Drug Addiction, Smoking Cessation Can Be Treated Concurrently

Fran Lowry

January 09, 2014

Smokers who are also addicted to stimulants can successfully quit smoking without hindering treatment for stimulant addiction, new research shows.

Results from a randomized, 10-week trial showed that smoking cessation therapy significantly increased smoking quit rates — both during treatment and at follow-up — without negatively affecting participation in stimulant addiction treatment.

"These findings, coupled with past research, should reassure clinicians that providing smoking-cessation treatment in conjunction with treatment for other substance use disorders will be beneficial to their patients," first author Theresa Winhusen, PhD, University of Cincinnati College of Medicine, in Ohio, said in a statement.

The study was published online December 9 in the Journal of Clinical Psychiatry.

Quit Smoking Treatment Typically Not Provided

The authors note that the prevalence rate of cigarette smoking among illicit drug users in the United States ranges from 49% to 98%, substantially higher than the 19.8% rate in the general population.

"Despite the pervasiveness and deadly consequences of smoking in addicted individuals, smoking-cessation treatment is typically not provided in substance use disorder treatment programs due, in part, to concern that it might impact negatively on nonnicotine substance use outcomes,” the authors write.

The aim of the study was to evaluate the impact of concurrent treatments for substance use disorder and nicotine-dependence for stimulant-dependent patients.

The 10-week, intent-to-treat (ITT) trial was conducted at 12 substance use disorder treatment programs between February 2010 and July 2012.

The researchers randomly assigned 271 patients to treatment as usual and 267 patients to treatment as usual with added smoking-cessation treatment. All patients met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for cocaine or methamphetamine dependence, smoked at least 7 cigarettes per day, had a carbon monoxide (CO) level ≥ 8 ppm, and had been smoking cigarettes for at least 3 months.

The average age of the study participants was 36 years, 52% were male, and 60% were white. About 56% were cocaine dependent, 39% were methamphetamine dependent, and 5% were dependent on both substances.

Usual treatment consisted of at least 1 treatment session per week, and the added smoking-cessation treatment consisted of extended-release bupropion, nicotine inhaler, smoking-cessation counseling, and contingency management for smoking abstinence, which awards prizes to encourage smoking cessation.

Patients who were assigned to receive additional smoking-cessation treatment also received 10-minute smoking-cessation counseling sessions once a week, using the Smoke Free and Living It manual.

Follow-up after the 10-week active treatment occurred at 3 and 6 months.

Approximately 89% of participants completed the 10-week active treatment part of the study, 85% completed the 3-month follow-up, and 79.6% completed the 6-month follow-up. These results were similar for both groups.

Outcomes were measured by drug and CO testing and by self-report during the 10-week trial and at 3- and 6-month follow-up.

Overall, participants assigned to treatment as usual with smoking-cessation treatment averaged 77.2% stimulant-abstinent weeks compared with 78.1% stimulant-abstinent weeks for those assigned to treatment as usual.

However, compared with those who got usual treatment only, participants getting the additional smoking-cessation treatment had significantly better outcomes for drug-free days at 6 months (P < .05), with a decrease in drug-free days from baseline of -1.3%, compared with -7.6% for those receiving treatment as usual, the authors report.

The results also showed that smoking cessation therapy significantly increased smoking quit rates at all time points without negatively affecting participation in stimulant addiction treatment.

With regard to smoking outcomes, the addition of smoking-cessation treatment resulted in significantly higher quit rates at week 10, with 25.5% of those getting the additional treatment having quit compared with 2.2% of those who did not get the added treatment (P < .0001; odds ratio [OR], 18.23; 95% confidence interval [CI], 7.78 - 42.69).

These results remained similar at 3-month follow-up (19.1% vs 3.0%; P < .0001; OR = 7.58; 95% CI, 3.52 - 16.32) and at 6-month follow-up (13.1% vs 3.7%; P = .0003; OR = 3.81; 95% CI, 1.84 - 7.88).

No Impact on Drug Use Outcomes

"We had predicted that treatment as usual concurrent with smoking-cessation treatment, relative to treatment as usual, would significantly improve stimulant-use outcomes," the authors write. "The results from ITT analyses indicate that stimulant use during active treatment and follow-up did not differ significantly between the treatment groups."

This suggests that adding smoking-cessation treatment to stimulant-addiction treatment in the outpatient setting does not affect stimulant use outcomes, the authors note.

But, they add, adding smoking cessation treatment resulted in significantly fewer drug-free days, and this result persisted at the 6-month follow-up.

"This finding is consistent with past research, which has found that concurrent smoking cessation and substance use disorder treatment for alcohol use disorders can enhance abstinence from substance use," they write.

A limitation of the study was the use of a more intensive smoking-cessation intervention that used 2 medications and 2 psychosocial treatments. Such a complex program is beyond the scope of many substance use disorder treatment programs that exist outside of the context of clinical trials, the authors note.

Another limitation was the relatively high rate of stimulant abstinence, and yet another was the lack of a biomarker for medication adherence.

The authors conclude that the results demonstrate that providing smoking-cessation treatment to stimulant-dependent outpatients, although it had no effect on stimulant use outcomes, "significantly improved smoking-abstinence outcomes, and did not significantly impact treatment attendance."

The study was funded by grants from the National Institute on Drug Abuse Center for the Clinical Trials Network. Dr. Winhusen reports no relevant financial relationships.

J Clin Psychiatry. Published online December 10, 2013. Abstract

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