Emma Hitt, PhD

April 29, 2012

April 29, 2012 (Atlanta, GA) — Opioid-addicted patients who were also nicotine dependent achieved better outcomes if they did not smoke during methadone detoxification, new research shows.

Paolo Mannelli, MD, from the Department of Psychiatry, Duke University, in Durham, North Carolina, presented the findings here at the American Society of Addiction Medicine (ASAM) 43rd Annual Medical-Scientific Conference.

"These results question the 'harm reduction' argument that an attempt to quit smoking may interfere with a concurrent attempt to discontinue other drug use," Dr. Mannelli told Medscape Medical News.

According to Dr. Mannelli, studies suggest that tobacco use may offset the benefit of existing effective interventions for opioid addiction (OA).

In addition, smoking rates in OA are higher than in other addictions, and they are 5 times higher than in the general population. "However, reports of smoking behaviors during detoxification are scarce," he said.

Window of Opportunity?

The current study sought to evaluate smoking behaviors during opioid detoxification.

Specifically, investigators examined whether nicotine dependence was associated with negative opioid detoxification outcomes and whether treatment smoking was associated with different opioid detoxification outcomes compared with nonsmoking.

A total of 174 patients (83% nicotine dependent) were randomly assigned to 1 of 2 methadone treatment sites. At one site, patients received permission to smoke during treatment for 4 hours per day (n = 101).

Their outcomes were compared with those of nonsmokers (n = 30) as well as those of smokers who were not allowed to smoke during treatment (n = 43).

Smoking, but not nicotine dependence, was strongly linked to opiate withdrawal intensity (P = 0.02) — that is, those who smoked showed significantly higher craving for opioids and cigarettes than nicotine-dependent patients who were not allowed to smoke and nonsmokers.

In addition, patients who smoked showed significantly lower detoxification completion rates and higher smoking rates in the week following discharge compared with nicotine-dependent patients who were not allowed to smoke during treatment.

"Further studies should investigate whether opioid detoxification offers a window of opportunity for smoking cessation interventions," Dr. Mannelli said.

According to Dr. Mannelli, an important question to answer is how to avoid relapse from smoking cessation in the medium-long term

"Although these are preliminary data, opioid-addicted patients should be informed that smoking during methadone taper and discontinuation may negatively interfere with the treatment and lead to failure," he said.

Reduced Chance of Success

Commenting on the study for Medscape Medical News, Kimber Richter, PhD, MPH, said one direct implication of these findings is that facilities that fail to address tobacco use during detox may be making detox harder on their patients and may be reducing their chances for success.

"Stopping smoking doesn't harm recovery, and it probably helps it — even in the earliest phases of treatment," said Dr. Richter, who is an associate professor of preventive medicine and public health at the University of Kansas Medical Center, in Kansas City.

"Providing nicotine replacement and/or non-nicotine medications such as varenicline or bupropion would be the humane thing to do during detox," she told Medscape Medical News.

"There are a lot of open questions about how best to implement these findings, but continuing to allow or encourage patients to smoke during detox is not doing their patients any good, and is probably hurting them."

Dr. Richter added that the findings do support laboratory/clinical studies that found that smoking levels are directly correlated with changes in opioid administration.

"When opioid dose goes up, so does cigarette self administration, and when opioid dose is reduced, participants smoke fewer cigarettes — this study suggests the relationship may work both ways — stopping smoking cuts down on opioid withdrawal, craving, and perhaps relapse."

The presentation was not commercially funded. The authors and Dr. Richter have disclosed no relevant financial relationships.

American Society of Addiction Medicine (ASAM) 43rd Annual Medical-Scientific Conference. Article session 6, presented April 20, 2012.

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