Smoking and opioid detoxification: behavioral changes and response to treatment

Abstract

Introduction: The relevance of tobacco use in opioid addiction (OA) has generated a demand for available and more effective interventions. Thus, further analysis of less explored nicotine-opioid clinical interactions is warranted.

Methods: A post-hoc analysis of OA participants in a double-blind, randomized very low dose naltrexone (VLNTX) inpatient detoxification trial evaluated measures of opioid withdrawal and tobacco use. Intreatment smokers were compared with nonsmokers, or smokers who were not allowed to smoke.

Results: A total of 141 (81%) of 174 OA participants were smokers, all nicotine-dependent. Inpatient smoking was a predictor of opioid withdrawal discomfort. Intreatment smokers (n = 96) showed significantly higher opioid craving (F = 3.7, p < .001) and lower detoxification completion rate (χ(2) = 7.9, p < .02) compared with smokers who were not allowed to smoke (n = 45) or nonsmokers (n = 33). Smoking during treatment was associated with more elevated cigarette craving during detoxification (F = 4.1, p < .001) and a higher number of cigarettes smoked at follow-up (F = 3.6, p < .02). Among intreatment smokers, VLNTX addition to methadone taper was effective in easing opioid withdrawal and craving more than other treatments, whereas the combination VLNTX-clonidine was associated with significantly reduced cigarette craving and smoking during detoxification.

Conclusions: Failure to address tobacco use may negatively affect pharmacologically managed opioid discontinuation. Opioid detoxification may offer a window of opportunity to expand smoking cessation treatment, hence improving OA outcomes. The observed effects support testing of VLNTX-clonidine in smoking cessation trials among individuals with or without substance abuse.

Trial registration: ClinicalTrials.gov NCT00135759.

Figure 1.

Flow diagram of clinical trial participants describing smoking and treatment status. CLO = clonidine; NONTX/CLO = no naltrexone–no clonidine; NTX = naltrexone; NTX/CLO = naltrexone + clonidine. *Patients receiving the two naltrexone doses were combined into a single naltrexone treatment condition as reported in Results section.

Figure 2.

Brief Questionnaire of Smoking Urges (QSU-Brief) scores rating cigarette craving for intreatment smokers (NDS), smokers who were not allowed to smoke during treatment (ND), and NDS patients treated with very low dose naltrexone–clonidine combination (dashed line). See text for comparisons.