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Towards a broader view of recovery
Journal of Substance Abuse Treatment, Vol. 10, pp. 101-105, Printed in the USA. All rights reserved.
1993
0740-5472/93
Copyright 0 1993Pergamon
$6.00 + .OO Press Ltd.
INTRODUCTION
Towards a Broader View of Recovery LORI D. KARAN,
MD
Division of Substance Abuse Medicine, Richmond, Virginia
Keywords - nicotine
dependency;
addiction;
chemical
ALTHOUGH ALCOHOL AND OTHER DRUGS, including
sedatives, stimulants, and narcotics, have long been recognized as addictive, tobacco use has been viewed more as a habit. This may have been in part due to the less marked tolerance, withdrawal symptomatology, and less conspicuous intoxicant effects of tobacco (Jaffe, 1990). The concept of drug dependence has continued to evolve, and tobacco smoking gradually has become recognized as a form of drug dependence. NIDA Research Monographs in the late 1970s (Krasnegor, 1979a, b) and the 1988 Surgeon General’s Report (U.S. Department of Health and Human Services, 1988), have focused on the addictive aspects of nicotine. Nicotine withdrawal and nicotine dependence are classified under “organic mental syndromes and disorders” and “psychoactive substance use disorders,” respectively in DSM-III-R (American Psychiatric Association, 1987). In fact, nicotine dependence is the most prevalent addiction and single most important preventable cause of death in the United States today (U.S. Department of Health and Human Services, 1989). Yet, historically, the diagnosis and treatment of nicotine dependence has not been integrated with the diagnosis and treatment of other chemical dependencies. A nicotine dependence committee was first formed within the American Society of Addiction Medicine, Inc. (ASAM) in 1985. The outgrowth of this committee’s work was to challenge the status quo. A thoughtprovoking and controversial workshop on tobacco-free inpatient treatment took place during the ASAM 1991 annual meeting. The initial project of publishing that workshop as a single article has grown into this special issue. This issue spotlights the philosophy, procedures, and history of some pioneering programs and
dependency.
includes pertinent related works in this field. What has evolved is a longitudinal interest in the movement to address nicotine dependence in persons with other addictive disorders. This issue contains a foreword (Goldsmith&Knapp, p. 107, this issue) that delineates and challenges the barriers to smoke-free environments and the treatment of nicotine addiction in chemically dependent persons. The notion of a broader view of recovery is put forth. Might not freedom from the compulsive use of nicotine be associated with improvements in physical, psychological, and social health, as well as spiritual growth which are similar to the goals of recovery for other addictions? Five inpatient chemical dependency treatment programs then explore their aspirations and experiences enforcing tobacco abstinence and motivating patients for continued cessation. These programs include The Gateway Rehabilitation Center in Aliquippa, Pennsylvania (Capretto, p. 113, this issue), the Medical College of Virginia (Karan, p. 117, this issue), The Cleveland Clinic (Kotz, p. 125, this issue), The CPC Parkwood Hospital (Fishman & Earley, p. 133, this issue), and The Minneapolis VA Medical Center (Pletcher, p. 139, this issue). All programs give a historical account of their efforts followed by a discussion of four key topics: staff issues, patient motivation, monitoring/ consequences, and community outreach. Despite the unique aspects of each program’s leadership, staffing, patient population, treatment philosophy, and treatment modalities, some striking similarities are apparent in these accounts. Hoffman and Slade (p. 153, this issue) graciously summarize these themes and provide an outline that treatment centers might follow in both becoming tobacco-free and actively addressing nicotine dependence. Potential roles and the need for regional approaches to face this problem are explored. At the time of this transformation in addictive disorders treatment, only the Minneapolis VA Medical
Requests for reprints should be addressed to Lori D. Karan, MD, Box 109 M.C.V. Station, Division of Substance Abuse Medicine, Richmond, VA 23298. 101
102
Center has been able to provide research data about their activities. These data are encouraging. Anne Joseph (p. 147, this issue) and her coworkers have found that patients were more interested in quitting tobacco and more likely to abstain from smoking after the changes in the policies and program at the Minneapolis VA Medical Center than before these changes. There was not an increase in early discharges from the program, nor did the patients feel that quitting smoking threatened their abstinence from other substances. Patients did regard smoking as different from the primary drug that brought them to treatment. In a second study, a small but significant positive effect, and not an adverse effect, was demonstrated for smoking cessation on drug and alcohol treatment outcome. Although all of the spotlighted programs continue to motivate patients for tobacco cessation and are enthusiastic in working with motivated individuals to quit, none of these inpatient programs persist in enforcing tobacco abstinence. As of Fall 1992, this author is aware of only Alina Lodge in New York State (piloting this frontier in 1985) (Delaney, 1988), The Halterman Center in London, Ohio, and The University of Texas Medical School at Houston that maintain a stance of requiring tobacco cessation. There has been little research about the DiClemente and Prochaska stages of change - precontemplation, contemplation, preparation, action, maintenance, and relapse (Prochaska & DiClemente, 1983; DiClemente et al., 1991) -in patients with chemical dependencies other than nicotine addiction. How a program might modify its treatment approaches and match them to a patient’s readiness for change has been explored for nicotine by Orleans and Hutchinson (p. 197, this issue), but not for other drugs. Educating patients and pursuing motivation before invoking abstinence challenges the premise that all therapeutic interventions are unsuccessful in the midst of active, mood-altering substance use. Additional questions arise when one considers treating concomitant addictions with different stages of change. Rephrased, is the role of the chemical dependency program to enforce tobacco abstinence and then to work on motivational factors so that maintenance of this action might be continued after treatment? Alternatively, might a chemical dependency treatment program educate persons about the addictive, psychoactive, and physically harmful aspects of nicotine, the benefits of quitting, and help persons anticipate their personal barriers to quitting, their internal and external supports, and design a personalized action plan for a specific time in the future? Is this latter approach feasible if at the same time, abstinence from all other addictive mood-altering substances is expected and enforced? Programs which recognize these differences struggle with how to give consistent messages to their patients. At this juncture, the questions seem endless about
L.D. Karan
best to optimize the treatment of nicotine addiction in persons with a past and/or present history of chemical dependency. With respect to the ability for patients to engage in treatment and overcome withdrawal in various therapeutic settings, is it better to tackle the addictions simultaneously or sequentially? How might external cues for the addictions interact, and how might this be affected by various degrees of motivation for individual drugs? Will the use of nicotine replacement improve treatment outcome and is there a role for nicotine maintenance? Understanding how nicotine addiction is similar and different from other drug addictions, including its neuroregulatory effects, diagnosis, course, and treatment, is helpful in clarifying concepts pertinent to all addictions. The original contributions in this issue begin to provide further insight into some of these areas. An article by Rosecrans and Karan (p. 161, this issue), uses the findings of drug discrimination research to propose a receptor mechanism for nicotine’s action. Nicotine may act as either an agonist or antagonist at its receptor. Nicotine’s actions as an antagonist may result in its ability to induce a refractory period, and this process has been termed desensitization. Individual differences in tobacco dependence may be due to differences in the initial sensitivity to either the aversive or rewarding effects of smoking, the ability and rate of desensitization, and the capability for up-anddown regulation of acetylcholine receptors. Whereas acute tolerance may be related to receptor desensitization, evidence of chronic tolerance has long thought to be related to the regulation of the numbers of acetylcholine receptors. A model relating various patterns of smoking with the capacity for acute and chronic tolerance is put forth, although it is noted that the full profiles of different patterns of smoking and the natural history of these patterns are not yet substantiated in research. Researchers from the Addiction Research Foundation in Toronto, Canada, and NIDA’s Addiction Research Center in Baltimore, Maryland, next team up to explore if relationships exist between the frequency of use of tobacco with that of alcohol, and various other drugs (Kozlowski et al., p. 171, this issue). It is suggested that cigarettes, coffee, and alcohol have a tighter association than the association of cigarettes with amphetamine, hallucinogens, cannabis, heroin, illegal methadone, other opiates, sedatives/tranquilizers, and/or glue/solvents. The strong relationship between nicotine and alcohol suggests that a measure of the severity of dependence to alcohol might be able to be used as an index of severity of dependence to cigarettes, and vice-versa. This may have both diagnostic and treatment implications. It is hypothesized that the absence of a dose-response relationship between the level of cigarette use and the level of opioid use may reflect a more homogeneously heavy cigarette
Introduction smoking population by the time these persons become opioid dependent. Similar reasoning could be extended to include stimulants; however, it should be noted that the data from this study was collected in the late 1970s and early 198Os, during the pre-crack era. Also, the lack of an association between the frequency of other drug use and cigarette smoking is less strong than the strength of the correlation of alcohol, caffeine, and cigarettes. The importance of John Hughes’ (p. 18 1, this issue) article is that it begins to look at indications for the use of nicotine replacement therapy during smoking cessation in patients who report a history of past alcohol and/or drug problems. The distinction between persons who have current vs. past problems with alcohol and other drugs is of interest. Further research is needed to see if these two groups warrant similar or different pharmacologic and/or nonpharmacologic smoking cessation strategies. The study in this issue looks at a subpopulation of persons in a randomized, placebo-controlled trial of nicotine gum. The 38 subjects who self-reported a past but not present history of alcohol/drug problems appeared more dependent on nicotine, less likely to stop smoking, and more likely to benefit from nicotine replacement than subjects without this history. However, these results are preliminary because formal diagnoses of alcohol/drug abuse/dependence were not obtained. Sees and Clark (p. 189, this issue) review some of the interrelationships between cigarette smoking and other chemical dependencies. They advocate that chemical dependency professionals should address and not ignore nicotine addiction; substance abusers are interested in smoking cessation, and there is no evidence in the literature that addressing nicotine addiction jeopardizes the achievement, maintenance, or preservation of sobriety. Orleans and Hutchinson (p. 197, this issue) surveyed the characteristics of tobacco use, motivation for quitting, and barriers for cessation in persons admitted to Carrier Foundation’s residential chemical dependency treatment program in Belle Mead, New Jersey, to identify ways to tailor nicotine addiction treatment goals and methods to the needs of these persons. The authors felt that because the patients surveyed were predominant!y heavy smokers with or at high risk of having medical sequelae due to their smoking, tracts with more intensive multicomponent behavioral treatment techniques and the possibility of adjunctive pharmacologic therapy were indicated. Some of their findings included that many smokers indicated that although they wanted to stop smoking, most were not sure that they could quit; that a majority of smokers lived with and/or associated with friends who were smokers; and that few of these persons were concerned that quitting smoking would threaten their sobriety. Therefore, treatment of nicotine addiction
103 might include working with patients to improve their feelings of self-efficacy and resist social pressures to smoke. The authors propose that nicotine addiction treatment in chemical dependency settings be geared to the smoker’s stage of change, so that smoking cessation would be offered to smokers in the action and maintenance stages to quit or stay quit, and motivational programs would be recommended to help contemplators and precontemplators move into action. Practical and effective strategies tailored to each of these stages of change are put forth, and a pilot foursession treatment program for motivating smokers in the precontemplation and contemplation stages of change to move into the action stage is depicted. This article should prove worthwhile to all chemical dependency treatment providers who are interested in addressing nicotine addiction in their programs. Terry Rustin (p. 209, this issue) proposes a set of visual analogue scales upon which smokers identify their position in each stage of change, based upon DiClemente and Prochaska’s model of these stages. He recognizes that measuring a client’s progress towards smoking cessation is important both for that individual’s therapy as well as for treatment matching and program evaluation research. These measures are more refined than simply noting the time an individual is abstinent from either tobacco or nicotine. The information is based upon self report. Whereas the contemplation, determination, and relapse ladders are subjectively based in thoughts and feelings, the action, abstinence, and maintenance ladders are more objectively based upon actions, quantity smoked, and time abstinent. I believe that the relapse ladder may need to be more finely developed in the future because considering smoking may be only one of many predictors of relapse. Rustin’s study showed highly consistent responses when subjects responded to the scale projected on a screen vs. printed on sheets of paper. In the future, longitudinal profiles of individual smokers can be followed to see the rates by which different smokers move through the stages of change, and how consistent these self reports are when compared with actual behavior. Janet Bobo and Carole Davis (p. 221, this issue) have approached the topic of smoking cessation techniques for persons with a history of alcohol problems in a novel fashion by surveying treatment professionals in recovery from alcoholism in rural Nebraska. Thirty-eight of 99 staff with a history of smoking were former smokers at the time of the survey, and only 5 of these individuals were abstinent from tobacco for less than 1 year. To further document the problems of having smoking staff address nicotine addiction, this survey found that former smokers and never smokers were more than six times as likely as current smokers to report that they routinely urged clients to quit smoking. The five most popular methods of
104
smoking cessation were quitting cold turkey (700’/0), relying on AA principles (28070), slowly reducing the number of cigarettes smoked (26Vo), finding a support group (11 (r/o), and using nicotine gum (11 Vo). The large percentage of recovering staff who quit smoking cold turkey does not indicate the ineffectivity of pharmacological, behavioral, and supportive psychologic therapies, but rather reflects historically the limited availability of these modalities, especially in rural areas. Identifying the methods which most effectively motivate and treat chemically dependent persons for nicotine addiction is of continued importance. The results of the survey by Bobo and Davis indicate that recovering persons do quit smoking with increasing time in recovery, and that they can lean upon methods which they found effective for recovery from their alcoholism. Of interest is that only 8% of the 81 recovering staff who ever quit smoking felt that their most successful attempt occurred during or within 6 months of completing their own intensive alcohol treatment program. Sixty-five percent of the recovering staff indicated that they did not feel more like drinking when they tried to quit smoking, although 11% felt otherwise. This data begins to address the timing and sequence by which some persons quit alcohol and cigarettes, as well as the impact of tobacco cessation efforts on the maintenance of sobriety from alcohol, once this is achieved. Especially in light of the clinical observation of patients who trade off one addiction for another, I wonder if person’s perceptions of the interrelationships between the two addictions would be more pronounced if both were active. An editorial by John Slade (p. 229, this issue) advocates considering cigarette smoking a disability similar to the disability invoked by other addictions, and protecting employees from job discrimination based upon this. New Jersey recently approved a law which sets this precedent. The result of job bias protection is the same outcome that was desired by cigarette manufacturers. However, recognition of smoking as a disability is far from the industry’s original goal of portraying cigarette smoking as a civil right. Exceptions when preferential employment may be given to nonsmokers include instances when smoking may worsen an employee’s health due to its compounding effects upon an occupational hazard, or when it interferes directly with job performance. Thus, state laws such as New Jersey’s, can help chemical dependency units attain nonsmoking staff to treat their addicted clients. Finally, Linda Redmond (p. 233, this issue) reviews and critiques The Clinical Management of Nicotine Dependence, as compiled and edited by James Cocores (1991). In the near future, Nicotine Addiction: Principles and Management by C. Tracy Orleans and John Slade will be published by Oxford University Press. This textbook is quite promising, as it is logically struc-
L.D. Karan
tured with an impressive list of both contents and authors. Rapid changes in public attitude and increased knowledge lends excitement to the future prospects for preventing, diagnosing, and treating nicotine addiction. Addressing this issue in chemically dependent persons is in its infancy. This issue is clinically relevant in that it highlights the key experiences and themes of chemical dependency programs which have pioneered this integration. Contributions that are authored by leaders in this field provide new insights and direction helpful for both understanding and treating nicotine addiction. By raising and exploring the notion of a broader view of recovery, which encompasses recovery from dependencies including nicotine, it is hoped that this special issue of The Journal of Substance Abuse Treatment will be a seminal contribution to addiction medicine.
REFERENCES Psychiatric Association. (1987). Diagnostic nnd Statistical Manual of Mental Disorders, Third Edition, Revised. Wash-
-American
ington, DC: Author. Bobo, J., & Davis, C.M. (1993). Recovering staff and smoking in chemical dependency programs in rural Nebraska. Journal of Substance Abuse Treatment, 10, 221-227. Capretto, N.A. (1993). Confronting nicotine dependency at The Gateway Rehabilitation Center in Aliquippa, Pennsylvania. Journal of Substance Abuse Treatment, 10, 113-l 16. Cocores, J.A. (1991). The clinical management of nicotine dependence. New York: Springer-Verlag. Delaney, G.O. (1988). Tobacco dependence in treating alcoholism.
NJ Medicine, 85, 131-134. DiClemente, C.C., Prochaska, J.O., Fairhurst, S.K., Velicer, W.F., Velasquez, M.M., & Rossi, J.S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clini-
cal Psychology, 59, 295-304. Fishman, M.L., & Earley, P.H. (1993). Treatment centers-The next challenge: The Counterpoint Unit at CPC Parkwood Hospital. Journal of Substance Abuse Treatment, 10, 133-137. Goldsmith, R., & Knapp, J. (1993). Towards a broader view of recovery. Journal of Substance Abuse Treatment, 10, 107-J 11. Hoffman, A., & Slade, J. (1993). Following the pioneers: Addressing tobacco in chemical dependency treatment. Journal of Sub-
stance Abuse Treatment, 10, 153-160. Hughes, J.R. (1993). Treatment of smoking cessation in smokers with past alcohol/drug problems. Journal of Substance Abuse Treatment, 10, 181-187. Jaffe, J.H. (1990). Tobacco smoking and nicotine dependence. In S. Wonnacott, M.A.H. Russell, J.D. Stolerman (Eds.), Nico-
tine psychopharmacology: Molecular, cellular, and behavioral aspects (pp. l-37). Oxford: Oxford University Press. Joseph, A.M. (1993). Nicotine treatment at the drug dependency program of the Minneapolis VA Medical Center: A researcher’s perspective. Journal of Substance Abuse Treatment, 10, 147-152. Karan, L.D. (1993). Initial encounters with tobacco cessation on the inpatient substance abuse unit of the Medical College of Virginia. Journal of Substance Abuse Treatment, 10, 117-123. Kotz, M.M. (1993). A smoke-free chemical dependency unit: The Cleveland Clinic experience. Journal of Substance Abuse Treat-
ment, 10, 125-131.
IO5
Introduction Kozlowski, L., Henningfield, J., Kennan, R.M., Lei, H., Leigh, G., Jelinek, L.C., Pope, M.A., & Haertzen, C.A. (1993). Patterns of alcohol, cigarette, and caffeine and other drug use in two drug abusing populations. Journal of Substance Abuse Treatment, 10, 171-179. Krasnegor, N.A. (Ed.). (1979a). Cigarettesmoking as a dependence process. (NIDA Research Monograph, 23. DHHS Publication No. (ADM)79-800.) Washington, DC: U.S. Government Printing Office. Krasnegor, N.A. (Ed.). (1979b). The behavioral aspects of smoking. NIDA Research Monograph, 26. DHHS Publication No. (ADM)79-882. Washington, DC: U.S. Government Printing Office. Orleans, C.T., & Hutchinson, D. (1993). Tailoring nicotine addiction treatments for chemical dependency patients. Journal of Substance Abuse Treatment, 10, 197-208. Pletcher, V.C. (1993). Nicotine treatment at the drug dependency program of the Minneapolis VA Medical Center: A program director’s perspective. Journal of Substance Abuse Treatment, 10, 139-145. Prochaska, J.O., & DiClemente, C.C. (1983). Stages and processes of self change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51,
390-395.
Rosecrans, J.A., & Karan, L.D. (1993). Neurobehavioral mechanisms of nicotine action: Role in the initiation and maintenance of tobacco dependence. Journal of Substance Abuse Treatment, 10, 161-170. Rustin, T.A., & Tate, J.C. (1993). Measuring the stages of change in cigarette smokers. Journal of Substance Abuse Treatment, 10, 209-220. Sees, K.L., & Clark, H.W. (1993). When to begin smoking cessation in substance abusers. Journal of Substance Abuse Treat-
ment, 10, 189-195. Slade, J. (1993). Protection
from job bias for people who smoke.
Journal of Substance Abuse Treatment, 10, 229-23 1. U.S. Department of Health and Human Services. (1988). The health consequences of smoking: Nicotine addiction. A Report of the Surgeon Genera/. Office on Smoking and Health, DHHS Publication No. (CDC) 88-8406. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (1989). Reduc-
ing the health consequences of smoking: 25 years of progress. A Report of the Surgeon General. Office on Smoking and Health, DHHS Publication No. (CDC) 84-8411. DC: U.S. Government Printing Office.
Washington,
’
1993
0740-5472/93
Copyright 0 1993Pergamon
$6.00 + .OO Press Ltd.
INTRODUCTION
Towards a Broader View of Recovery LORI D. KARAN,
MD
Division of Substance Abuse Medicine, Richmond, Virginia
Keywords - nicotine
dependency;
addiction;
chemical
ALTHOUGH ALCOHOL AND OTHER DRUGS, including
sedatives, stimulants, and narcotics, have long been recognized as addictive, tobacco use has been viewed more as a habit. This may have been in part due to the less marked tolerance, withdrawal symptomatology, and less conspicuous intoxicant effects of tobacco (Jaffe, 1990). The concept of drug dependence has continued to evolve, and tobacco smoking gradually has become recognized as a form of drug dependence. NIDA Research Monographs in the late 1970s (Krasnegor, 1979a, b) and the 1988 Surgeon General’s Report (U.S. Department of Health and Human Services, 1988), have focused on the addictive aspects of nicotine. Nicotine withdrawal and nicotine dependence are classified under “organic mental syndromes and disorders” and “psychoactive substance use disorders,” respectively in DSM-III-R (American Psychiatric Association, 1987). In fact, nicotine dependence is the most prevalent addiction and single most important preventable cause of death in the United States today (U.S. Department of Health and Human Services, 1989). Yet, historically, the diagnosis and treatment of nicotine dependence has not been integrated with the diagnosis and treatment of other chemical dependencies. A nicotine dependence committee was first formed within the American Society of Addiction Medicine, Inc. (ASAM) in 1985. The outgrowth of this committee’s work was to challenge the status quo. A thoughtprovoking and controversial workshop on tobacco-free inpatient treatment took place during the ASAM 1991 annual meeting. The initial project of publishing that workshop as a single article has grown into this special issue. This issue spotlights the philosophy, procedures, and history of some pioneering programs and
dependency.
includes pertinent related works in this field. What has evolved is a longitudinal interest in the movement to address nicotine dependence in persons with other addictive disorders. This issue contains a foreword (Goldsmith&Knapp, p. 107, this issue) that delineates and challenges the barriers to smoke-free environments and the treatment of nicotine addiction in chemically dependent persons. The notion of a broader view of recovery is put forth. Might not freedom from the compulsive use of nicotine be associated with improvements in physical, psychological, and social health, as well as spiritual growth which are similar to the goals of recovery for other addictions? Five inpatient chemical dependency treatment programs then explore their aspirations and experiences enforcing tobacco abstinence and motivating patients for continued cessation. These programs include The Gateway Rehabilitation Center in Aliquippa, Pennsylvania (Capretto, p. 113, this issue), the Medical College of Virginia (Karan, p. 117, this issue), The Cleveland Clinic (Kotz, p. 125, this issue), The CPC Parkwood Hospital (Fishman & Earley, p. 133, this issue), and The Minneapolis VA Medical Center (Pletcher, p. 139, this issue). All programs give a historical account of their efforts followed by a discussion of four key topics: staff issues, patient motivation, monitoring/ consequences, and community outreach. Despite the unique aspects of each program’s leadership, staffing, patient population, treatment philosophy, and treatment modalities, some striking similarities are apparent in these accounts. Hoffman and Slade (p. 153, this issue) graciously summarize these themes and provide an outline that treatment centers might follow in both becoming tobacco-free and actively addressing nicotine dependence. Potential roles and the need for regional approaches to face this problem are explored. At the time of this transformation in addictive disorders treatment, only the Minneapolis VA Medical
Requests for reprints should be addressed to Lori D. Karan, MD, Box 109 M.C.V. Station, Division of Substance Abuse Medicine, Richmond, VA 23298. 101
102
Center has been able to provide research data about their activities. These data are encouraging. Anne Joseph (p. 147, this issue) and her coworkers have found that patients were more interested in quitting tobacco and more likely to abstain from smoking after the changes in the policies and program at the Minneapolis VA Medical Center than before these changes. There was not an increase in early discharges from the program, nor did the patients feel that quitting smoking threatened their abstinence from other substances. Patients did regard smoking as different from the primary drug that brought them to treatment. In a second study, a small but significant positive effect, and not an adverse effect, was demonstrated for smoking cessation on drug and alcohol treatment outcome. Although all of the spotlighted programs continue to motivate patients for tobacco cessation and are enthusiastic in working with motivated individuals to quit, none of these inpatient programs persist in enforcing tobacco abstinence. As of Fall 1992, this author is aware of only Alina Lodge in New York State (piloting this frontier in 1985) (Delaney, 1988), The Halterman Center in London, Ohio, and The University of Texas Medical School at Houston that maintain a stance of requiring tobacco cessation. There has been little research about the DiClemente and Prochaska stages of change - precontemplation, contemplation, preparation, action, maintenance, and relapse (Prochaska & DiClemente, 1983; DiClemente et al., 1991) -in patients with chemical dependencies other than nicotine addiction. How a program might modify its treatment approaches and match them to a patient’s readiness for change has been explored for nicotine by Orleans and Hutchinson (p. 197, this issue), but not for other drugs. Educating patients and pursuing motivation before invoking abstinence challenges the premise that all therapeutic interventions are unsuccessful in the midst of active, mood-altering substance use. Additional questions arise when one considers treating concomitant addictions with different stages of change. Rephrased, is the role of the chemical dependency program to enforce tobacco abstinence and then to work on motivational factors so that maintenance of this action might be continued after treatment? Alternatively, might a chemical dependency treatment program educate persons about the addictive, psychoactive, and physically harmful aspects of nicotine, the benefits of quitting, and help persons anticipate their personal barriers to quitting, their internal and external supports, and design a personalized action plan for a specific time in the future? Is this latter approach feasible if at the same time, abstinence from all other addictive mood-altering substances is expected and enforced? Programs which recognize these differences struggle with how to give consistent messages to their patients. At this juncture, the questions seem endless about
L.D. Karan
best to optimize the treatment of nicotine addiction in persons with a past and/or present history of chemical dependency. With respect to the ability for patients to engage in treatment and overcome withdrawal in various therapeutic settings, is it better to tackle the addictions simultaneously or sequentially? How might external cues for the addictions interact, and how might this be affected by various degrees of motivation for individual drugs? Will the use of nicotine replacement improve treatment outcome and is there a role for nicotine maintenance? Understanding how nicotine addiction is similar and different from other drug addictions, including its neuroregulatory effects, diagnosis, course, and treatment, is helpful in clarifying concepts pertinent to all addictions. The original contributions in this issue begin to provide further insight into some of these areas. An article by Rosecrans and Karan (p. 161, this issue), uses the findings of drug discrimination research to propose a receptor mechanism for nicotine’s action. Nicotine may act as either an agonist or antagonist at its receptor. Nicotine’s actions as an antagonist may result in its ability to induce a refractory period, and this process has been termed desensitization. Individual differences in tobacco dependence may be due to differences in the initial sensitivity to either the aversive or rewarding effects of smoking, the ability and rate of desensitization, and the capability for up-anddown regulation of acetylcholine receptors. Whereas acute tolerance may be related to receptor desensitization, evidence of chronic tolerance has long thought to be related to the regulation of the numbers of acetylcholine receptors. A model relating various patterns of smoking with the capacity for acute and chronic tolerance is put forth, although it is noted that the full profiles of different patterns of smoking and the natural history of these patterns are not yet substantiated in research. Researchers from the Addiction Research Foundation in Toronto, Canada, and NIDA’s Addiction Research Center in Baltimore, Maryland, next team up to explore if relationships exist between the frequency of use of tobacco with that of alcohol, and various other drugs (Kozlowski et al., p. 171, this issue). It is suggested that cigarettes, coffee, and alcohol have a tighter association than the association of cigarettes with amphetamine, hallucinogens, cannabis, heroin, illegal methadone, other opiates, sedatives/tranquilizers, and/or glue/solvents. The strong relationship between nicotine and alcohol suggests that a measure of the severity of dependence to alcohol might be able to be used as an index of severity of dependence to cigarettes, and vice-versa. This may have both diagnostic and treatment implications. It is hypothesized that the absence of a dose-response relationship between the level of cigarette use and the level of opioid use may reflect a more homogeneously heavy cigarette
Introduction smoking population by the time these persons become opioid dependent. Similar reasoning could be extended to include stimulants; however, it should be noted that the data from this study was collected in the late 1970s and early 198Os, during the pre-crack era. Also, the lack of an association between the frequency of other drug use and cigarette smoking is less strong than the strength of the correlation of alcohol, caffeine, and cigarettes. The importance of John Hughes’ (p. 18 1, this issue) article is that it begins to look at indications for the use of nicotine replacement therapy during smoking cessation in patients who report a history of past alcohol and/or drug problems. The distinction between persons who have current vs. past problems with alcohol and other drugs is of interest. Further research is needed to see if these two groups warrant similar or different pharmacologic and/or nonpharmacologic smoking cessation strategies. The study in this issue looks at a subpopulation of persons in a randomized, placebo-controlled trial of nicotine gum. The 38 subjects who self-reported a past but not present history of alcohol/drug problems appeared more dependent on nicotine, less likely to stop smoking, and more likely to benefit from nicotine replacement than subjects without this history. However, these results are preliminary because formal diagnoses of alcohol/drug abuse/dependence were not obtained. Sees and Clark (p. 189, this issue) review some of the interrelationships between cigarette smoking and other chemical dependencies. They advocate that chemical dependency professionals should address and not ignore nicotine addiction; substance abusers are interested in smoking cessation, and there is no evidence in the literature that addressing nicotine addiction jeopardizes the achievement, maintenance, or preservation of sobriety. Orleans and Hutchinson (p. 197, this issue) surveyed the characteristics of tobacco use, motivation for quitting, and barriers for cessation in persons admitted to Carrier Foundation’s residential chemical dependency treatment program in Belle Mead, New Jersey, to identify ways to tailor nicotine addiction treatment goals and methods to the needs of these persons. The authors felt that because the patients surveyed were predominant!y heavy smokers with or at high risk of having medical sequelae due to their smoking, tracts with more intensive multicomponent behavioral treatment techniques and the possibility of adjunctive pharmacologic therapy were indicated. Some of their findings included that many smokers indicated that although they wanted to stop smoking, most were not sure that they could quit; that a majority of smokers lived with and/or associated with friends who were smokers; and that few of these persons were concerned that quitting smoking would threaten their sobriety. Therefore, treatment of nicotine addiction
103 might include working with patients to improve their feelings of self-efficacy and resist social pressures to smoke. The authors propose that nicotine addiction treatment in chemical dependency settings be geared to the smoker’s stage of change, so that smoking cessation would be offered to smokers in the action and maintenance stages to quit or stay quit, and motivational programs would be recommended to help contemplators and precontemplators move into action. Practical and effective strategies tailored to each of these stages of change are put forth, and a pilot foursession treatment program for motivating smokers in the precontemplation and contemplation stages of change to move into the action stage is depicted. This article should prove worthwhile to all chemical dependency treatment providers who are interested in addressing nicotine addiction in their programs. Terry Rustin (p. 209, this issue) proposes a set of visual analogue scales upon which smokers identify their position in each stage of change, based upon DiClemente and Prochaska’s model of these stages. He recognizes that measuring a client’s progress towards smoking cessation is important both for that individual’s therapy as well as for treatment matching and program evaluation research. These measures are more refined than simply noting the time an individual is abstinent from either tobacco or nicotine. The information is based upon self report. Whereas the contemplation, determination, and relapse ladders are subjectively based in thoughts and feelings, the action, abstinence, and maintenance ladders are more objectively based upon actions, quantity smoked, and time abstinent. I believe that the relapse ladder may need to be more finely developed in the future because considering smoking may be only one of many predictors of relapse. Rustin’s study showed highly consistent responses when subjects responded to the scale projected on a screen vs. printed on sheets of paper. In the future, longitudinal profiles of individual smokers can be followed to see the rates by which different smokers move through the stages of change, and how consistent these self reports are when compared with actual behavior. Janet Bobo and Carole Davis (p. 221, this issue) have approached the topic of smoking cessation techniques for persons with a history of alcohol problems in a novel fashion by surveying treatment professionals in recovery from alcoholism in rural Nebraska. Thirty-eight of 99 staff with a history of smoking were former smokers at the time of the survey, and only 5 of these individuals were abstinent from tobacco for less than 1 year. To further document the problems of having smoking staff address nicotine addiction, this survey found that former smokers and never smokers were more than six times as likely as current smokers to report that they routinely urged clients to quit smoking. The five most popular methods of
104
smoking cessation were quitting cold turkey (700’/0), relying on AA principles (28070), slowly reducing the number of cigarettes smoked (26Vo), finding a support group (11 (r/o), and using nicotine gum (11 Vo). The large percentage of recovering staff who quit smoking cold turkey does not indicate the ineffectivity of pharmacological, behavioral, and supportive psychologic therapies, but rather reflects historically the limited availability of these modalities, especially in rural areas. Identifying the methods which most effectively motivate and treat chemically dependent persons for nicotine addiction is of continued importance. The results of the survey by Bobo and Davis indicate that recovering persons do quit smoking with increasing time in recovery, and that they can lean upon methods which they found effective for recovery from their alcoholism. Of interest is that only 8% of the 81 recovering staff who ever quit smoking felt that their most successful attempt occurred during or within 6 months of completing their own intensive alcohol treatment program. Sixty-five percent of the recovering staff indicated that they did not feel more like drinking when they tried to quit smoking, although 11% felt otherwise. This data begins to address the timing and sequence by which some persons quit alcohol and cigarettes, as well as the impact of tobacco cessation efforts on the maintenance of sobriety from alcohol, once this is achieved. Especially in light of the clinical observation of patients who trade off one addiction for another, I wonder if person’s perceptions of the interrelationships between the two addictions would be more pronounced if both were active. An editorial by John Slade (p. 229, this issue) advocates considering cigarette smoking a disability similar to the disability invoked by other addictions, and protecting employees from job discrimination based upon this. New Jersey recently approved a law which sets this precedent. The result of job bias protection is the same outcome that was desired by cigarette manufacturers. However, recognition of smoking as a disability is far from the industry’s original goal of portraying cigarette smoking as a civil right. Exceptions when preferential employment may be given to nonsmokers include instances when smoking may worsen an employee’s health due to its compounding effects upon an occupational hazard, or when it interferes directly with job performance. Thus, state laws such as New Jersey’s, can help chemical dependency units attain nonsmoking staff to treat their addicted clients. Finally, Linda Redmond (p. 233, this issue) reviews and critiques The Clinical Management of Nicotine Dependence, as compiled and edited by James Cocores (1991). In the near future, Nicotine Addiction: Principles and Management by C. Tracy Orleans and John Slade will be published by Oxford University Press. This textbook is quite promising, as it is logically struc-
L.D. Karan
tured with an impressive list of both contents and authors. Rapid changes in public attitude and increased knowledge lends excitement to the future prospects for preventing, diagnosing, and treating nicotine addiction. Addressing this issue in chemically dependent persons is in its infancy. This issue is clinically relevant in that it highlights the key experiences and themes of chemical dependency programs which have pioneered this integration. Contributions that are authored by leaders in this field provide new insights and direction helpful for both understanding and treating nicotine addiction. By raising and exploring the notion of a broader view of recovery, which encompasses recovery from dependencies including nicotine, it is hoped that this special issue of The Journal of Substance Abuse Treatment will be a seminal contribution to addiction medicine.
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NJ Medicine, 85, 131-134. DiClemente, C.C., Prochaska, J.O., Fairhurst, S.K., Velicer, W.F., Velasquez, M.M., & Rossi, J.S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clini-
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tine psychopharmacology: Molecular, cellular, and behavioral aspects (pp. l-37). Oxford: Oxford University Press. Joseph, A.M. (1993). Nicotine treatment at the drug dependency program of the Minneapolis VA Medical Center: A researcher’s perspective. Journal of Substance Abuse Treatment, 10, 147-152. Karan, L.D. (1993). Initial encounters with tobacco cessation on the inpatient substance abuse unit of the Medical College of Virginia. Journal of Substance Abuse Treatment, 10, 117-123. Kotz, M.M. (1993). A smoke-free chemical dependency unit: The Cleveland Clinic experience. Journal of Substance Abuse Treat-
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Introduction Kozlowski, L., Henningfield, J., Kennan, R.M., Lei, H., Leigh, G., Jelinek, L.C., Pope, M.A., & Haertzen, C.A. (1993). Patterns of alcohol, cigarette, and caffeine and other drug use in two drug abusing populations. Journal of Substance Abuse Treatment, 10, 171-179. Krasnegor, N.A. (Ed.). (1979a). Cigarettesmoking as a dependence process. (NIDA Research Monograph, 23. DHHS Publication No. (ADM)79-800.) Washington, DC: U.S. Government Printing Office. Krasnegor, N.A. (Ed.). (1979b). The behavioral aspects of smoking. NIDA Research Monograph, 26. DHHS Publication No. (ADM)79-882. Washington, DC: U.S. Government Printing Office. Orleans, C.T., & Hutchinson, D. (1993). Tailoring nicotine addiction treatments for chemical dependency patients. Journal of Substance Abuse Treatment, 10, 197-208. Pletcher, V.C. (1993). Nicotine treatment at the drug dependency program of the Minneapolis VA Medical Center: A program director’s perspective. Journal of Substance Abuse Treatment, 10, 139-145. Prochaska, J.O., & DiClemente, C.C. (1983). Stages and processes of self change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51,
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Rosecrans, J.A., & Karan, L.D. (1993). Neurobehavioral mechanisms of nicotine action: Role in the initiation and maintenance of tobacco dependence. Journal of Substance Abuse Treatment, 10, 161-170. Rustin, T.A., & Tate, J.C. (1993). Measuring the stages of change in cigarette smokers. Journal of Substance Abuse Treatment, 10, 209-220. Sees, K.L., & Clark, H.W. (1993). When to begin smoking cessation in substance abusers. Journal of Substance Abuse Treat-
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from job bias for people who smoke.
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Washington,
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