Nicotine and Opioids: a Call for Co-treatment as the Standard of Care
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troduction Healthcare providers have a critical opportunity to concurrently address tobacco and opioid dependence. The policy spotlight on the U.S. opioid epidemic and the dramatic increase in overdose deaths presents an opportunity to bring renewed focus on strategies that potentiate addiction treatment, including nicotine addiction treatment. Over-prescription of opioid pain relievers beginning in the 1990s led to a rapid escalation of dependence, a resurgence of heroin use, and arrival of powerful synthetic opioids such as fentanyl which increased 45% from 2016 to 2017.1,2 In 2017, there were 70,237 drug overdose deaths in the U.S.,1 and heroin overdoses more than tripled from 2010 to 2014.3 In the face of these dire statistics, smoking is often seen as less harmful and a lower treatment priority than opioids which represent a clear, imminent risk.4 Yet, Address correspondence to Chad D. Morris, PhD, University of Colorado, Anschutz Medical Campus, 1784 Racine Street, Campus Box F478, Building 401, Aurora, CO 80045, USA. Email: [email protected]. Christine E. Garver-Apgar, PhD, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
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Journal of Behavioral Health Services & Research, 2020. 1–12. c 2020 National Council for Behavioral Health. DOI 10.1007/s11414-020-09712-6
Nicotine and Opioids: a Call for Co-treatment as the Standard of Care
MORRIS & GARVER-APGAR
smoking combustible tobacco products, not opioid use, remains the leading cause of death and disability in the U.S., with at least 480,000 dying annually due to smoking-related causes.5 The general prevalence of current cigarette smoking among U.S. adults is 14% (16% for men and 12% for women).6 Smoking is highest among those aged 18–44 (15%) and 45–64 (17%). Hispanic adults (10%) are less likely to be current smokers compared with non-Hispanic black (15%) and non-Hispanic white adults (16%).6 In comparison, smoking prevalence among patients using illicit opioids or who are receiving methadone maintenance treatment is between 74 and 97%.7–11 This is an extremely high rate of co-use even when compared to co-use with other illicit drugs or alcohol.12 For instance, 97% of heroin users in one study of methadone or buprenorphine treatment used an average of 20 cigarettes or a pack per day.13 Co-occurring tobacco and opioid use creates an additive effect of increasing toxicity and related health consequences across all body systems,14 leading these users to face unnecessarily high mortality and morbidity.15,16 While the shared biological underpinnings of nicotine and opioid addiction are well-established, clinical and policy implications have garnered limited attention. Smoking is a primary risk factor for opioid addiction, and there is ample evidence that co-treatment of tobacco and opioid use leads to better outcomes among those seeking treatment for drug use generally and opioid addiction specifically. This article summarizes the neurobiological and clinical evidence suggesting that there is a clinical and ethical imperative to promote
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