JACQUES Denis, MD Catholic University of Louvain, Mont-Godinne

Transcription

1 JACQUES Denis, MD Catholic University of Louvain, Mont-Godinne

2 Tobacco in psychiatry? WITHDRAWAL SMOKERS VS NON SMOKERS 2

3 Tobacco in psychiatry? Smoking is common in patients in psychiatry Treatment appears often to be neglected with regard to both systematic history and follow-up notes (Wye et al. 2010) Failure to treat tobacco dependence in mental health and addiction treatment settings is not consistent with a harm reduction model (Prochaska 2010) WITHDRAWAL SMOKERS VS NON SMOKERS 3

4 Not only one substance WITHDRAWAL SMOKERS VS NON SMOKERS 4

5 Not only one substance Among adolescents, the three most frequently consumed substances are tobacco, alcohol and marijuana (Latimer & Zur 2010) Prevention treatment increasingly proposes multi-substance programs (Leatherdale & Ahmed 2010) WITHDRAWAL SMOKERS VS NON SMOKERS 5

6 Alcohol and tobacco WITHDRAWAL SMOKERS VS NON SMOKERS 6

7 Alcohol and tobacco In the general U.S. population, 48% of alcohol-dependent people are reported to also be tobacco-dependent. (Le Start et al. 2010) In patients seeking treatment in the U.S., there is an estimated prevalence of 80% of smokers (Chatteriee & Barlett 2010) In a study conducted in Belgium, 82% of patients hospitalized for alcohol withdrawal have nicotine dependence (van den Abeele et al. 2008) WITHDRAWAL SMOKERS VS NON SMOKERS 7

8 Never the one without the other one? WITHDRAWAL SMOKERS VS NON SMOKERS 8

9 Never the one without the other one? The interactive effect of alcohol and nicotine has been demonstrated on the cholinergic system in rats brains and explains this frequent association (Jama et al. 2010) Their respective action on the reward circuit at mesolimbic level appears to facilitate concurrent alcohol and tobacco consumption (Laitha & Sershen 2010) WITHDRAWAL SMOKERS VS NON SMOKERS 9

10 Never the one without the other one? Heavy drinkers are less likely to attempt to quit smoking (Zimmerman et al.1990) In a smoking cessation treatment (n=236) for heavy drinking smoker 41,5% lapsed when drinking alcohol During moderate drinking days: 4 times greater risk of smoking lapse than non drinking day During heavy drinking days: doubled the risk of lapsing compared with moderate drinking (Kahler et al.2010) WITHDRAWAL SMOKERS VS NON SMOKERS 10

11 Never the one without the other one? Among adolescent substance users, the approach to tobacco dependence is essential. (Ramo et al. 2010) WITHDRAWAL SMOKERS VS NON SMOKERS 11

12 Simultaneous dual alcoholtobacco withdrawal? WITHDRAWAL SMOKERS VS NON SMOKERS 12

13 Simultaneous dual alcoholtobacco withdrawal? In situations of dual dependence the studies lean toward the issues being intertwined. (Cooney et al. 2007) The differentiated analysis of the motivations for stopping each of the products needs to be investigated and tobacco abstinence self-efficacy might more accurately predict an individual's future success to cope with the urge to drink than alcohol abstinence self-efficacy (Demmel et al. 2009) WITHDRAWAL SMOKERS VS NON SMOKERS 13

14 Simultaneous dual alcoholtobacco withdrawal? In our clinical practice: The argument put forward by some physicians is that withdrawal would be more difficult. A case-report: a patient who smoked 20 cigarettes and drinked 10 beers per day comes into hospitalization and quit drinking. Five years later: this patient is always alcohol abstinent but he smokes 35 cigarettes per day. Plague or cholera? What s Evidence Based? WITHDRAWAL SMOKERS VS NON SMOKERS 14

15 Simultaneous dual alcoholtobacco withdrawal? The first central question would obviously be to see to what extent the patients would be ready to consider giving up both substances (Stotts et al. 2003) But the real issue is finding out what information patients can rely on to make their choice? What advice do they get and what training do caregivers have? WITHDRAWAL SMOKERS VS NON SMOKERS 15

16 Simultaneous dual alcoholtobacco withdrawal? Many opportunities to intervene with smokers and binge drinkers are lost. Efforts to increase physician education and to identify and reduce other barriers may help. (Denny et al. 2003) The importance of training to motivational interviewing in post-graduate doctors of psychiatry and its impact on their perceptions about being able to consider preparing a patient to give up both substances (Jacques et al. 2010) WITHDRAWAL SMOKERS VS NON SMOKERS 16

17 Docteur D.JACQUES

18 Study: subject and method In our study, we analyse perceptions among twelve first-year postgraduates in Psychiatry, before and after training in Motivational Interviewing, with regard to the idea of suggesting that patients might consider simultaneous dual alcohol-tobacco withdrawal. (but the precise goal of the study was not revealed) JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 18

19 Study: subject and method The study was conducted over a five year period (recruitment between October 2005 and October 2010) and concerned perceptions among twelve first-year postgraduates in Psychiatry who had not received motivational interview training. JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 19

20 Study: subject and method At time 0 the participants were given a questionnaire containing 25 items evaluating their perceptions with regard to alcohol and tobacco dependency, making use of visual analog scales. We will focus on the analysis of three of these items, expressed as follows: JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 20

21 "For each consultation, during the anamnesis, you systematically question consumption habits (alcohol, tobacco, cannabis, heroin, cocaine, etc)" Never Always JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 21

22 "In cases of dual-dependency (alcohol and tobacco), you advise the patient to consider cessation of both substances simultaneously" Never Always JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 22

23 "You feel helpless when faced with a patient with an alcohol dependency who relapses after a period of abstinence" Very rarely Very often JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 23

24 Study: subject and method The same training in motivational interviewing techniques was given to those participating in the study over a one year period, covering: basic theory of motivational interviewing, theory of the reward circuit, neurobiological bases for phenomena of alcohol and nicotine dependency and exercises in the form of filmed role plays which are subsequently reviewed (10 training sessions in total). JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 24

25 Study: subject and method After one year (time 1) and at the end of the training period, the Postgraduates were asked to complete the questionnaire again JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 25

26 Results n=12 JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 26

27 Results n=12 JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 27

28 Results n=12 Pair 1 Advise the cessation of both substances t-student Average Ecart Type t Sig. -5, , ,335,000 Time 0-Time 1 Pair2 Systematic anamnesis of consumption habits -3, , ,901,002 Time 0-Time 1 Pair3 Helpless feelings faced relapse 2, , ,617,000 Time0-Time 1 JANNE P. QUIT SMOKING? QUIT DRINKING? WHY NOT BOTH? 28

29 Study: subject and method In relation to the ideas received, we wanted to compare the intensity of the symptoms of alcohol withdrawal in alcoholic patients who smoke and who continue to smoke, versus alcoholic patients who do not smoke The study was primarily observational. WITHDRAWAL SMOKERS VS NON SMOKERS 29

30 Study: subject and method The inclusion criteria : 1. Patients presenting themselves spontaneously for a consultation with a request for hospitalization who were considering alcohol detoxification 2. Aged between 40 and 50 years old 3. Presence of an alcohol dependence (depending on D.S.M. IV criteria) with or without nicotine addiction (assessed by Fagenstroem's simplified test) and without other psychiatric or somatic co morbidities WITHDRAWAL SMOKERS VS NON SMOKERS 30

31 Study: subject and method The inclusion criteria : 4. Evolving alcohol dependence from 5 to 10 years 5. Daily alcohol consumption between 5 and 10 units per day 6. For the alcohol-dependent patients, smokers were withheld who were not considering stopping smoking during the hospitalization and who therefore did not receive any nicotine replacement. WITHDRAWAL SMOKERS VS NON SMOKERS 31

32 Study: subject and method Our selection criteria focused on patients in the "precontemplation" stage concerning any tobacco dependence and in the "preparing to change" stage concerning alcohol. Patients who smoke were not prompted to give up smoking from when they had stated their desire to not stop smoking. The results are therefore not biased by the stress which could have been induced by being told to stop smoking. Our study's design does not allow conclusions to be drawn for patients under 40 years old and over 50 years over. The study does not assess the situation of patients who are in a "precontemplation" stage in relation to alcohol and who may have been forced to give up alcohol for somatic reasons. Although our inclusion criteria limited the disparity in the population of alcohol-dependent patients with or without tobacco dependence, a sharp division remained in the population studied which may be the source of significant bias. WITHDRAWAL SMOKERS VS NON SMOKERS 32

33 Study: subject and method The parameters measured were 1. blood pressure and 2. cardiac frequency at 6.00 pm on the first day of hospitalization 3. the doses of Diazepam dispensed on the first day, 4. the CIWA-Ar score (Clinical Institute Withdrawal Assesment of alcohol scale revised) (Sullivan et al. 1989) at 8.00 am on the second day of hospitalization. WITHDRAWAL SMOKERS VS NON SMOKERS 33

34 Study: subject and method The statistic treatment of the results was made with parametric methods and twotailed. The average comparison was made with t-test of Student. The link between qualitative variables was analyzed with a multiple regression. WITHDRAWAL SMOKERS VS NON SMOKERS 34

35 Results The two groups of non-smokers alcoholdependent (n=24) and smokers alcoholdependent (n=24) are comparable. The sex ration is the same in the two groups: female (n=9) and male (n=15). WITHDRAWAL SMOKERS VS NON SMOKERS 35

36 Results WITHDRAWAL SMOKERS VS NON SMOKERS 36

37 Results average Average standard error Cardiac frequency Non Smoker Cardiac frequency Smoker Systolic Blood Pressure Non Smoker Systolic Blood Pressure Smoker 91,52 2,33 99, ,92 0,17 13,56 0,25 Diazepam (mg) Non Smoker Diazepam (mg) Smoker CIWA Non smoker CIWA Smoker 46,80 58,26 16,04 19,7 1,80 2,85 0,89 1,07 WITHDRAWAL SMOKERS VS NON SMOKERS 37

38 Results t-test t p Cardiac Frequency -2,324 0,025 Systolic Blood Pressure -2,124 0,040 Diazepam (mg) -3,452 0,001 Ciwa -2,640 0,011 WITHDRAWAL SMOKERS VS NON SMOKERS 38

39 Results A STD error p OR Cardiac Frequency 0,062 0,29 0,035 1,064 Systolic Blood Pressure 0,619 0,308 0,045 1,857 Diazepam (mg) 0,085 0,03 0,004 1,089 CIWA 0,162 0,068 0,017 1,176 WITHDRAWAL SMOKERS VS NON SMOKERS 39

40 Conclusions WITHDRAWAL SMOKERS VS NON SMOKERS 40

41 Conclusions Our observational study tended to show that in hospitalized alcohol-dependent patients and aged between 40 and 50 years old with an evolving problematic alcohol consumption from 5 to 10 years, the symptoms of alcohol withdrawal were more pronounced among active smokers versus non-smokers. WITHDRAWAL SMOKERS VS NON SMOKERS 41

42 Conclusions This observation tended to emphasise that physical suffering is more marked in alcohol-dependent patients and active smokers compared to patients who were only alcohol-dependent during alcohol detoxification. WITHDRAWAL SMOKERS VS NON SMOKERS 42

43 Conclusions When drafting the recommendations concerning alcohol-tobacco dual dependencies, more studies are needed, in particular to compare the intensity of the withdrawal symptoms between alcoholdependent patients and smokers who are giving up both substances versus just giving up smoking or alcohol alone. Adding nicotine replacement products or not during the detoxification period also needs to be investigated. WITHDRAWAL SMOKERS VS NON SMOKERS 43

44 More research needed WITHDRAWAL SMOKERS VS NON SMOKERS 44

45 More research needed ALCOHOL AND TOBACCO DEPENDENT PATIENTS ALCOHOL AND TOBACCO DEPENDENT PATIENTS QUIT DRINKING ONLY QUIT DRINKING AND SMOKING WITH NICOTINE REPLACEMENT WITHOUT NICOTINE REPLACEMENT WITHDRAWAL SMOKERS VS NON SMOKERS 45

46 THANK YOU FOR YOUR ATTENTION WITHDRAWAL SMOKERS VS NON SMOKERS 46

47 REFERENCES 1. Cooney, N., Litt, M., Cooney, J., Pilkey, D., Steinberg, H., & Oncken, C. Alcohol and tobacco cessation in alcoholdependent smokers: analysis of real-time reports. Psychology Of Addictive Behaviors: Journal Of The Society Of Psychologists In Addictive Behaviors, 2007, 21(3), Denny, C., Serdula, M., Holtzman, D., & Nelson, D. Physician advice about smoking and drinking: are U.S. adults being informed?. American Journal Of Preventive Medicine, 2003, 24(1), Demmel, R., & Nicolai, J. Motivation to quit smoking and to refrain from drinking in a sample of alcohol-dependent inpatients: Importance of abstinence, self-efficacy, and treatment outcome. Addictive Disorders & Their Treatment, 8(2), 2009, Ellingstad, T., Sobell, L., Sobell, M., Cleland, P., & Agrawal, S. Alcohol abusers who want to quit smoking: implications for clinical treatment. Drug And Alcohol Dependence, 1999, 54(3), WITHDRAWAL SMOKERS VS NON SMOKERS 47

48 REFERENCES 5. Jacques D, Zdanowicz N, Reynaert C, Janne P. Quit Drinking? Quit Smoking? Why not both? Analysis of perceptions among Belgian Postgraduates in Psychiatry. Psychiatr Danubina Nov;22 Suppl 1:S Kahler, C., Borland, R., Hyland, A., McKee, S., Thompson, M., & Cummings, K. Alcohol consumption and quitting smoking in the International Tobacco Control (ITC) Four Country Survey. Drug And Alcohol Dependence, 2009, 100(3), Kahler, C., Borland, R., Hyland, A., McKee, S., O'Connor, R., Fong, G., & Cummings, K. Quitting smoking and change in alcohol consumption in the International Tobacco Control (ITC) Four Country Survey. Drug And Alcohol Dependence, 2010, 110(1-2), Prochaska JJ: Failure to treat tobacco use in mental health and addiction treatment settings: a form of harm reduction? Drug and Alcohol dependence, 2010; 110(3): Ramo, D., Prochaska, J., & Myers, M. Intentions to quit smoking among youth in substance abuse treatment. Drug And Alcohol Dependence, 2010, 106(1), WITHDRAWAL SMOKERS VS NON SMOKERS 48

49 REFERENCES 10. Sullivan J.T., Sykora K.,Schneidermann J., Naranjo C.A., Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale. British Journal of Addiction, 1989, 84: Stotts, A., Schmitz, J., & Grabowski, J. Concurrent treatment for alcohol and tobacco dependence: are patients ready to quit both?. Drug And Alcohol Dependence, 2003, 69(1), World Health Organization. Disease burden in 2000 attributable to selected leading risk factors, 2002, alhealthrisks_report_full.pdf 13. Zimmerman, R., Warheit, G., Ulbrich, P., & Auth, J. The relationship between alcohol use and attempts and success at smoking cessation. Addictive Behaviors, 1990, 15(3), WITHDRAWAL SMOKERS VS NON SMOKERS 49

50 CRAVING : INCREASE OF GLUTAMATE FIRST ALCOHOL DRINK: FIRST CIGARETTE: GABA GABA GLU (De Witte 2009) WITHDRAWAL SMOKERS VS NON SMOKERS 50

51 In the literature, data concerning the animal model (Lallemand et al. 2006) tends to demonstrate that the cerebral suffering from a physiological point of view is less significant when dependent rats undergo alcohol and tobacco withdrawal simultaneously than when they undergo withdrawal from only one substance at a time. For humans, this question needs to be evaluated and complemented in the light of the emotional implications of stopping consumption compulsions. WITHDRAWAL SMOKERS VS NON SMOKERS 51

52 In 1996, Miller WR highlighted that the therapist s empathy was a highly predictive factor in the development of the treatment of patients with dependency. We could make the hypothesis that training in motivational interviewing technique, by lessening the sensation of helplessness among therapists, facilitates envisaging withdrawal from several substances. WITHDRAWAL SMOKERS VS NON SMOKERS 52