Vol. 11, No. 10
In This Issue
Readers speak up about nicotine addiction
Attracting people into change
Thoughts of a non-avid sports fan
David Mee-Lee M.D.
Last month I suggested it was time for the addiction and mental health treatment fields to get serious about nicotine addiction. If you missed it, here’s the link.
This prompted quite a few readers to comment. I think they are worth sharing – with some editorial response.
Jerry Shulman has been a longtime colleague and friend who has been an addiction treatment clinician, administrator and consultant for over 40 years. He has an elder statesman perspective:
Some thoughts about smoking. I remember when patients (and their counselors) were permitted to smoke during group and lectures. I remember when staff would provide adolescent patients with cigarettes and light them during breaks because the adolescents were not permitted to possess cigarettes or matches (I wonder what the legal authorities would say about that).
I completely agree with the article you referenced about smoking cessation and stimulant addicts but I think the conclusion did not go far enough. Rather than smoking cessation NOT being a problem in people who are addicted to other drugs, NOT stopping is the problem. Smoking serves as a relapse trigger for those addicted to other drugs, particularly if the route of administration of their “drug of choice” was smoking (e.g., crack cocaine, marijuana).
I think the reasons why programs are so hesitant to introduce tobacco cessation programs include:
(1) The consequences of smoking are long-term, not immediate as they might be with other drugs (e.g., violence, DUI’s, overdoses, automobile accidents);
(2) A concern that patients will refuse to be admitted to a non-smoking program,
thereby reducing revenue; and
(3) The fact that many of the staff smoke.
(4) Possibly the biggest obstacle is the belief, even if unconscious, that the problem is the identified drug of use rather than the reliance on psychoactive substances to cope.
About 30 years agoin New Jersey, I was presenting at an impaired professionals (physicians) meeting, an Alcoholics Anonymous (AA) variant but not International Doctors in AA (IDAA). The physician speaker before me said to these doctors in recovery, “If you are still smoking, you are not sober!” To say you could have heard a pin drop would be an understatement.
Shulman & Associates,Training and Consulting in Behavioral Health
Note Jerry’s point No. 4 above about why he thinks programs are hesitant about tobacco cessation: “The belief….that the problem is the identified drug of use rather than the reliance on psychoactive substances to cope.” It is important to recognize that Tobacco Use Disorder is one manifestation of the disease of addiction so that as Jerry says, it isn’t just a problem with tobacco use(the drug), it is a problem with the illness (addiction).
Addiction affects just about every organ system of the human body and the brain reward system is impacted by all addictive drugs and behaviors. Treating other addictive drugs, but not nicotine, affects full recovery. It is as though we treated the insomnia of depression but not the energy, suicidal or other manifestations of depression.
The addiction disorder itself is what needs treatment, not just particular drugs used as part of the brain reward circuits that drive the illness.
Here is the American Society of Addiction Medicine’s Short Definition of Addiction with italics inserted to highlight some points.
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
Re nicotine addiction: The Watergate mole Deep Throat’s dictum, “Follow the money” continues to have much wisdom. When third party payers get serious about paying for nicotine addiction interventions, it will be a lot easier for the likes of me to get serious about trying to help people with this problem. It is sad that, if/when I intervene re nicotine, strictly speaking, it’s charity work. Hats off to the inpatient program of your example. What they’re attempting is without question a good thing. I suspect they’re able to somehow bundle or mask those interventions within the scope of inpatient level of care. For me at the outpatient level of care, the reimbursement system says that intervening re nicotine is like intervening re sugar consumption with a diabetic.
At any level of care,we address a client’s use of heroin, alcohol, methamphetamine, cocaine etc. Why can we not include tobacco in that list, since it is all part of addiction as a disease? A client can go to a primary care physician and receive physical health care for the physical complications of tobacco use disorder and that is reimbursed. So we can work hand in hand with general healthcare for nicotine replacement therapy (NRT) while we work on the other aspects of addiction and recovery.
What Fred is saying however is: if a client has only tobacco use disorder and not addictive use of other drugs, reimbursement is not always available. That is why the new edition of The ASAM Criteria has taken a stand that addiction is addiction and nicotine addiction is just like other manifestations of addiction illness, needing the same reimbursement coverage.
–> If the treatment field doesn’t believe this though, we will send mixed signals to payers. They get the message about the physical complications of tobacco use disorders and pay for that treatment and NRT. But they get the message from too many addiction and mental health clinicians that we don’t think tobacco use disorder is addiction needing treatment and reimbursement. No wonder they don’t pay!
In doing clinical reviews on cases, I have come across multiple consumers that appear to have moved from their “drug of choice” in the recovery process to participate in alternative behaviors that are highly addictive. The primary substitute I have found looks like gambling–the documentation related to substituting the “high” of chemicals with the “high” of gambling- is completely blown off by multiple consumers.
Could this be a possible focus for a future Tips and Topics? You have addressed the nicotine issue-many addicts believe that it is better to stop the use of their drug of choice and minimize the fact that nicotine is also a deadly and addictive chemical. There is a focus in the treatment we offer to address the nicotine aspect, but now I am seeing more gambling and would love to get your input.
Gwen Thomas-LeBlanc, MS, CCS
Director of SubstanceAbuse Services
Northwest Alabama Mental Health
Gwen is highlighting exactly what the ASAM definition of addiction stresses and what the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (APA), Fifth Edition (DSM-5) designed:
- “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry……This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.” (my inserted italicspoints to the “other behaviors” that includeGambling Disorder).
- So a person’s switch “to participate in alternative behaviors that are highly addictive” as Gwen has observed is fully understandable if the client is not in full recovery for their addiction illness.
- DSM-5 now includes Gambling Disorder in the Substance-Related and Addictive Disorders chapter
- The ASAM Criteria has a whole new section onGambling Disorder in pages 357 -366.
Hi Dr. Mee-Lee:
Tobacco addiction is a very relevant issue in the addiction field. For years the myth of not quitting while abstaining from the other drugs was perpetuated by the counselors in the field. Years ago an article mentioned that nicotine killed more people than all the other drugs combined. As a substance that affects the health of the user more than other areas of the person’s life it was overlooked by treatment facilities. I am glad and support your effort to bring to attention this addictive substance to treatment facilities and be incorporated in a person’s recovery.
The only response I would add to Roberto’s correct comment is that he talks in the past tense asif this is all behind us now: “was perpetuated by the counselors in the field….. was overlooked by treatment facilities.” SoRoberto is only half correct: there are still many counselors and programsfor whom his comments apply today and not in the past.
Good morning Dr. Mee-Lee,
I just got through reading your always wonderful newsletter. Your references to tobacco as being the same as addictions to other drugs like alcohol, heroin and cocaine left me wondering, although the similarities are clear.
All of our psychiatric inpatients suffer from co-occurring disorders, many severe and persistently mentally ill (SPMIs) NGRI, and nearly everyone is a tobacco user. We prohibit alcohol use on grounds, but those who attend community events and clubhouses smoke heavily when they are on their own (usually Not Guilty by Reason of Insanity (NGRI) with unescorted community privileges.) As a non-smoker I’m very grateful for the respite from second hand smoke.
As a supervisor, I’m aware that some of my staff smell strongly of tobacco but I don’t see this being addressed with any of the smokers who leave grounds to smoke during breaks and lunch hours. While staff is subject to random drug screens, nicotine isn’t screened for or sanctioned.
I do have one question though: The other drugs you mention are known to exacerbate mental illness. Nicotine, by contrast, has been shown to be helpful for those with psychosis in studies with which our patients enthusiastically agree! I feel the reason we’ve not focused much on nicotine, until the tobacco ban was instituted, is that the use of nicotine does not seem to lead to psychiatric hospitalization, as the other psychoactive drugs definitely do. We have discussed the possibility of allowing e-cigarettes along with the other types of nicotine replacement therapy that are available. I’d be very interested in your thoughts.
My response to Laura:
As regards your question, while there is some evidence that nicotine doesn’t exacerbate psychiatric illness and may even help (as patients vote with their increased use), I still would advocate for trying to attract these patients into full recovery. Addiction is a co-occurring disorder with its own overall effects on health outcomes. Nicotine addiction, even if patients find smoking useful, kills in ways much more than the just the effect on their mental illness. The other physical health costs on their lives create much harm and death. If they had co-occurring diabetes or cancer, we would want to get them on the path to health. Too many mental health clinicians already don’t take addiction illness seriously, soI would not want to have any policies that encourage or condone ignoring addiction illness.
If a mental health patient felt beer and wine helped their anxiety, but we diagnosed that they had alcohol use disorder; and if the beer and wine didn’t seem to exacerbate anxiety and may even help calm them down sometimes – would we be OK with the therapist condoning the patient’s having a beer or two in the alcohol gazebo on the grounds of the facility? I think this is an equal analogy/situation, so I’d be interested in your opinion if I have articulated the same situation as nicotine with mental health patients; or if you think it IS different with nicotine addiction versus alcohol addiction? Let me know what you think. I am interested in understanding how different clinicians think about this.
Speaking for myself and without doing further research, I’d have to say that I do see a difference between alcohol and nicotine/tobacco. I fully agree with you that tobacco is extremely addictive and medically dangerous. It clearly exacerbates anxiety in patients who are addicted but unable to smoke, not only because of hospital rules but also lack of money or other wherewithal to obtain tobacco. I and my colleagues do advocate for full recovery but we have some determined smokers. However I think alcohol has more negative psychiatric effects including disinhibition, depression, altered judgment, symptom relapse and the likelihood of engaging in dangerous activities or situations. I also think that while intoxicated, patients are more likely to pick up other drugs. I would not advocate for the alcohol gazebo! But I do engage in discussions related to harm reduction for patients who are likely to drink.
Does it bear mentioning that some of the medications we use present increased risk for medical problems, particularly obesity and diabetes? I don’t think they areas dangerous as cigarettes, but there is some precedent for thinking about some level of acceptable medical risk.
Still, the main issue we face is that many patients clearly and vociferously do not want to quit smoking and it seems far easier to help them see reasons to abstain from alcohol and drugs of abuse than it is to develop the case for quitting tobacco. Notably, use of alcohol is prohibited in privilege packets and conditional release plans, while using tobacco in the community does not slow down conditional release from the hospital. And tobacco is the drug many are actively using while hospitalized.
The issues Laura raises, especially in psychiatric facilities working with severe mental illness, are a work in progress. They are troublesome to figure out. However, I know there are many public and private hospitals and addiction and mental health facilities that are fully smoke and tobacco-free.
Also, the evidence is not clear on whether smoking in people with severe mental illness actually is helpful to their schizophrenia. There are many mixed reviews and theories on the high rate of smoking in people with schizophrenia. Wikipedia does a nice job of outlining the range of study and thought on this.
I end up where Wikipedia opens on this topic: “Increased rates of smoking among people with schizophrenia has a number of serious impacts, including increased rates of mortality, increased risk of cardiovascular disease, reduced treatment effectiveness, and greater financial hardship. Studies have also shown that in a male population, having a schizophrenia spectrum disorder puts a patient at risk of excess tobacco use. As a result, researchers believe it is important for mental health professionals to combat smoking among schizophrenics.” http://en.wikipedia.org/wiki/Schizophrenia_and_smoking
I welcome those of you who have success stories on how you made the transition. Please write to me so I can share your wisdom and experience to support Laura and others inher situation think this through. I know I don’t have all the answers, butI know there are people and programs out there who do have the experience and expertise to help.
Thanks David for spotlighting nicotine addiction. I was fortunate enough to have David McMaster as my intake counselor and now long-term friend to constantly raise my consciousness about getting sober from alcohol, but dying from smoking. He has been tireless in his efforts in Wisconsin (WINTIP) to get nicotine cessation part of treatment. He calls it “smobriety”. Dr. Harold Kruse is trying to do the same nationally. It’s a big deal and you’re a great champion!
American Psychiatric Association: Diagnostic and StatisticalManual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013.
Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-OccurringConditions. Third Edition. Carson City, NV: The Change Companies.
By now, if you are not interested in tobacco use disorder and nicotine addiction, you probably will not have gotten this far in reading this January edition. But in case you have, here is one tip which applies to all efforts to attract people into recovery.
We have been discussing tobacco use. We know that people are at different stages of interest and readiness to address a whole host of issues in treatment – taking medication, stopping or moderating certain behaviors, changing lifestyles, relationships or ways of thinking.
So while it may seem that I advocate mandating recovery for all addictive substances and behaviors, I do advocate it at the policy and program design level. But I am not mandating recovery at the individual patient and client level. Recovery is always something to attract people to; not mandate them into.
Attracting people into recovery means starting where they are at and helping them to discover a better path
If a person is not ready for total abstinence, we develop with them NOT a recovery, relapse prevention plan, but a “discovery, dropout prevention” plan. How do we keep them engaged in treatment so we have a chance to facilitate a self-change process?
If they “dropout” physically and/or emotionally, we have lost the opportunity to work with stage-matched interventions to improve outcomes. But how do we help clients “discover” that if they change what they are not yet ready to do, it will be more satisfying, effective, peaceful and joyful? Of course this is easier said than done. It is a unique path for each person we work with. There are, however, many methods and models you can employ. You probably have your favorite techniques to do person-centered work. In case you are ready to expand, here are a few suggestions:
–> Motivational Interviewing
–> Interactive Journaling
–> Transformational Care Planning
It is easy to mandate compliance with policies and procedures at the administrative and agency level. When it comes to people – whether patients, clients, consumers, clinicians, counselors and all staff – the focus always is on an individualized,person-centered plan. Clients need a plan that makes sense to them and to which they will adhere, not just comply, if they want to see lasting change.
Staff need an individualized staff development plan that honors and works with their need for stage-matched interventions too – whether that be the staff person not ready to stop smoking; or always late with his or her paperwork; or late to work.
I am not an avid sports fan. There are a couple of ways you can tell this is so:
1. I use my DigitalVideo Recorder (DVR) to save the sports event I have interest in, so I can watch it when I am ready. No need for me to be right inthe moment “live” as it is happening. This way, I can start watching an hour or more after the event starts; fast-forward through the commercials (sorry advertisers); and just watch the good parts.
“Good parts” are when the score is very close and there is a battle of strategy, strength, skill and psychology. Actually I am more interested in the psychology of close races and how the athletes handle stress and figure outhow to do something different if they are not winning.
2. I am a “fair weather fan”. I am only interested in the team or sportsperson if they are winning or losing in competitive tight races. If they are losing badly at the bottom of the heap with no hope of the playoffs or the trophy, then I’m out of there. Now I know if you are committed to a particular team through good and bad; thick and thin; this is not a good thing to say. But it is not because I am a disloyal person. It is because I am interested in sports more for the psychology, as I said, of how athletes deal with the close struggle for supremacy.
Besides the psychology, I am interested in teams that have some geographic relationship to me. So January was not a good month for this non-avid sports fan:
- The New England Patriots (National Football League) lost and missed the chance to play for their fourth Super Bowl ring – geographic interest having lived in the Boston area for 17 years
- The San Francisco 49ers (National Football League) lost and missed the chance to play for their sixth Super Bowl ring – geographic interest since living an hour and a half from San Francisco; and second year quarterback, Colin Kaepernick, is fun to watch to see if he will run the ball himself to get a first down.
- In tennis and the Australian Open tournament: Serena Williams, No. 1 seed lost in a third-round match; and Maria Sharapova, No. 3 seed also lost – both these athletes show such commitment and strength to overcome injuries and adversity in their careers. I wanted them to be rewarded for that.
It wasn’t all bad though. Li Na (China) and No. 4 seed won the tennis tournament after twice being in the final. Her persistence, hard work and belief in herself paid off. What an inspiration to never give up.
So there you have it sports fans and non-sports fans. There is much to learn from watching how teams and athletes compete.
(The third way you can tell I am not an avid sports fan – I had to Google all this information to be sure I got the facts right!)
Until next time
See you again in late February