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