One addiction at a time

CrossCurrents

By Kim Goggins

 

When Jill* entered the Aurora Centre in Vancouver, she knew it was the help she needed to recover from her crystal meth and alcohol addiction and ultimately regain custody of her children. She knew it was a tobacco­free facility, but remained ambivalent about dealing with her tobacco dependency, not thinking her pack­a­day addiction was a real concern.

But it became a serious concern when she was caught smoking during her six­week residency and placed on a tobacco contract with the centre. Although she was able to abstain from crystal meth and alcohol, one more mistake like this and she would be released from the program.

“This changed her attitude,” recalls Gail Malmo, program director of the centre, which serves women and is part of the BC Women’s Hospital and Health Centre. “She wrote in her journal that she shared with the group that she realized the lengths to which she would go to have her smokes: she would lie, break rules and even jeopardize her treatment – and that’s her chance of having her children returned to her sooner. If smoking wasn’t such a big deal, she asked herself, why would she risk all of this for it? That was when Jill became committed to change.”

Jill’s success story illustrates what can happen when substance use treatment programs integrate smoking cessation into their services. This focus makes sense, given the startling statistics: While number of smokers in the general population is decreasing, studies show that 80 to 95 per cent of people with alcohol and other substance issues use tobacco. It is the leading cause of death in people treated for alcohol and other substance use problems. Yet most Canadian substance use treatment programs are not doing much in the way of formalized treatment for tobacco dependency.

“In our society of smoking and nicotine, tobacco dependency has been viewed very differently than dependency on other sub­stances or alcohol,” says Malmo, whose centre is one of the few – perhaps the only – addiction treatment programs in Canada that are completely tobacco­free. “Smoking has been characterized for too long as just a bad habit,”she says.“It wasn’t treated with the same seriousness as addiction because it didn’t seem to have the same daily impact as other drugs.”

The Aurora Centre is distinct in its approach to addiction treatment not only because it restricts smoking on the grounds but because the abstinence­based program also bans smoking for the duration of the treatment experience, including when clients are not on site. Tobacco dependency is also a topic in the daily lectures, discussion groups and educational group therapy.

Several issues stop many addiction professionals from treating tobacco dependency as any other addiction, says Malmo. In addition to the firmly entrenched belief that smoking is just a bad habit is the long­held assumption within the addictions movement that it is too much to address more than one substance at a time. “The only thing that’s ever exempted – ever – in an abstinence­based treatment centre is tobacco,” says Malmo. “We ask them to stop everything else except smoking, but why does tobacco have special status? When you start presenting people with evidence, the evidence speaks for itself; education is important in this field and it’s starting to spread.”

Resistance to integrating tobacco cessation into addiction treatment programs may also reflect the fact that addiction treatment professionals themselves are two to three times more likely to smoke than the general population, according to a recent study by Dr. Doug Ziedonis, chair of the Department of Psychiatry at the University of Massachusetts Medical School and University of Massachusetts Memorial Medical Centre. He says this is part of the problem because addiction professionals further the misconception that their clients don’t want to give up smoking or can’t give up everything at the same time.

“It’s one of those preposterous things that if you take a step back, you think, ‘Wow, how did we get into this delusional thinking?’” says Ziedonis. “It’s just amazing for addiction specialists because we know the power of denial, minimization and rationalization. Tobacco addiction should be the poster child for that. That’s the shared delusion; it’s the co-dependency of the whole field.”

Resistance by staff who smoke was indeed a barrier when the Aurora Centre initially went smoke-free in May 2006, but their misgivings weren’t the only challenge, notes Malmo, who points to the reluctance of referral agencies and the resultant unwillingness of some clients to quit smoking as other barriers.

“We all want our clients to succeed, but when you’re trying something new, and there isn’t yet a lot of evidence available, people are fearful that it will contribute to treatment failure,” says Malmo. “It was a challenge to encourage our referral agents to trust us and continue sending us clients.”

Every year, the Aurora Centre treats approximately 200 women in its six­week residential program and 100 through the five­week day program. Evaluations after the first year of being smoke­free show that 62 per cent of clients at three months post­treatment had stayed quit or cut down.

When Dr. Milan Khara studied for the American Society of Addiction Medicine Certification exam in 2006, he said looking at relative models of people who have died from different substances opened his eyes to the true problem of tobacco. “Eighty per cent of all substance-related mortalities are from tobacco use, yet we were ignoring tobacco in addiction services, which made no sense,” he says. “We’re spending all our energy treating people for their opiate problems or their alcohol problems when in fact they’re going to die from tobacco use. That was the motive for realizing we had to do something.”

Khara refutes the widely held myth that smoking cessation during the treatment of other addictions may hurt recovery, and says it may actually improve outcomes.

One year ago, Khara opened the first Tobacco Dependence Clinic in Vancouver, taking referrals of existing clients with a diagnosis of substance use disorders and/or mental illness. The intensive treatment program consists of formal assessment and treatment planning, comprising 26 weeks of free pharmacotherapy and weekly group counselling. The successful program will soon open its third clinic within Vancouver Coastal Health.

“We see people who never believed they could quit doing just that and challenging many of our assumptions,” says Khara, who is the clinical director of the clinic, which is modelled after the Nicotine Dependence Clinic at the Centre for Addiction and Mental Health in Toronto. “There is increasing research evidence that these populations do want to quit and can do so successfully with suitably intensive intervention,” says Khara. “Our work will contribute to this body of evidence.”

Debbra Behrens, a tobacco addiction specialist at Womankind Addiction Services in Hamilton, Ontario, shares this view. Within the five­week residential treatment program that includes tobacco addiction programming and limits smoking on the property to specific areas, she sees her clients open up more in therapy once the tobacco is gone. “Tobacco changes the way we feel and the way we deal with things – that’s why we use it,” she says. “If clients remove tobacco along with the other substances, the issues and feelings they have to deal with come to the forefront. And clients can’t go for a smoke break and bury those issues under tobacco.”

At the two Tobacco Dependence Clinic sites in Vancouver, “off-label” pharmacotherapy – levels that are higher than conventional doses of NRT and/or the use of more than one product simultaneously – is used to tailor treatment to an individual’s degree of nicotine dependence. The high cost of NRT is often an obstacle to this population, but here, it is offered for free. “Pharmacotherapy at least doubles the likelihood of successfully quitting and should be offered to everyone,” says Khara, noting that his biggest challenge is to find ongoing funding for pharmacotherapy.

Still, many clients, like Jill, are not always ready to give up their “first addiction,” but Khara and Malmo are optimistic. “I think as the initiative spreads, we’ll start to see a change,” says Malmo.“ As the culture and attitudes shift so that tobacco use becomes more integrated into the mandate of most addiction service providers, then we’ll see readiness on the part of clients.”

 

*not her real name

 

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