addiction pathophysiology
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What makes sane people do crazy things?
Addiction: the individual perspective
Dr Simon Thornley
Aims/objectives To understand modern medical
perspectives of addiction and motivation, using smoking as an example
To understand what interventions help people to overcome addictions
To consider a novel subject, sugar consumption, from an addiction perspective.
My story
Parents as committed smokers Hospital doc Caffeine Nicotine studies / withdrawal symptoms Obesity and food and scientific backlash
Quiz
What addictive drug does the most damage to health? Heroine, cocaine, P, alcohol, cigarettes.
What element of tobacco smoke damages health? Nicotine or Tar
What is thought to be the main reason that people smoke? Pleasure or normality
How do you best know how addicted someone is to cigarettes? CPD or TTFC?
Your experiences with addiction
In pairs, discuss one episode over the last 6 months, inwhich you felt you were affected by either your own or someone else’s addiction.
What happened? Did you try and improve the situation?
If so, how?
Letter to the Herald
“Smokers are not always rational. I discovered this at an early age when travelling in the car with my parents. A ritual of protest would unfold as my brothers and I would plead with them to abstain from smoking during the trip. Inevitably, our voices would be drowned out by my parents’ desire to quench their tobacco withdrawal with a freshly lit cigarette.”
Smoking: an addiction?
Is smoking a problem for health?
Who wants to quit?
WHY DO PEOPLE SMOKE?
Use more than intended Difficulty quitting Priority over social activities Use despite harm Tolerance Withdrawal
What are features of addiction?
How does Nicotine cause addiction?
Nicotine & the brain Activation of reward
centres lead to strong sub-conscious urges to smoke in the presence of ‘cues’
Similar mechanism as pleasure from food, sex, caffeine, alcohol (hence weight gain)
1. Positive reinforcement: pleasure
Dopamine release in
the mid brain
Subsequent repeat puffing makes behaviour more likely
Puff on a cigarette gives
a rapid nicotine ‘hit’
‘Feel good factor’ reinforces behaviour
2. Negative reinforcement: withdrawal
Withdrawaldiscomfort
Puff on acigarette
WithdrawalreliefMore
puffs
Repetition of this process leads to deeply entrenched behaviour
Nicotine broken down
Signs and symptoms
Duration Prevalence
Irritability < 4 weeks 50%
Depression < 4 weeks 60%
Restlessness < 4 weeks 60%
Poor concentration <2 weeks 60%
Increased appetite >10 weeks 70%
Sleep disturbance <1 week 25%
Urges to smoke >2 weeks 70%
Mouth ulcers >4 weeks 40%
Constipation >4 weeks 17%
Withdrawal
Intrepid JourneysNicotine
CAN YOU HELP A SMOKER? Interventions for smoking cessation
Smoking cessation is easy!
AA is for ask
BB is for brief advice to quit
CC is for cessation support
Ministry of Health. 2007. New Zealand Smoking Cessation Guidelines.Wellington: Ministry of Health.
Brief Advice: Personalise
“To improve your health, the best thing you can do is stop smoking - particularly to improve your [personal health issue]. Different options suit individual smokers which have been proven to help, such as [treatment options]. Would you like to try one of these?”
Benefits of quitting Increased life expectancy (8 years) Lung cancer risk ↓ by ½ after ten years Heart disease risk ↓ to non-smoker level after 10
years Lung function decline reduced Reproductive health improved Post-operative recovery improved
Source: RCP Tobacco Advisory Group PowerPoint Files. Available at: www.rcplondon.ac.uk/pubs/books/tag/index.asp
How can I support my smoker? Self-help materials Give face-to-face support Refer for face-to-face support (AKP) Refer for Telephone support Pharmacotherapy
nicotine replacement therapy (patches, gum etc)bupropionnortriptylinevarenicline
DOES CESSATION SUPPORT WORK?
Behavioural
Pharmaceutical
Nicotine delivery
Time to first cigarette Smokes within 30 minutes after waking:
Higher degree of tobacco dependenceMore NRT (full strenth patch and gum prn)
Smokers after 30 minutes after waking: Lower degree of tobacco dependenceLess NRT (medium strength patch & gum
prn)
Chew-park-chew
How long to treat? Abstinence vs harm reduction 8-12 weeks (abstinence model) Required for re-adaptation of smoker’s
brain As long as required (harm reduction) Encourage ‘gum in glove box’ for relapse
prevention
Safety and myths
Over 30,000 patients used NRT for over 30 years
Nicotine is responsible for addiction – not cancer
What to tell patients… Not a magic cure, effort still needed Provides nicotine, but more slowly and
lower dose than cigs Takes edge off discomfort Oral product can be unpleasant initially,
must persevere to benefit Need to use for 2-3 months continuously Ignore small print in medication inserts
GROUPSBang for your buck.
Running a group
5-10 ideal Some skills 4-6 sessions Quiet room Quit cards Remember: “There is no teaching
without learning”
First session
Series of questions “Well, most of you sound like you want to
give up smoking, but something within you keeps you reaching for cigarettes, why is this?”
“Tell us about the times you have stopped smoking for a few hours or days? What happened? Did you feel strange or different to normal?”
First session
“Have any of you tried to cut down and stop in the past? What happened then?”
“Tell us about the situations that tend to set off your smoking?”
“What things have helped you stop in the past?”
“What aspect of cigarettes causes damage to your health – nicotine, tar or both?”
“When you smoke a cigarette, how fast do you experience a hit or rush?”
Explain addiction-E.g. Monster on your
shoulder tells you to smoke
Cigarettes feed the monster Time off smoking kills the
monster (not one puff) Worst is over in a month
Ask about cues Stress Smokers Beer, coffee
Support?
Debunk myths Doesn’t cause cancer Prolongs addiction Cutting down doesn’t cut it!
Quit day Set quit day (work vs w/e,
holiday) Throw away cigarettes,
ashtrays etc Enlist friends/family support Non smoker identity
Debunk myths
If you want to stop you must first cut down
Nicotine is dangerous The best way to quit is cold-turkey -
using NRT is like having local anaesthetic when going to the dentist – yes it can be done, but it makes the post quit period alot more bearable.
Sugar and carbs, are they addictive?
Is there an obesity epidemic?
Year
Obesity %
(BM
I>30kg/m
2)
51015202530
1980 1990 2000
Australia Austria
1980 1990 2000
Canada Czech
1980 1990 2000
Denmark
Finland France Germany Hungary
51015202530
Ireland
51015202530
Italy Japan Korea Netherlands Norway
NZ Portugal Slovakia Spain
51015202530
Sweden
51015202530
Switzerland
1980 1990 2000
UK US
Bread - White vs Vogel’s
Is Obesity an addiction?
Anecdote, often limited to severely obese “Atkins Diet” An executive who had had obesity
surgery, laxatives, etc “often I would shake until I could put some sugar in my mouth”
“I had an hour’s drive from my office to my home, and I knew every restaurant, every candy machine and every soft drink dispenser along the whole route.”
“For the first three weeks I cut all sugar and flour from my diet and suffered mood swings and depression, even a sense of hopelessness, I had horrible stomach pains, all my joints and muscles throbbed, and I had the shakes constantly...horrible headaches went along with all this.... People who knew me started thinking I was hiding a drug problem. The symptoms have been gone for about two weeks now, and the cravings are finally starting to subside… I look at birthday cake today and all I see is myself curled up in the foetal position crying in bed. “
“Any addictive type of hypothesis can't explain the rise that we've seen over the last 20 to 30 years of obesity. It's not that the whole population becoming more of an addictive personality type or whatever. I think there are other factors to explain obesity at a population level.”
“I think the processes within the brain, of how the brain handles drugs like nicotine and how the brain handles nutrients like glucose are very different indeed.”Boyd Swinburn, Professor of Population Health, Deakin University 13 Jan 2009
Summary
Addiction – loss of control Withdrawal and tolerance key Time to reward crucial (NRT) Behavioural and pharmacological
treatment Abstinence vs harm reduction Food consumption shows lack of control
similar to other addictions Still controversial
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