MYTH #1. Nicotine is a harmful, medically dangerous drug. Nicotine: Myths, Realities & Treatment OBJECTIVES FACT. CSAM Board Review Course, 10/23/08

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1 Nicotine: Myths, Realities & Treatment CSAM Board Review Course, Newport Beach, CA Presented by David P.L. Sachs, MD Director, Palo Alto Center for Pulmonary Disease Prevention & Clinical Associate Professor, Division of Pulmonary & Critical Care Medicine Stanford University School of Medicine Stanford, CA October 23, 2008 OBJECTIVES Difference between nicotine dependence vs. tobacco dependence Genetic basis for nicotine dependence CNS Neuropathophysiology Chronic medical disease nature of tobacco dependence Tobacco-Dependence Treatment Paradigm shift Long-term maintenance & relapse prevention Nicotine Dependence Treatment California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 2 MYTH #1 Nicotine is a harmful, medically dangerous drug FACT Nicotine is one of the most addicting drugs Humans and animals easily become dependent on nicotine California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 3 California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 4 Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 1

2 Nicotine Serves as a Positive Reinforcer and Is Rewarding to Animals Animals Also Experience Physical Symptoms of Nicotine Withdrawal Similar to cocaine, amphetamine & alcohol The Face of Nicotine Withdrawal Video clip from study by Bengt E. Hildebrand, et al. Psychopharmacol 1997;129: California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 7 Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 2

3 FACT Nicotine is one of the most addicting drugs Humans and animals easily become dependent on nicotine But, is nicotine harmful or medically dangerous? Medical Consequences of Nicotine Dependence None Chronic, nicotine medication use after stopping tobacco use likelihood of cardiac events 1,2,3 Sources: 1 Murray RP, et al. Chest : Arch Int Med : Mahmarian JJ, et al. J Am Coll Cardiol : California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 9 California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 10 FACT Nicotine is medically safe Medical Consequences of Tobacco Dependence Massively Overwhelming!! California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 11 California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 12 Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 3

4 90% 30% Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 4

5 Addictive Nature of: Addictive Nature of: Drug Dependence Criteria Cigarettes Drug Dependence Criteria Cigarettes Nicotine Animal self-administration Animal self-administration Psychoactive & pleasant effects Psychoactive & pleasant effects Compulsive use despite harmful effects High relapse rate after stopping use (in absence of treatment) Development of tolerance & physical dependence California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 19 Compulsive use despite harmful effects High relapse rate after stopping use (in absence of treatment) Development of tolerance & physical dependence California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 5

6 What Is Tobacco Dependence? Nicotine Dependence Tobacco Dependence REALITY #1 Nicotine is highly addictive BUT is not a harmful, medically dangerous drug. California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 21 California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 22 REALITY #2 Tobacco smoke kills. Nicotine, per se, does not. California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 23 REALITY #3 Nicotine, delivered as a medication, is safe & effective even for years to life. California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 24 Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 6

7 MYTH #2 Cigarette smoking is merely a vile, nasty, bad habit. California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 25 Genetics of Nicotine Addiction I Different Genes May Be Involved In Smoking Initiation Maintaining Nicotine Dependence Maintaining Tobacco Dependence Facilitating Stopping Tobacco Use» DRD2» SLC6A3 Sources: Lerman C, Berrettini W. Am J Med Genetics B: Lerman C, et al. Health Psychol : California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 27 Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 7

8 Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 8

9 SUPRESS FACT Cigarette smoking is NOT a habit California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 36 Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 9

10 What Is Cigarette Smoking? The Primary Symptom of Tobacco Dependence California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 37 What Is Tobacco Dependence? It is a CHRONIC MEDICAL DISEASE California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 38 Treatment of Tobacco Dependence: U.S. Food & Drug Administration June 9, 1997 Treatment of Tobacco Dependence: CALIFORNIA THORACIC SOCIETY (CTS) POSITION PAPER Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 10

11 Both Guidelines Concluded Treatment of Tobacco Dependence: PHS 2008 Clinical Practice Guideline Tobacco Dependence Exhibits Features of a Chronic Disease: Long-Term disorder Periods of relapse & remission Requires ongoing rather than acute care The data compellingly show that pharmacologic and counseling treatment each independently boost treatment effectiveness Sources: 1) Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Dept of Health & Human Services. Public Health Service. May ( 2) California Thoracic Society. Position Paper: Medical Management for Tobacco Dependence ( 41 California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 42 Both Guidelines Concluded Numerous Effective Pharmacotherapies for Treating Tobacco Dependence Are Available Should be used with essentially all patients» Preferably a combination of at least 2 medications Sources: 1) Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Dept of Health & Human Services. Public Health Service. May ( 2) California Thoracic Society. Position Paper: Medical Management for Tobacco Dependence ( California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 43 REALITY #4 Cigarette smoking is far more than a habit: It is the cardinal symptom of tobacco dependence California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 44 Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 11

12 REALITY #5 Tobacco dependence is a chronic medical disease & must be treated as such. Nicotine Absorption from Tobacco Smoke Extra-ordinarily fast Highly concentrated Puff-to-puff» 10x more concentrated in arterial blood which is what the brain sees! in 5-7 seconds Than in venous blood NO medication delivers nicotine as fast or concentrated» Finger tip control over mood and cognitive state California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 45 California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 46 Natural History of Tobacco Dependence, Clinical Trials, & Relapse Prevention Natural History of Tobacco Dependence: THE COLD TURKEY QUIT California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 12

13 Tobacco-Dependence Medications: Clinical Trial Results Medication Matters Improved Treatment with Tobacco-Dependence Medications: Clinical Trial Results Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 13

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15 Key Concepts High nicotine-dependent patients do not have as good treatment outcome as lownicotine dependent patients Given the same treatment True for varenicline 1 High nicotine-dependent patients need more intense treatment 2 1 Swarts S, et al. Presented at the Society for Research on Nicotine and Tobacco, 13 th California Society of Addiction Medicine- 10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 57 Annual Scientific Session, Austin, TX, 2/24/ Sachs DPL, Benowitz NL. Eur Respir J 1996;9: California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 58 Key Concepts Short-Term Treatment for Tobacco Dependence A Chronic Medical Disease Is Not Effective Minimum Recommended Treatment Duration: At Least One Year Dose Matters Improved Treatment with: Individualized Medication Dosing California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 15

16 Duration Matters Improved Treatment-Outcome with: 1-Year or 6-Months vs. 12-Weeks Treatment 62 The Longer The Better Similar Findings With: Nicotine Medication Treatment 1 Bupropion Treatment 2 Varenicline Treatment 3 6-Months to 6-Years Treatment 2- to 5-fold better stop smoking rates than 6 weeks or 3 months 1 Blöndal T, et al. BMJ 1999;318: Hays TF, et al. Ann Int Med 2001;135: Tonstad S, et al. JAMA 2006;296: California Society of Addiction Medicine-10/23/08 Sachs/Palo Alto Center for Pulmonary Disease Prevention 64 Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 16

17 Keys To Effective Treatment Adequate: Diagnosis to Enable an Optimal Treatment Plan Dose(s) of Medication(s) Combination of Medication(s) Duration of Treatment To Suppress Completely: Nicotine Withdrawal Symptoms References for Further Reading I 67 Sachs DPL. Medical Management of Tobacco Dependence: Concepts & Treatment Objectives. In Hodgkin JE, Celli BR, Connors GL, (Eds). Pulmonary Rehabilitation: Guidelines to Success, 4 th Edition. St. Louis: Elsevier, 2008 (In Press). American College of Chest Physicians. Treating Tobacco Dependence: American College of Chest Physicians Tool Kit, 3 rd Edition. Northbrook (IL): ACCP, 2008 (Available early 2009). Fiore MC, et al. A Clinical Blueprint To Accelerate the Elimination of Tobacco Use. JAMA 2008;299: Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline, Rockville, MD: USDHHS. Public Health Service. May ( Kozlowski LT, et al. Advice on Using Over-The-Counter Nicotine Replacement Therapy Patch, Gum, or Lozenge To Quit Smoking. Addict Behav 2007;32: Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 17

18 References for Further Reading II Jorenby DE, et al. Efficacy of Varenicline, an α4β2 Nicotinic Acetylcholine Receptor Partial Agonist, vs Placebo or Sustained-Release Bupropion for Smoking Cessation: A Randomized Controlled Trial. JAMA 2006;296: Bars M, et al. Tobacco Free with FDNY The New York City Fire Department World Trade Center Tobacco Cessation Study. Chest 2006;129; Sachs DPL. Tobacco-Dependence Treatment Time To Change the Paradigm. Chest 2006;129; California Thoracic Society. Position Paper: Medical Management for Tobacco Dependence ( Lillington GA, Leonard CT, Sachs DPL. Smoking Cessation: Techniques and Benefits. Clin Chest Med 2000;21: References for Further Reading III Sachs DPL. Tobacco Dependence: Pathophysiology & Treatment. In Hodgkin JE, Celli BR, Connors GL, (Eds). Pulmonary Rehabilitation: Guidelines to Success, 3 rd Edition. Philadelphia: Lippincott Williams & Wilkins, 2000: Cromwell J, et al. Cost-Effectiveness of the Clinical Practice Recommendations in the AHCPR Guideline for Smoking Cessation: Agency for Health Care Policy and Research. JAMA 1997;278: Mahmarian JJ, et al. Nicotine Patch Therapy in Smoking Cessation Reduces the Extent of Exercise-Induced Myocardial Ischemia. J Am Coll Cardiol 1997;30: How To Identify & Treat Tobacco- Dependent Patients Obtain American College of Chest Physicians (ACCP) Tobacco Cessation Tool Kit Phone: Fax: accp@chestnet.org Web: How To Identify & Treat Tobacco- Dependent Patients Obtain U.S. Public Health Service CLINICAL PRACTICE GUIDELINE: Treating Tobacco Use And Dependence NCI (National Cancer Institute) CANCER CDC (Centers for Disease Control) CDC PHS Agency for Healthcare Research & Quality US Surgeon General s Web Site Nicotine: Myths, Realities, & Treatment; Presented by David P.L. Sachs, MD 18