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:

https://changecompanies.net/tipsntopics/2013/12/tobacco-and-nicotine-addiction-deaf-clinicians-resources/

This prompted quite a few readers to comment. I think they are worth sharing – with some editorial response.

Reader #1

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:

Hi David:

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 ago in 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.

Jerry Shulman

Shulman & Associates, Training and Consulting in Behavioral Health

Jacksonville, Florida

GDShulman@aol.com

Editorial Comment

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 withitalics 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.”

http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/15/the-definition-of-addiction

Reader #2

David:

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.   

Fred

Maine

Editorial Comment

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 ofThe 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!

Reader #3

Dr. Mee-Lee,

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 Substance Abuse Services

Northwest Alabama Mental Health

Editorial Comment

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 italics points to the “other behaviors” that include Gambling 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 on Gambling Disorder in pages 357 -366.

Reader #4

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.

Roberto

Massachusetts

Editorial Comment

The only response I would add to Roberto’s correct comment is that he talks in the past tense as if this is all behind us now: “was perpetuated by the counselors in the field….. was overlooked by treatment facilities.” So Roberto is only half correct: there are still many counselors and programs for whom his comments apply today and not in the past.

Reader #5

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.

Thanks,

Laura Dollieslager

Virginia

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, so I would not want to have any policies that encourage or condone ignoring addiction illness.