Copyright Alcohol Medical Scholars Program1 The Relationships Between Alcohol Use Disorders and...

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The Relationships Between Alcohol Use Disorders and

Nicotine Dependence

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

April 26, 2002

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INTRODUCTION• Material is relevant to health

professionals– Medical Students– Nurses– Staff

• Goal: To place alcohol use disorders and

nicotine dependence into clinical perspective

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OVERVIEW

• Introduction to substance use disorders

• Application to alcohol use disorders

• Relevance to nicotine use disorders

• Relationships among the two substance use disorders

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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

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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.)

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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

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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

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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

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ALCOHOL INTOXICATION

• Problems thinking clearly while drunk

• Impaired motor skills

• Impaired judgment

• Blackouts

• Hangovers

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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

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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

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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

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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.)

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ACUTE NICOTINE EFFECTS

• Feeling energized

• Enhanced concentration

• Improved performance

• May decrease some effects of alcohol

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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

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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

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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

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ACUTE EFFECTS OFALCOHOL NICOTINE

• Decreased concentration

• Sedation

• Impaired motor function

• Increased energy

• Improved concentration

• Heightened performance

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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

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NATURAL HISTORY

• Continued combined use reflects reinforcing effects

• Using one drug may use of other

• Co-use progresses to avoid discomfort

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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)

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TREATMENT ISSUES

• Cognitive behavioral approach

• Medications

• Groups

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COGNITIVE BEHAVIORAL THERAPY

• Increase motivation for abstinence

• Re-establish life style conducive to abstinence

• Optimize physical functioning

• Relapse Prevention

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MEDICATIONS FOR RELAPSE PREVENTION

ALCOHOL DEPENDENCE

• Naltrexone (Trexan, Revia)

• Acamprosate (Campral)

NICOTINE DEPENDENCE

• Nicotine Replacement

• Buproprion

(Zyban, Wellbutrin)

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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

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ACAMPROSATE

• Calcium acetylhomotaurinate

• GABA, NMDA action

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

• FDA approval pending

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SMOKING CESSATION

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

• Nicotine Replacement

• Buproprion

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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

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BUPROPRION

• FDA approved for smoking cessation

• Antidepressant

• Mechanism involves serotonin, norepinephrine, dopamine

• Increased quit rates, abstinence

• Risk for seizures above 450 mg/day

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TREAT BOTH DEPENDENCIES

Voluntary smoking cessation

DOES NOT IMPAIR

alcohol dependence treatment

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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