Many people managing opioid use disorder also use tobacco or nicotine throughout their recovery. Dr. Jon Ebbert speaks with us to talk about the gateway hypothesis, addiction psychology, and individualized treatment for recovery.
- Purchase Ending the Crisis by Dr. Holly Geyer
- Learn more about pain management and safe opioid use on our Opioid Resource Center
- Comments or questions? Email us at mcppodcasts@mayo.edu.
- If you or a loved one are dealing with a substance use disorder, visit Substance Abuse and Mental Health Service Administration.
Read the transcript:
Dr. Benjamin Lai: Hello. Welcome to Ending the Opioid Crisis. I’m Dr. Benjamin Lai.
Dr. Holly Geyer: And I’m Dr. Holly Guyer.
Dr. Benjamin Lai: This is a podcast series aimed at getting a deeper understanding of the opioid crisis that has ravaged our country today. I’m thrilled to have our guest, Dr. John Ebbert, with us. Dr. John Ebbert is a professor of medicine and associate chair of the Department of Medicine at Mayo Clinic. He also serves as medical director of Mayo Clinic’s Nicotine Dependance Center and is the telehealth section lead of the Division of Community, Internal Medicine, Geriatrics and Palliative Care at Mayo Clinic.
Dr. Ebbert is very active in research, especially in the field of nicotine dependency and medical cannabis, with over peer reviewed publications. Dr. Ebbert, welcome to the show.
Dr. Jon Ebbert: Pleasure to be here. Thanks for having me.
Dr. Benjamin Lai: Dr. Ebbert, you are an expert in the field of nicotine dependency, and you’ve also done a lot of work and patient care on medical cannabis. I wanted to start by asking you, how common is nicotine use disorder in the general population in our country?
Dr. Jon Ebbert: So, it depends upon the survey. But if you look at general national surveys put out by some of our public health agencies, it’s about one in five people have reported some type of commercial nicotine or tobacco product in the last month. And that breaks down to just cigarets being the most common e-cigarettes cigars, smokeless tobacco and pipes. There’s a lot of different products on the market, but it’s about one in five.
People still report use of a commercial tobacco product in the last month.
Dr. Benjamin Lai: And have we seen more and more adolescent and children using nicotine products with the increasing use of e-cigarettes and vaping?
Dr. Jon Ebbert: Yes, we have. So, that has been one of the significant public health concerns since the advent of the electronic cigarette is that it starts to introduce nicotine to users who otherwise wouldn’t have used tobacco products.
Dr. Benjamin Lai: Is there much evidence or research on nicotine use being a gateway to other drugs, especially in the younger population?
Dr. Jon Ebbert: So, it’s a great question. So, you’re getting at, I think, this idea of a gateway hypothesis and the gateway hypothesis in general suggests that patients who develop substances abuse such as more what we consider to be at least clinically more severe methamphetamine or heroin addiction, that they started out with nicotine or they started out with alcohol. Now, there are some studies that support a gateway hypothesis, with nicotine being one of the gateway drugs, if you will.
But other studies sort of refute that. And they say that nicotine is So, concomitantly used or used at the same time as other substances of abuse that it’s very difficult to extract whether single users of nicotine or e-cigarettes go on to develop heroin addiction at a later time, or than patients who otherwise would have developed who are just happened to be using nicotine.
At the same time, it’s very difficult. So, I would say the data is mixed and I think in general the addiction field continues to debate Gateway. But one of the things that we think about in tobacco dependance in particular is you can look at e-cigarettes. If we just go back to the example that you gave and you can ask the question, are people who use e-cigarettes at a population level more commonly going to tobacco than the people who otherwise would have used tobacco staying off tobacco because they can have access to cigarettes.
So, let me simplify that. What is the population impact of e-cigarettes? Does it make more tobacco users or less? And the answer is it’s probably a wash. And it’s a wash because there are some people who would have otherwise used tobacco products who just tiny cigarettes and there are some people who might have otherwise used tobacco in the absence of e-cigarettes who tend to use it because they started on e-cigarettes.
So, I would say the population impact is negligible overall with electronic cigarettes. That’s a complicated answer, but it’s a complicated problem, isn’t it?
Dr. Benjamin Lai: Yes.
Dr. Jon Ebbert: You’re asking our patients who pick up and we won’t use any brand names of our patients who are picking up a commonly used electronic cigaret more likely to smoke because what do we want to prevent? At the end of the day, nothing kills more people than smoked tobacco. Period. Hard Stop. That’s it. It’s the most common cause of death and disability in the United States.
And it’s one of the most common causes of death and disability in the world. So, we have to think from a population perspective, how do we prevent that? And we’re always looking at electronic cigarettes to figure out if that’s part of the problem or whether it’s a potential solution.
Yeah, you’re right. That’s super complex. In my practice, I treat a lot of patients with opioid use disorder. One of the ways I treat them is through the use of buprenorphine, Suboxone, for example. I would say that the majority, if not all of my patients who have opioid use disorder are also smokers or users of nicotine product. Is nicotine use disorder more common in general in patients with an opioid use disorder?
Dr. Benjamin Lai: Has that been looked at?
Dr. Jon Ebbert: So, yeah, it’s been looked at a lot of different angles with a lot of different populations. And if you lump, let’s lump opioid use disorder into the broad category of psychiatric illness or mental health disorder, then you would say as a broad population of anybody with a mental health disorder or substance abuse or subcategory that you describe opioid use, the prevalence of tobacco use is double what it is in a non-using or non-psychiatric population.
So, it’s a double and you might just have a high proportion of smoker. You said almost all. And that may be what it certainly feels like and it certainly looks like that sometimes. But in general it’s double the prevalence that we see in a non-using population.
That to me is very interesting. Is there any similarities in, for example, maybe the neural pathways of the two disorders you think?
Yeah. So, it’s fascinating. So, one of the things I love about studying addiction in general is thinking about the neurophysiology or the neuropharmacology. The brain is an amazing, amazing system. Central nervous system does not create neurotransmitters for which there are no neuro receptors and there are no neuro receptors for which there are no neurotransmitters. And in the universe of chemicals, there’s only a finite number of chemicals that you can make.
So, and when we think about neurophysiology, the effect of a neurotransmitter is different depending upon where it affects the brain. So, let’s talk about dopamine. Let’s drive it home a little bit with addiction. So, dopamine is a drug of reinforcement. It developed with humans teleological or as we developed, to reinforce behaviors that result in the procreation of the species.
So, you were positively reinforced when you ate, drank water or had sex because that procreate, it promotes the survival of the species. And you were rewarded for that. Where that reward comes from is in a place in the brain. Deep part of the brain called the nucleus accumbens and dopamine in that area results in reward, but dopamine in the prefrontal cortex results in increased attention.
So, like real estate, neurotransmitter and physiology and neurotransmitter biochemistry is all about location, location, location. Well, what’s fascinating about that dopamine is when you look at the dopamine in the deep brain associated with reward, all the drugs of addiction commonly act in that same neurotransmitter system. So, when you look at heroin and alcohol and cannabis and nicotine, it’s all in the same area.
Dr. Jon Ebbert: It’s all in that nucleus accumbens resulting in drug reinforcement and perpetuation of addiction.
Dr. Benjamin Lai: They’re all sort of related and essentially just using that dopamine as the common pathway. I’m interested to know, John, what it’s like for somebody who struggles with withdrawal from nicotine. We talk a lot about opioid withdrawal. Are some of the symptoms similar?
Dr. Jon Ebbert: Yeah, So, they can be very similar. And some of the similarity of different drugs is related to where those drugs had their pharmacologic impact. So, when we think about nicotine, for example, nicotine results in not only release of dopamine but acetylcholine in the intestine and it results in norepinephrine and all of these different impacts when someone stops. Those are the impacts that they feel.
So, you might get constipation, you might get irritable. You may feel fatigue. So, the withdrawal that you experience from nicotine is very similar to some of the opioid effects or opioid withdrawal, because some of those impacts of opioids on your intestine are opioids in the addiction center, opioids on some of the wakefulness centers of the brain. When you stop them, they have those different effects when you withdraw them.
There’s some overlap, but some tend to predominate. So, opioid withdrawal may have more severe sort of catecholamine effects and maybe nicotine has more, maybe constipation, irritability and craving effects. So, each drug is going to have a little bit, but there is a lot of overlap. So, if you’re going to have someone stop both of them at the same time, maybe to your point, it would be very difficult to differentiate that clinical symptom is from opioid withdrawal, and that clinical symptom is from nicotine withdrawal because every patient’s different and everybody’s going to have a different withdrawal experience.
Dr. Benjamin Lai: That to me is very interesting.
Dr. Holly Geyer: Every 8 minutes, someone in the US dies of an opioid overdose. The drugs we have long trusted to help kill pain are now killing us. But what if we were equipped with the information to use opioids wisely, store them safely, avoid their risks and reverse their problems? What if we could help the loved ones misusing opioids and support them as they seek treatment?
My book, “Ending the Crisis”, shares Mayo Clinic’s collective insight into the lives of every person struggling to understand opioids and their role in managing pain or dealing with the complications caused by these powerful drugs. Visit the link in the notes of this episode or visit uat-mcpress.mayoclinic.org/opioids to get your copy today.
Dr. Benjamin Lai: John, I want to move on to the other side of nicotine use disorder, treatment of nicotine disorder. You play a huge role at Mayo Clinic. Would you mind telling me and the audience a little bit about different treatment options for nicotine use disorder?
Dr. Jon Ebbert: You think about the disease that you’re interested in, which is opioid dependance and a very devastating disease, but you don’t have a lot of treatment options. And I treated it an addiction that kills , people a year in the United States, which is equal to three fully loaded, sevens crashing every day for an entire year. And I have three drugs.
I also treat acne, which I have drugs and kills nobody. So, you can see where we spent our time, energy and resources on. And it’s not treatment of something that kills a half a million people each year. I only have three drugs and those are nicotine replacement prion, which is an antidepressant and then varenicline, which is a unique pharmacologic agent that acts in the deep neuro receptors that perpetuate addiction.
Dr. Benjamin Lai: Is there the right patient for the right treatment, or is it something that we could layer on? What is your approach?
Dr. Jon Ebbert: That’s a great question. We always try to individualize the treatment, and at least in my clinical practice, when I’m treating tobacco dependance and my counselors treat a lot of tobacco dependance. They’re always trying to figure out what they’ve been on before, what they’re interested in trying. Those are the ways that we start to have that discussion. You you have one drug, you’re probably using a lot of debate, but my nicotine replacement comes in five different forms.
The gum, the patch, the laws into the inhaler in the nasal spray. And So, I get to choose. I have a little bit more of an armamentarium, but it’s always going back to what is that patient interested in trying. Because as you know, if you can engage the patient in the treatment, the treatments are not going to work, right?
So, we start with what patient preferences might be and then we sort of go from there.
Dr. Benjamin Lai: John, in Opioid use Disorder, we are now increasingly aware of the importance of a bio psychosocial approach, integrating not just the medicine part, but really looking into patient’s psychology and socioeconomics and social background. What about nicotine use? You’re part of the nicotine dependency center. Is that something that is also emphasized?
Dr. Jon Ebbert: Yeah, it’s really powerful to think about. If you have that perspective, the biopsychosocial approach that it generalizes to most effective treatments for addiction. So, when we give treatment or we render treatment to patients, we always engage family members if they’re interested in our in patient intensive tobacco treatment program, which has shifted slightly now, it’s more of a residential outpatient program.
But in that program we actually have significant others come in and we spend time with the patient in that significant other because that addiction, like opioids, is not only impacting the patient, but it’s also impacting the other people around them. And you can leverage that right to benefit the patient by building that support and helping them understand rather than being frustrated with the patient for relapsing or going back to use, you can actually help that person be more compassionate and help that person go back to quitting again by educating the people around them.
So, we do wholeheartedly embrace the biopsychosocial model because that’s really what I believe is the best way to approach addiction.
Dr. Benjamin Lai: How do you counsel on somebody who’s relapsed?
Dr. Jon Ebbert: So, we’ve got numbers in tobacco treatment that suggest that most smokers have to quit at least a few times before they have a successful abstinence. Wow. And yeah, so that that’s a lot. When you look at the curves of relapse and you look at alcohol, heroin and nicotine. Most of that relapse is happening in within the first hours in relapse continues out to to months and all the curves are almost super impossible.
And so, that’s really interesting to think about because we talked about common neurochemistry. Then you also might expect that some of the clinical manifestations of relapse would be similar across the drugs, and they’re almost identical. So, when we counsel patients, we say this is part of the process. We know that addiction is defined by relapses in remission is when relapse going back, remissions quitting again.
We know that that’s addiction. This is part of the process. What did that feel like? What did you learn from that? We developed what we call a fire plan for patients. If you find yourself automatically picking up a cigarette and lighting it, that can be a learning opportunity for you. That’s not failure. That’s building that bridge to successful long-term abstinence.
So, we leverage that. We leverage that moment to say, what did you learn from that? How are you going to change that? And So, as you know as well as I do, when you’re treating addiction independence, shame can’t enter the room because shame is really what entered the room to get the person in that situation in the first place.
A lot of shame. There’s a lot of shame in addiction. So, we have to make this a shameless experience. So, we help patients make every opportunity a learning experience, and that’s really kind of how we approach relapse and more concretely will intensify. Pharmacotherapy will remind them of some of the behavioral things that they’ve learned, and then we’ll make every day a new day.
Dr. Benjamin Lai: I used to practice in a very rural part of our country, and now that I practice here at Mayo Clinic, I have the luxury of having you as a colleague, for example, where I can refer my patients over to the Nicotine Dependance Center for help, for perhaps colleagues who work in a more underserved area who may not have easy access to the nicotine dependance or a multidisciplinary group.
What is one of the biggest piece of advice you could give to our primary care colleagues to help our patients quit smoking?
Dr. Jon Ebbert: The first thing I’d say is help is on the way. We’re trying to do some new investigations to leverage the EMR to facilitate maybe, perhaps digital engagement with patients. And so that’s always interesting. But resources are available. All states have a quit line, and if a patient is interested in getting free nicotine replacement, for example, they can call one quit.
Now, it’s funded by states and it’s supported through the federal government. There’s also smoke free act gov, which is a place patients can go and download free apps and download free quit support and then become an x dawg free resources that people, if they have a phone, if they have the internet, you can actually access. So, a lot of these are very accessible to us in the rural areas where you don’t have the luxury of having perhaps a nicotine dependance treatment program around.
Dr. Benjamin Lai: That’s great to know. Do you have any thoughts or advice on somebody who wants to try to quit opioids and nicotine at the same time?
Dr. Jon Ebbert: So, my thoughts would be I would encourage it. There is some data and perhaps it’s debated somewhat that if you have patients who you’re treating for addiction, there’s two important things to remember. One is that and we have this data from alcohol treatment. If you get patients abstinent from alcohol but they keep smoking, they’re more likely to die from smoking than they would have from alcohol if they had kept drinking.
And I understand that in the microcosm of addiction. We just want to get that patient off the substance. And we may not want to make their lives harder, but it’s a myth as many people who are receiving treatment for addiction want to quit is the general population, which is about %. I encourage patients to quit the substance of interest.
It could be opioids in our case here, but also to quit smoking at the same time, because there’s a lot of commonalities in the approach and it doesn’t make sense to try to improve your life only to die from tobacco dependance, which we never really intervened on. That’s one thing. And the other thing I’d say that the literature seems to suggest is that there’s data suggesting that if you have a patient who is being treated for opioid dependance and they’re also addicted to tobacco and you treat the opioid dependance, but they keep smoking, they’re more likely to relapse to opioid, It’s because they kept smoking.
So, and that’s because the reason why people smoke and use opioids is because there’s actually a synergistic effect from those drugs. They sort of cohabitate and they sort of cooperate in your brain. And the somnolence that’s created from opioids is counteracted by the stimulant effect of nicotine. And So, the brain learns to associate those to drugs. So, if you keep using that one drug, that brain is always triggered to think about that other drug.
So, it makes sense why it might increase the risk for relapse not all the time, but a certain percentage of the patients. So, two things I think about quitting both at the same time reduces your risk for dying from a tobacco related illness and it reduces your risk to relapse.
Dr. Benjamin Lai: That’s great to know. John. I want to ask you if you have any advice for somebody who comes to you and say, Doc, I’ve tried two, three, four dozen times. Is there still hope for me? What is your advice to them?
Dr. Jon Ebbert: I’d say there’s always hope. And the hope that you have is the hope that you create. You have to believe in something. And this sort of maybe goes back to the step and we don’t step like we do in alcohol addiction, step patients through nicotine dependance. But that first step is really understanding that this is beyond your control and something bigger than yourself.
And it doesn’t have to be God. It can be nature, it can be a river, it could be an ocean that there’s something bigger than you. And I think that one of the fundamental attributes of addiction is really that total consumption of thinking about self and consumed in your pain and wallowing in your pain and the opportunity that patients have through treatment is to get outside of self think bigger than yourself.
And the perfect example that is a when I listen to my patients who’ve gone through AA, what kept them sober was helping someone else stay sober. And what is that about? It’s about getting outside of self. So, I always go back to where are you at with your addiction. You feel hopeless. How can you find hope outside yourself if you don’t necessarily right now believe in yourself?
And we start from there.
Dr. Benjamin Lai: John Ebert, thank you very much for your time, your expertise and your advice. That is all from us for this episode of Mayo Clinic podcast on opioids Ending the Crisis. You can check out our website at Mayo Clinic. Press at M.S., Press dot Mayo Clinic. George For more episodes of our podcast series. If you or someone you know are struggling with an opioid use disorder or another substance use disorder, we recommend speaking with your primary care provider or going to the Substance Abuse and Mental Health Services Administration website.
We’ll see you next time.
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