1. Copyright Alcohol Medical Scholars Program1 The Relationships Between Alcohol Use Disorders and Nicotine Dependence Margaret Rukstalis, M.D. University of Pennsylvania School of Medicine April 26, 2002

2. Copyright Alcohol Medical Scholars Program2 INTRODUCTION Material is relevant to health professionals –Medical Students –Nurses –Staff Goal: To place alcohol use disorders and nicotine dependence into clinical perspective

3. Copyright Alcohol Medical Scholars Program3 OVERVIEW Introduction to substance use disorders Application to alcohol use disorders Relevance to nicotine use disorders Relationships among the two substance use disorders

4. Copyright Alcohol Medical Scholars Program4 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

5. Copyright Alcohol Medical Scholars Program5 DSM IV DEPENDENCE 1.Tolerance 2.Withdrawal-usually the opposite of acute effects 3.Using more than intended or more often 4.Persistent desire to cut back 5.Lots of time using or recovering 6.Decreased function: social/occupational/recreational 7.Continued use despite physical/psychological problems (lung disease, cancer, depression, etc.)

6. Copyright Alcohol Medical Scholars Program6 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

7. Copyright Alcohol Medical Scholars Program7 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

8. Copyright Alcohol Medical Scholars Program8 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

9. Copyright Alcohol Medical Scholars Program9 ALCOHOL INTOXICATION Problems thinking clearly while drunk Impaired motor skills Impaired judgment Blackouts Hangovers

10. Copyright Alcohol Medical Scholars Program10 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

11. Copyright Alcohol Medical Scholars Program11 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

12. Copyright Alcohol Medical Scholars Program12 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

13. Copyright Alcohol Medical Scholars Program13 DSM IV: NICOTINE DEPENDENCE 1.Tolerance 2.Withdrawal-irritability, anxiety, insomnia 3.Using more than intended or more often 4.Persistent desire to cut back 5.Lots of time using (NOT recovering) 6.Decreased function: social/occupational/recreational functioning 7.Continued use despite physical/psychological problems (lung disease, cancer, depression, etc.)

14. Copyright Alcohol Medical Scholars Program14 ACUTE NICOTINE EFFECTS Feeling energized Enhanced concentration Improved performance May decrease some effects of alcohol

15. Copyright Alcohol Medical Scholars Program15 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

16. Copyright Alcohol Medical Scholars Program16 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

17. Copyright Alcohol Medical Scholars Program17 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

18. Copyright Alcohol Medical Scholars Program18 ACUTE EFFECTS OF ALCOHOL NICOTINE Decreased concentration Sedation Impaired motor function Increased energy Improved concentration Heightened performance

19. Copyright Alcohol Medical Scholars Program19 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

20. Copyright Alcohol Medical Scholars Program20 NATURAL HISTORY Continued combined use reflects reinforcing effects Using one drug may use of other Co-use progresses to avoid discomfort

21. Copyright Alcohol Medical Scholars Program21 GENETIC vs. ENVIRONMENT Nicotine Dependence Alcohol Dependence Genetic Environment Genetic R= 0.68 (0.61-0.74) Environment R= 0.23 (90.14-0.3)

22. Copyright Alcohol Medical Scholars Program22 TREATMENT ISSUES Cognitive behavioral approach Medications Groups

23. Copyright Alcohol Medical Scholars Program23 COGNITIVE BEHAVIORAL THERAPY Increase motivation for abstinence Re-establish life style conducive to abstinence Optimize physical functioning Relapse Prevention

24. Copyright Alcohol Medical Scholars Program24 MEDICATIONS FOR RELAPSE PREVENTION ALCOHOL DEPENDENCE Naltrexone (Trexan, Revia) Acamprosate (Campral) NICOTINE DEPENDENCE Nicotine Replacement Buproprion (Zyban, Wellbutrin)

25. Copyright Alcohol Medical Scholars Program25 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

26. Copyright Alcohol Medical Scholars Program26 ACAMPROSATE Calcium acetylhomotaurinate GABA, NMDA action Acamprosate vs. placebo –Greater completion rates –Longer time to first drink –Higher abstinence FDA approval pending

27. Copyright Alcohol Medical Scholars Program27 SMOKING CESSATION Cognitive Behavioral Therapy –Group or individual –Homework assignments –Set a quit date –Relapse Prevention Nicotine Replacement Buproprion

28. Copyright Alcohol Medical Scholars Program28 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

29. Copyright Alcohol Medical Scholars Program29 BUPROPRION FDA approved for smoking cessation Antidepressant Mechanism involves serotonin, norepinephrine, dopamine Increased quit rates, abstinence Risk for seizures above 450 mg/day

30. Copyright Alcohol Medical Scholars Program30 TREAT BOTH DEPENDENCIES Voluntary smoking cessation DOES NOT IMPAIR alcohol dependence treatment

31. Copyright Alcohol Medical Scholars Program31 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