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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
Copyright Alcohol Medical Scholars Program 2
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 3
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 4
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.)
Copyright Alcohol Medical Scholars Program 6
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
Copyright Alcohol Medical Scholars Program 11
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 12
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 13
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.)
Copyright Alcohol Medical Scholars Program 14
ACUTE NICOTINE EFFECTS
• Feeling energized
• Enhanced concentration
• Improved performance
• May decrease some effects of alcohol
Copyright Alcohol Medical Scholars Program 15
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
Copyright Alcohol Medical Scholars Program 16
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 17
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 18
ACUTE EFFECTS OFALCOHOL NICOTINE
• Decreased concentration
• Sedation
• Impaired motor function
• Increased energy
• Improved concentration
• Heightened performance
Copyright Alcohol Medical Scholars Program 19
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
Copyright Alcohol Medical Scholars Program 20
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 21
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
Copyright Alcohol Medical Scholars Program 23
COGNITIVE BEHAVIORAL THERAPY
• Increase motivation for abstinence
• Re-establish life style conducive to abstinence
• Optimize physical functioning
• Relapse Prevention
Copyright Alcohol Medical Scholars Program 24
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
Copyright Alcohol Medical Scholars Program 26
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 27
SMOKING CESSATION
• Cognitive Behavioral Therapy– Group or individual– Homework assignments– Set a quit date– Relapse Prevention
• Nicotine Replacement
• Buproprion
Copyright Alcohol Medical Scholars Program 28
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 29
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 30
TREAT BOTH DEPENDENCIES
Voluntary smoking cessation
DOES NOT IMPAIR
alcohol dependence treatment
Copyright Alcohol Medical Scholars Program 31
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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