copyright alcohol medical scholars program1 the relationships between alcohol use disorders and...

Copyright Alcohol Medical Scholars Program 1

The Relationships Between Alcohol Use Disorders and

Nicotine Dependence

Margaret Rukstalis, M.D.University of Pennsylvania School of Medicine

April 26, 2002


INTRODUCTION• Material is relevant to health

professionals– Medical Students– Nurses– Staff

• Goal: To place alcohol use disorders and

nicotine dependence into clinical perspective


OVERVIEW

• Introduction to substance use disorders

• Application to alcohol use disorders

• Relevance to nicotine use disorders

• Relationships among the two substance use disorders


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


DSM IV DEPENDENCE1. Tolerance2. Withdrawal-usually the opposite of acute effects3. Using more than intended or more often4. Persistent desire to cut back5. Lots of time using or recovering6. Decreased function:

social/occupational/recreational7. Continued use despite physical/psychological

problems (lung disease, cancer, depression, etc.)


DSM IV ABUSE• Only diagnose if no history of dependence• Criteria: repetitive problems in any one of

four areas1. Failure to fulfill major role obligations2. Use in hazardous situation3. Legal problems4. Use despite problems

• Applies to most drugs--but not nicotine


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


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


ALCOHOL INTOXICATION

• Problems thinking clearly while drunk

• Impaired motor skills

• Impaired judgment

• Blackouts

• Hangovers


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


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


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


DSM IV: NICOTINE DEPENDENCE

1. Tolerance2. Withdrawal-irritability, anxiety, insomnia3. Using more than intended or more often4. Persistent desire to cut back5. Lots of time using (NOT recovering)6. Decreased function:

social/occupational/recreational functioning7. Continued use despite physical/psychological

problems (lung disease, cancer, depression, etc.)


ACUTE NICOTINE EFFECTS

• Feeling energized

• Enhanced concentration

• Improved performance

• May decrease some effects of alcohol


EPIDEMIOLOGY: NICOTINEUse• 72% men, 61% women ever smoked• 33% men, 6% women ever chewed tobaccoDaily smoking ~50% • males> females; whites>non-whitesNicotine dependence

• 24% in the National Co-morbidity Survey• Majority (90%) nicotine dependent, also drink

alcohol


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


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


ACUTE EFFECTS OFALCOHOL NICOTINE

• Decreased concentration

• Sedation

• Impaired motor function

• Increased energy

• Improved concentration

• Heightened performance


EPIDEMIOLOGY

• Non-alcoholics who drink are twice as likely to smoke

• 80%+ alcoholics smoke cigarettes

• Alcohol dependent smokers smoke more cigarettes/day vs. non-alcoholics


NATURAL HISTORY

• Continued combined use reflects reinforcing effects

• Using one drug may use of other

• Co-use progresses to avoid discomfort


GENETIC vs. ENVIRONMENT

GeneticsEnvironment

GeneticsEnvironment

Nicotine DependenceAlcohol Dependence

Genetic

Environment

Genetic

R= 0.68 (0.61-0.74)

Environment

R= 0.23 (90.14-0.3)


TREATMENT ISSUES

• Cognitive behavioral approach

• Medications

• Groups


COGNITIVE BEHAVIORAL THERAPY

• Increase motivation for abstinence

• Re-establish life style conducive to abstinence

• Optimize physical functioning

• Relapse Prevention


MEDICATIONS FOR RELAPSE PREVENTION

ALCOHOL DEPENDENCE

• Naltrexone (Trexan, Revia)

• Acamprosate (Campral)

NICOTINE DEPENDENCE

• Nicotine Replacement

• Buproprion

(Zyban, Wellbutrin)


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


ACAMPROSATE

• Calcium acetylhomotaurinate

• GABA, NMDA action

• Acamprosate vs. placebo – Greater completion rates– Longer time to first drink– Higher abstinence

• FDA approval pending


SMOKING CESSATION

• Cognitive Behavioral Therapy– Group or individual– Homework assignments– Set a quit date– Relapse Prevention

• Nicotine Replacement

• Buproprion


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


BUPROPRION

• FDA approved for smoking cessation

• Antidepressant

• Mechanism involves serotonin, norepinephrine, dopamine

• Increased quit rates, abstinence

• Risk for seizures above 450 mg/day


TREAT BOTH DEPENDENCIES

Voluntary smoking cessation

DOES NOT IMPAIR

alcohol dependence treatment


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

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