Building a Rehabilitative Outpatient Model of Recovery for Nicotine Dependent Patients

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Building a Rehabilitative Outpatient Model of
Recovery for Nicotine Dependent Patients

• Mary Bonnette, PhD, MSN, RN
• May 28, 2009

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• Tobacco Policies Affect Smoking Behavior
• Surgeon Generals Report, 1989
• US Dept. of Health and Human Services, CDC
• Chart found in The Medical Clinics of North
  America, Cigarette Smoking, March 1992, Michael
  C. Fiore, Guest Editor

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Physiopathology of addiction

• 1) Understand the disease/disorder
• 2) Treatment is based on understanding
• the physiopathology

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Historical Perspective

• 1935 Bill Wilsons AA Big Book
• 1970 National Institute on Alcohol Abuse and
  Alcoholism (NIAAA)
• Compartmentalization of addictions-NIAAA, NIDA
• End of stigma in science and medicine
  substantial evidence for genetic vulnerability
  for all addictions (Gordis,1997)
• Concurrent implementation of nicotine dependency
  treatment along with other drugs of addiction
  (Slade, 1997)

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Addiction Defined

• Drug Addiction is a chronically relapsing brain
  disorder
• George Koob, Denise Kandel, Nora Volkow
• (August 2008) Chapter 6 Pathophysiology of
  Addiction in Psychiatry, 3rd Edition

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Addiction Theory

• Competing theories of addiction
• Highjacked Brain Hypothesis (HBH)
• Reward Deficiency Syndrome (RDS)
• --Biogenetic Model
• Hypoism Human Nature Paradigm

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Highjacked Brain Hypothesis

• Proposed by Alan Leshner while Director of the
  National Institute of Drug Abuse (NIDA, 1996)
• The drug is the cause of addiction
• Switch is thrown with the use of the drug
• Does not explain or reconcile with human
  experiences or occurrences and nature of
  addiction such as non-substance addictions (i.e.
  gambling, shopping, binge eating and
  co-dependency relationships)
• Focus of treatment is after the fact
• Fails to answer the fundamental question of why
  some people become addicted with the use of
  addictors and others do not?

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Reward Deficiency Syndrome

• Biogenetic Theory of Addiction Causation
• Developed by Kenneth Blum, PhD,
  (neuropharmacologist) and others
• 1991- reward cascade model as applied to multiple
  addictive, impulsive and compulsive behaviors
• 2000 Expanded Reward Deficiency Syndrome A
  Biogenetic Model for the Diagnosis and Treatment
  of Impulsive, addictive, and compulsive behaviors

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RDS

• Genetic conditions associated with drug
  addictions are found in behavioral addictions
• Linked to hard-wired system in brains cells
  and signaling molecules
• Inborn genetically related disruption (alleles)
  in the intercellular signaling supplants an
  individuals feeling of well being (feeling ok)
  with anxiety, anger, or drive to relieve negative
  emotions.
• Addiction occurs when there is a dysfunction in
  the reward system regulating mechanisms located
  in the limbic brain, specifically the
  dopaminergic system D2 receptor.
• Dopamine (pleasure) molecule release in nucleus
  accumbensgt D2 receptors gt sense of wellbeing
  stress levelsgtcascade or domino effect releasing
  serotonin gt endorphins (enkephalins) at
  hypothalamus.
• Maintains endogenous normal instinctive, or
  unconscious drives.
• Dysfunction in this cascade is hypothesized to be
  the result of multiple genetic variants
  (polygenetic) causing a hypodopamaniergic
  trait(s)
• gtVulnerbility to exogenous stimulant(s)(behaviors)
  DA fix to feel good or ok.
• Exogenous (addictor) drugs in the environment
  mimic endogenous molecules
• Carriers of DAD2 A1 allele are vulnerable
  (variable among individuals)
• gtExpressed changes in the electrical activity of
  the brain
• Core phenotype arising from this breakdown in the
  dopamine circuit represents RDS

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Hypoism paradigm for addiction etiologyDan
Umanoff, MD, Addiction Theorist (1996)

• The trait of addictability, the neurobiological
  capability to become addicted is caused by
  critically low functional activity of a group of
  genetic alleles (muted forms.
• Addictions occur against the conscious will and
  control of those addicted.
• Not anyone can become addicted as the current
  theories propose.
• Prevention of addiction involves the development
  of the understanding of the cause of addictions
• The trait of addictability has never been studied
  or researched
• Backed by valid science and supported by animal
  addiction studies documented in the literature
  relating addictions to genetic alleles present in
  the limbic system- Also family, twin and adoption
  studies.
• In addition to addictability other symptoms such
  as decision making disasters and evaluation
  mistakes may be caused by these same alleles or
  mutations.
• Addictability needs to be studied
  epidemiologically, not just specific addictions
  the underlying disease (disorder) is the critical
  problem and not the mere addictions.
• Alleles that lower activity anywhere within the
  regulating systems of the brain are capable of
  producing a hypo functioning.
• All instincts are genetically determined,
  regulated and coordinated by multiple regulating
  mechanisms in the unconscious part of the brain
  located in limbic system.
• (fMRI studies confirm this (Volkow, Fowler
  Wang, 2003)
• Supporting reports for pre-existing genetic basis
  for the susceptibility to dependence and co
  morbid traits (Gelernter et al, 2006 Hiroi
  Agatsuma, 2005)

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Theoretical Foundations for Treatment

• General Systems Theory Bertalanffy (1930,1968)
• Patterns of interactions are viewed as wholes
  rather than isolated events
• A way of understanding the interconnectedness of
  natural structures in the universe
• Premise components of a system, when isolated,
  behave differently than when interacting within a
  system
• Key characteristic of systems theory has to do
  with the natural flow of information
• Regardless of the point of origin, information
  spreads up and down the system.
• Information has a domino effect in the whole
  system
• Problems/disturbances/blockages can impact the
  entire system as the body continuously strives
  for functional equilibrium/balance/homeostasis.

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Implications of Systems Theory for Healthcare
Practitioners

• Historical perspective
• In the past, medical science attempted to
  isolate phenomenon,
• reduce it to its most basic unit and
  independently investigate it as if each unit or
  system of the body functioned independently and
  apart from the whole system.

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Systems Model in Nursing

• Betty Neuman, PhD,RN (Clinical Psychology)
  pioneer of nursing involvement in Mental Health
• Published The Neuman Systems Model Application
  to Nursing Education and Practice (1982) based on
  general systems theory

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Groundbreaking Neuroscientific Research

• Candace Pert, PhD, Research Professor, Dept. of
  Physiology and Biophysics Georgetown University
  Medical Center
• 1972 research lead to the discovery of the opiate
  receptor bodywide communication system linking
  the body and mind
• Established the bio-molecular basis for emotions
• Demonstrated organisms ability to share
  information across cellular barrier.
• Triangular link between three systems that use
  peptides to communicate with one another-brain,
  endocrine system, immune system

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Rehabilitative Recovery Process Model for
Nicotine Addiction

• Susan Moner, MD (1996) Internal Medicine
• Systematic review of clinical trials using
  acupuncture in treatment of opiate, alcohol,
  cocaine, and nicotine dependence
• -basic ear (auricle) point protocols found to be
  most effective in treating withdrawal symptoms.

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Stages of the Drug Treatment Process- Moner (1996)

• Detoxification
• Rehabilitation
• Relapse Prevention

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Detoxification

• Goals
• Counter effects of drug withdrawal
• Return individual to a neutral physiological and
  emotional state (generally 3-7 days)

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Rehabilitation

• Goal
• Generally 15-90 days
• Combined with patient education and
  counseling/coaching to develop strategies for
  sustained change

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Relapse Prevention

• Begins near the end of Rehabilitative stage
• Rehabilitative view points to chronic nature of
  the disorder of addiction and need to address
  different stages of the process

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Research

• Often lack clarity about which aspect of drug
  treatment is being studied
• Lack of measurement of symptoms attributable to
  withdrawal, relaxation and dysphoria.
• Not a good fit for RCT due to systemic effect.
• Therapist bias minimized in RCT.
• Therapist support and guidance beneficial factor
  in process of recovery

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Dipole (Molecular) Theory of Interactions of
Nerve Signals

• Ling Y Wei (1980) Biophysical Research
• Mathematical Biology, Electrical Engineering
  Dept., University of Waterloo, Ontario, Canada

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Research questions

• What is the physical origin of the nerve impulse?
• How do nerve signals interact with each other?
• What governs interactions

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Dipole Theory-mechanism of actionDr. Ling Wei
-1980

• Surface dipoles of nerve membranes form a
  potential barrier which under resting condition
  blocks the entry of the Na ions into the
  membrane. Upon stimulation, some dipoles in the
  ground state flip up to the upper state and thus
  reduce the barrier. When barrier is sufficiently
  lowered, there is a net inward driving force of
  Na ions thereby a nerve impulse is produced.
  The falling phase of the impulse follows the flop
  down of the dipoles to the ground state. The
  energy of the dipoles can go two ways decreased
  by relaxation and increased by stimulation . The
  energy balance equation can be reduced to the
  transition rate equation.

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Transition Rate Equation

• To excite the nerve use low frequency
• To sedate the nerve use high frequency

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Significance of Dipole Theoryof interactions of
nerve signals

• Conclusion Applying sufficient strength of a
  single stimulus at a proper frequency, it is
  possible to regulate some body functions
  dictated by nerve impulses, such as autonomic
  nervous system. If some body functions are
  controlled by nerve messages (autonomic nervous
  system) then disorders of these functions could
  be normalized by external stimulation of
  appropriate strengths and frequencies

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Application of Dipole theory of for addiction
therapy

• Provides a physical basis for understanding
  Neurotherapies such as
• --Nogiers Auriculotherapy
• --Lamys phoophoresis
• --Volls electroacupuncture
• --TENS (transcutaneous electro-neuro-
• stimulation

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Neurotherapy

• Neurotherapy is a biophysical, chemical free
  application of electrical stimulation energy to
  nerve endings on the surface of the auricle to
  physiologically alleviate symptoms of nicotine
  withdrawal by redirecting the flow of electrical
  energy through neurological pathways and
  signaling molecules, thus creating endogenous
  neutrality and natural balance of mood, thoughts
  and physical symptoms

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Case Study Design

• Qualitative
• Retrospective
• Instrumental
• Explored effects of
• Neurostimulation (auricle) in combination with
  addiction education, behavioral training and
  coaching support

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Sample Selection

• Simple Random Sampling
• - precise population
• -knowledge of addiction/neurotherapy
• -moderate-severely addicted
• Criteria for selection
• -unable to stop smoking on own/other methods
• -1 year smoke free after use of
• auricular neurotherapy

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Data Collection-2005

• Interviews (60-90 minutes) conducted by
  co-investigator
• open-ended questions
• -family history of addictions
• -experience with the therapy
• -how the experience differed from other
• methods used
• -what was helpful

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Data Analysis

• Audiotaped interviews-
• -wholistic analysis for overall sense of data
• -within case analysis of narrative for details
  of topics and themes
• -pattern matching was applied and category
  saturation.

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Findings

• 6 Caucasian participants-3 male, 3 female
• -motivated
• -self identified in action stage of readiness
• based on adaptation of Prochaska, Norcross
  DiClemente (1994) Transtheoretical Model for
  Stages of Change Chart
• Pre-contemplation, Contemplation, Preparation,
  Action
• -Each reported a biological family history of
  addiction behavior

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Detoxification

• Average number of neurotherapy interventions
  during first 48 hours 1-3
• Received neurotherapy during Detoxification
• Stage only 3 (2 male, 1 female)
• Themes
• 1) Recognition of differences between
• physical need to smoke and want to smoke
• 2) Intensity or number of therapy sessions
  required

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Detoxification StageNeed vs. Want

• Physical anxiety associated with needing to smoke
  was extinguished
• Want to smoke associated with conditioned
  response was not immediately extinguished.
  Thoughts to smoke associated with previous smoke
  routines faded soon after thought occurred

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Detoxification, Rehabilitation, Relapse Prevention

• Received therapy during all 3 stages
• 3 (1 male, 2 females)
• varying degrees of intensity of interventions
  and supportive therapy intermittently for 3-4
  years.

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Participant descriptionsDetoxification Stage

• Similar to initial first drag of cigarette
  although natural
• Visual clarity
• Tired
• sleepy
• Difficulty concentrating (first days)

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Participant descriptions during Rehabilitation
Stage

• Major reasons for reactivation of smoking
• were identified
• 1) physical exposure to cigarette smoke or other
  priming drugs
• 2) Unusually stressful situations

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Major Themes-Rehabilitation/Recovery Stage

• Knowledge about addiction-appreciation expressed
  about learning about the brain.
• Conditioned usage
• Strength gained through individualized coaching
  support and management plan
• Learning how to breathe better/relaxation to help
  manage cues
• Surprised by reduction of stress levels

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Themes associated with Relapse Prevention Stage

• Preventive maintenance for anticipated stressful
  events or situations such as surgery
• Ongoing need for coach to encourage the
  engagement of stress reduction activities such as
  exercise and deep breathing.
• All participants found therapy useful regardless
  of stage of the treatment process
• Spousal/friend support
• Most reported changes in lifestyle to support
  related to caffeine, alcohol and food intake
• 4/6 participants had no weight gain.

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Underlying Assumptions

• Individuals function as a bodywide system (Pert,
  1997)
• Disorders are considered imbalances in the
  natural flow of information carried by
  neuropeptides (molecules) and their receptors
  (Pert, 1997)
• In health, the body is in a natural balanced and
  functioning homeostatic state.
• In illness, the imbalances are identified by the
  presenting patterns of symptoms and signs of the
  disorder (Pert, 1997)
• Electrical stimulation of auricle points is known
  to influence the bodys production of opiate
  peptides in drug addiction (Wen, Ho, Ling, Ma,
  Choa, 1979).
• Electrical stimulation can heighten a sense of
  well being, promote relaxation, reduce anxiety
  and stress, and improve sleep (Oleson, 2003)
• fMRI studies have shown direct correlation with
  anatomical structures known to Western science
  (Alimi, Geissmann Gardeur, 2000)
• Points of low electrical impedance on the skin
  can be located with a sensitive ohmmeter (Moner,
  1996 Oleson, 2003)
• Becoming and remaining smoke free is a process
  for most (Moner, 1996)
• Applying interventions using a structured
  rehabilitative approach can potentially improve
  the ability of smokers to remain smoke free
• An individualized approach of guided and
  progressive interventions including neurotherapy
  combined with addiction education, behavior
  training and coaching support can increase the
  smokers ability to become and remain smoke free.

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Findings

• Neurotherapy can be an effective tool with
  cumulative benefits in all stages of the recovery
  process detoxificaton, rehabilitation recovery
  and relapse prevention.
• Participants experiences illustrate the need for
  an individualized and multi-demsional approach
  with an option for more intensity as needed.
• Stated reasons for becoming smoke free
• health, family, social, financial, emotional

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Addiction Process

• An active process of taking steps on a
  continuing basis in ones life, not just not
  doing your addiction. Recovery is from the
  underlying disorder, not from the manifested
  behavior involving an entire self-concept and
  lifestyle based on a hypo functioning of low
  activity of multiple neurotransmitters effecting
  thinking, feeling, and acting.
• Umanoff, p 996

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Implications for Practice

• Current acute care model for smokers is
  limited.
• IOM calls for controlling conflicts of interest,
  restricting pharmaceutical funding and panel
  members participation in Clinical Practice
  Guideline development .
• A chronic care rehabilitative model of recovery
  is the future of nicotine addiction treatment.
• Development of a rehabilitative outpatient model
  using neurotherapy opens a new era for
  practitioners of physical nursing/medicine.
• Neurotherapy, combined with addiction
  education/counseling/coaching support is a viable
  safe option for outpatient treatment. Could be
  used to complement conventional chemical (drug)
  treatment in the outpatient setting.
• Nicotine addiction is largely ignored in academic
  nursing and medical practice settings although it
  is recognized widely as a major, if not the
  major, ongoing global epidemic of the century.