Transcript The Relationships Between Alcohol and Nicotine Use Disorders

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
1.
2.
3.
4.
5.
6.
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
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
1.
2.
3.
4.
5.
6.
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
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
Environment
Nicotine Dependence
Genetics
Environment
Environment
Genetic
R= 0.23 (90.14-0.3)
Genetic
R= 0.68 (0.61-0.74)
Copyright Alcohol Medical Scholars Program
21
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