Smoking Cessation and People Taking Medication for Opioid Use Disorders

If you are someone who has an opioid use disorders and especially if you take methadone or buprenorphine the likelihood is very high that you also use nicotine. Smoking cessation is probably something that you have considered but at which you have not been successful. This combined use is explored in a newly published monograph, of which I was pleased to have been a co-author. The lead author, William White, someone whom I have admired for many years, has written extensively about substance use disorders.

The monograph focuses on a troubling fact – although there is substantial evidence for the effectiveness of medications for opioid use disorders (“MOUD”), most people who use one of the medications get only a partial benefit because they stop taking it prematurely. The rate of subsequent return to opioid use is unfortunately very high.

A similar problem exists regarding medications for nicotine use disorders – the durations of use are usually too short. A significant difference, however, is that, while there is a broad consensus among opioid treatment professionals supporting longer term MOUD use, standard recommendations in the smoking cessation field have been for shorter durations of medication use. I find myself in the awkward position of suggesting to my patients that they ignore the instructions attached to nicotine patches, gum, and lozenges regarding how long to take the medications because I am convinced that they are too short. I believe that the reason the treatment outcomes in the Triple Track program are better than those of traditional smoking cessation is that we use methods that are effective in treating other substance use disorders – one specific element being to continue the use of effective medication for up to one year or more rather than for just a few months.

The 50-page MOUD monograph dedicates two pages to the issue of smoking. Here is a condensed list of what it says:

• The majority (80%-98%) of adult and adolescent MOUD patients report tobacco dependence at admission – four to six times the smoking rate in the general population.

• MOUD patients who smoke are at increased risk of experiencing tobacco-related disease and death. A long-term follow-up study of 53,172 hospitalized patients with opioid use disorder found that 39% died of smoking-related conditions. 

• The high smoking rates among MOUD patients may be linked to nicotine’s potentiation of opioid effects and its reduction of restlessness, irritability, and depression.

  • Smoking intensity (number of cigarettes per day) is higher among patients on agonist medication (buprenorphine or methadone) than those on antagonist medication (naltrexone). Smoking intensity reduces by nearly a third when antagonist medication is initiated.

  • Heavy-smoking methadone patients require higher dosages of methadone, and those with higher smoking intensity report more frequent opioid withdrawal symptoms and higher anxiety than those with lower smoking intensity – factors that could influence treatment adherence and retention.

    
    

• A majority of MOUD patients express a desire to stop smoking, yet rates of smoking cessation are low among opioid users and MOUD patients – far lower than rates for the general population.

• Nicotine replacement therapy combined with counseling increase rates of successful smoking cessation among MOUD patients but is rarely provided within the context of MOUD.

• MOUD patients who achieve tobacco abstinence have higher rates of MOUD adherence than those who are current smokers. Smoking is associated with higher risk of MOUD non-adherence (e.g., in-treatment illicit opioid use) than among current MOUD non-smoking patients.

• Smoking cessation and MOUD retention are associated in some studies, but not in others; the exact nature and mechanisms involved in the smoking and MOUD retention relationship remain unclear due to insufficient investigation.

More briefly:

• Cigarettes smoking among MOUD patient is the norm and often leads to premature death.

• People who take naltrexone, which is an opioid antagonist, smoke less that do people who take the opioid agonists buprenorphine and methadone.

• Desire by patients to stop smoking is high but success rates are low.

• MOUD treatment programs do not adequately address their patients’ smoking

• Stopping smoking may be associated with staying on medication for longer durations and therefore having a higher rate of recovery from opioid use disorders (OUD).

  
  

If this summary has stirred your interest in exploring the entire monograph, you can read it here. The section on smoking cigarettes can be found on pages 19 to 20.

The idea that stopping tobacco use might be beneficial to OUD recovery deserves emphasis because of the widely held misconception that the opposite is the case. I have been making efforts to reach out to treatment programs that specialize in working with MOUD patients to encourage them to intensify their focus on smoking cessation. So far, my efforts have been unsuccessful. I believe, however, that continued efforts are worthwhile and I will post updates in this space of any new developments. In the meantime, if any readers are interested in contacting our program to explore treatment with us, please click here.