Smoking & Recovery Stuyt
Smoking & Recovery Stuyt
Smoking & Recovery Stuyt
Impact of Tobacco
on Recovery
Helping Treatment Professionals Move in Their
Stage of Change Regarding Tobacco-Free
Substance Abuse Treatment
DA Concentration (% Baseline)
200 200
NAc shell
% of Basal DA Output
150 150
Copulation Frequency
100 100
15
Empty 10
50
Box Feeding
5
0 0
0 60 120 180 ScrScr Scr Scr
BasFemale 1 Present Female 2 Present
Time (min) Sample 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Number
Mounts
Intromissions
Ejaculations
% of Basal Release
900
800 DA
DA 300 DOPAC
700 DOPAC HVA
600 HVA
500 200
400
300
200 100
100
0
0 1 2 3 4 5 hr 0
0 1 2 3 4 5 hr
Time After Amphetamine Time After Cocaine
250
NICOTINE 250 Accumbens MORPHINE
% of Basal Release
% of Basal Release
Dose (mg/kg)
200 Accumbens
200 0.5
Caudate 1.0
150 2.5
150 10
100
100
0
0 1 2 3 hr 0
0 1 2 3 4 5hr
Time After Nicotine Time After Morphine
DRUG
Addiction
Rats exposed to nicotine as adolescents
self-administer more nicotine than rats
exposed as adults Levin ED et al.
Psychopharm 2000;169:141-149
Learning Processes Underlying
Drug Addiction (N. White, 1996)
Amygdala-NAc (Incentive) promotes
approach to and interaction with drug related
cues (produces behavior unconsciously)
Caudate-Putamen (Habit) promotes
repetition of behaviors performed in the
presence of drug-related stimuli (produces
behavior unconsciously)
Hippocampus (Declarative) promotes
focusing of cognitive processes on drug
related situations (conscious)
Glutamate Signaling
The amygdala, hippocampus and
frontal cortex talk to the reward
pathway by releasing glutamate
Changes in sensitivity to glutamate
enhance the release of DA from VTA to
NA, promoting CREB and delta fos B
Strengthens pathways that link
memories of drug taking with reward -
LTP
Addictive Drugs and
Stress Increase
Sensitivity of DA Cells in
Mice (Saal et al. Neuron
2003;37:577-582)
Brain Development
Human brains continue to develop after birth
and are not fully developed until late
adolescence/early adulthood
Amygdala is on-line at birth
Hippocampus is on-line about 18 months of
age
Prefrontal cortex (judgment) not fully
developed until late adolescence/early
adulthood
Use of drugs/alcohol can impede development
Functions
Reward pathway NA GO system
Middle Prefrontal Cortex STOP
system
Amygdala warning system
Hippocampus episodic new
memory and learning, salience
Neurons that are wired together
fire together
Effects of Drug Use on
the Hippocampus
Drugs of abuse are potent negative
regulators of adult neurogenesis in
the hippocampus
Chronic administration of opiates,
THC or ethanol decrease
hippocampal function, decreasing
ability of adult brain to adapt to new
information
Possible Negative Effects of
Nicotine on Memory and
Cognition
Nicotine self-administration in rats profoundly
decreases, in a dose dependent fashion,
neurogenesis and increases cell death in the
hippocampus (Abrous et al. J Neuroscience 2002;22:3656-
3662)
Steeper decline in IQ seen in smokers than non-
smokers between 11 and 64 years of age (Whalley et
al. Addictive Behaviors 2005;30:77-88)
Adolescents who smoke cigarettes show
impairment of memory and other cognitive
functions (Jacobsen et al. Biological Psychiatry 2005)
Brain recovery in abstinent alcoholic individuals
is affected by chronic smoking (Meyerhoff et al. 2006)
Chronic Tobacco Use
Chronic cigarette smoking is associated
with increased brain atrophy in individuals
> 50 years of age
Active cigarette smoking is associated with
diminished neurocognitive performance -
domains include:
Executive functions (Razani et al. 2004)
General intellectual abilities (Deary et al. 2003)
Memory (Hill et al. 2003, Schinka et al. 2003)
Psychomotor speed and cognitive flexibility
(Kalmijn et al. 2002)
Given the neurobiology of
all drugs of abuse, how can
inpatient treatment help?
By allowing the brain an opportunity
to heal and the hippocampus to
regenerate improving the patients
ability to adapt to new information
they are receiving in treatment
Providing a safe environment
removing patient from chronic
stress/abuse/trauma
Providing an environment free of all
addictive drugs, including tobacco
Treatment that Promotes
Neurogenesis
Enriched environment that promotes
physical activity and learning (Gage, Science
2000;287:1433-1438)
SSRI medication, Lithium, ECT,
Transcranial magnetic stimulation
(normalization of serotonin and glucocorticoid
dysfunction, activation of growth factor and cAMP
pathways)
Paroxetine increased verbal declarative
memory and hippocampal volume in
PTSD (Vermetten et al. Biol Psych 2003;54:693-702)
My Experience
with Tobacco Free
Programs
Study methods program #1
28-day private, non-profit,
hospital-based, in-patient
Chemical Dependence program
Prospective study - Comparison of all
patients admitted over two consecutive
years.
Year I patients were allowed to go outside
to smoke.
Year II patients were expected to
completely refrain from tobacco use during
treatment.
Both years - patients were given a great
deal of education regarding tobacco use
and encouraged to quit.
Patients did not refuse to enter
treatment because they could
not smoke
Year I Year II
Total
number
admitted
174 174
Followed
for one
year after
87 83
treatment
AMA
discharge
rate
22% 16%
Demographic variables for
patients followed for one year
after treatment
Male 72%
Caucasian 85%
Alcohol 56%
primary drug of
abuse
There was no significant change
in financial class of patients
admitted
40
35
30
Percentage
25 Year 1
20
15 Year 2
10
5
0
Medicare
Medicaid
Commercial
BC/BS
Private pay
Funding source
Significant difference in sobriety
rates between tobacco users and
non-tobacco users
100
percentage of patients
80
Non-tobacco users
60 N=54
40 Tobacco users
N=116
20
0
1 2 3 4 5 6 7 8 9 10 11 12
P<.0001
month
Patients who were convinced to
quit tobacco use during
treatment
Sober
Total % for one %
year
Percent
Caucasian
78% 77%
No difference in primary drug of
choice before and after going
tobacco free
Six months One year
Drug of Choice before after
tobacco free tobacco free
a
p <.0001
In the year after going tobacco
free - patients were expected to
refrain from all tobacco use
a
p <.0001
Patients decision regarding
tobacco use before and after
program is tobacco free
One year
Six months
Decision regarding after
before
tobacco use after tobacco
tobacco free
treatment free
N=111
N=157
Plans to continue
tobacco
75% 61%
Quit using tobacco
with plans to remain 12% 24%
abstinent
Never used tobacco 13% 15%
Conclusions
There are no down sides to creating
a tobacco free in-patient or
residential treatment program.
In a tobacco free environment, even
patients with very poor coping skills
are able to practice not smoking and
develop coping skills for this which
they can translate to behavior with
drugs/alcohol outside treatment.
Conclusions
More patients are likely to quit tobacco
use in a tobacco free environment.
A tobacco free environment encourages
patients to move in their stage of
change regarding their own tobacco use.
A tobacco free environment helps the
patients brains to heal and improves
their cognition/ability to learn and retain
information.