Smoking During Medically Managed Opioid Withdrawal is Associated with Increased Craving for Opioids and Nicotine

Over 80% of people with opioid addiction smoke tobacco. Smoking rates remain high among people who undergo medically managed withdrawal (detoxification). It is not known if smoking cessation during opioid detoxification treatment impacts craving, withdrawal symptoms, or subsequent substance use. Very low doses of naltrexone (0.125 mg–0.25 mg) given concurrently to patients receiving methadone for detoxification has been associated with reduced opioid withdrawal and craving. Using data from a randomized clinical trial of very low-dose naltrexone administered during detoxification, researchers conducted an observational study of craving, opioid treatment completion, and substance use in the next week among 174 subjects categorized as in-treatment smokers, non-smokers, and smokers not allowed to smoke. Smoking cessation counseling and pharmacotherapy were not offered as part of treatment.

• In-treatment smokers had more severe opioid craving scores—but not more severe opioid withdrawal scores—than non-smokers and smokers not allowed to smoke.
• In-treatment smokers had higher cigarette craving scores than smokers who were not allowed to smoke.
• In-treatment smokers were less likely to complete detoxification treatment (59% versus 79%) and smoked more cigarettes in the week after treatment (20 versus 13 per day) than smokers not allowed to smoke. No differences were found in use of opioids, alcohol, cocaine, or cannabis.
• Among the in-treatment smokers, those treated with very low-dose naltrexone had lower opioid withdrawal and craving scores than those receiving placebo.

Comments:

This study provides preliminary evidence that smoking cessation during opioid detoxification treatment may improve both opioid and nicotine addiction outcomes by reducing craving. Furthermore, among those who do smoke during opioid detoxification, very low-dose naltrexone may attenuate the disadvantages of continuing to smoke during treatment. Randomized clinical trials of smoking cessation and very low-dose naltrexone are warranted to determine whether they can improve opioid and nicotine addiction outcomes.

Alexander Y. Walley, MD, Msc

Reference:

Mannelli P, Wu LT, Peindl KS, Gorelick DA. Smoking and Opioid Detoxification: Behavioral Changes and Response to Treatment. Nicotine Tob Res. Apr 9, 2013 [Epub ahead of print]. doi: 10.1093/ntr/ntt046.