  2004)
• Compared MI, standard psycho-ed counseling and
  advice
• MI 32 contacted tobacco treatment provider vs.
  11 standard and 0 advice

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Treatment

• Influence mood and depression history with
  treatment modality (Haas 2004)
• Random assignment to cognitive behavioral therapy
  vs. health education
• Depressed patients had higher rates of abstinence
  with cognitive behavioral therapy

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

• Depressed patients who stop have more severe
  withdrawal and poorer outcomes
• Best outcomes when cessation is coupled with
  effective pharmacotherapy

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Integrating smoking cessation in substance abuse
treatment

• Prochaska A meta-analysis of smoking cessation
  interventions with individuals in substance abuse
  treatment or recovery.
• Cessation during addictions treatment were
  associated with a 25 increased likelihood of
  long-term abstinence from alcohol and illicit
  drugs
• Intervention effect non-significant at long term
  follow up
• Journal of Consulting and Clinical Psychology,
  2004

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Integrating smoking cessation in substance abuse
treatment

• Mercy Recovery Center non-smoking hospital
  setting
• Patients provided with nicotine replacement
  products (patch, gum)
• Some resistance to admission based on smoking
  policy
• Some AMA discharges relate to nicotine craving

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Integrating smoking cessation in substance abuse
treatment

• Heavy nicotine dependence may increase
  naltrexone-related side effects in alcoholic
  patients
• Poly-pharmacological interventions may improve
  long-term tobacco abstinence rates

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Referrals

• Acuity? Match acuity level to referral.
• Withdrawal?
• Suicidality?
• Hallucinations/delusions?