neurobiology of nicotine addiction - mayo
TRANSCRIPT
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Neurobiology of Nicotine
Addiction
David McFadden, MD, MPH
Mayo Clinic Nicotine Dependence
Center
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Outline
Addiction defined
• Nicotine absorption
• Nicotine neurophysiology
• Conditioning Cues
• Nicotine withdrawal
• Dealing with frustration
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Frustration
• Patient viewpoint--ambivalence
– 90% know cigarette smoking is harmful and
want to quit.
– Most smokers feel guilty and feel they have
let themselves, their spouse, family and care
provider down.
– But most smokers are reluctant to quit and
make only brief attempts to quit and often
experience relapse if they do quit.
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Frustration
• Health Care Provider viewpoint
– Failure to help patient quit smoking may
weaken care provider’s resolve to try again
– Tendency to “blame” the patient for “non
compliance”
– Failure to understand the addictive physiology
and consequences of nicotine addiction which
promotes relapse
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Psychoactive Substance
Dependence DSM_IV Three or more of the following:
• Tolerance
• Substance taken in larger amounts or over a
longer period than intended
• Persistent desire or unsuccessful efforts to cut
down or control use
• Great deal of time spent in activities necessary to
obtain or use the substance or recover from its
effects
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Dependence diagnosis criteria
(continued) • Important social, occupational, or recreational
activities given up or reduced because of use
• Continued use despite knowledge of having
had persistent or recurrent problems caused by
the substance
• Withdrawal symptoms when attempt to
discontinue
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Cigarette smoking-not a “habit”
• Habits=automatic routine, repeated
regularly and without thinking
• Addictions are compulsions characterized
by subjective distress when routine
behaviors are forbidden.
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Nicotine “hard-wired”
• Nicotine creates a motivation for the
“target” behavior (smoking) that is
rendered undeniable by the abnormal
amplified negative emotional
consequences of unresolved compulsion.
• This association becomes “hard-wired”
and persists over time
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Addiction—alternative view
• “Continued smoking could no longer be
considered a manifestation of motivation
deficit, but instead must be considered a
disorder of an abnormally amplified
motivation “NOT to quit”
• Cessation treatment should focus less on
the consequences of tobacco use and
more on the amplified motivations NOT to
quit © 2012 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED
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Nicotine absorption
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There seems no doubt that the “kick” of a cigarette is due to the concentration of nicotine in the blood-stream…and this is a product of the quantity of nicotine in the smoke and the speed of transfer of that nicotine from the smoke to the blood-stream.
Nicotine is in the smoke in two forms as free nicotine base (think of ammonia) and as a nicotine salt (think of ammonium chloride) and it is almost certain that the free nicotine base is absorbed faster into the blood-stream.
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Forms of Nicotine as a function
of pH
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Nicotine state
• Protonated and free base
• Only the “free base” form can volatilize in
gaseous form and be absorbed in the
lungs
• Tobacco companies add ammonia to the
tobacco leaf which by increasing pH
increase nicotine conversion to “free base”
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Cigarette-efficient nicotine
delivery device • Capable of producing very rapid peaks in
the arterial concentration of nicotine
• Nicotine absorbed in alveoli of lung and
circulates via pulmonary veins to Left
heart. (bypasses the right heart)
• Nicotine circulates to brain within 7-10
seconds where nicotine receptors
stimulate dopamine release
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Cigarettes and Tobacco
Dependence
• Cigarette is the most efficient delivery device for
nicotine that exists- better than intravenous
• Cigarette manufacturers have modified cigarettes
over the past decades to maximize nicotine delivery
to the brain
• High doses of arterial nicotine cause upregulation of
the nicotinic acetylcholine receptors
• Genetic factors influence tobacco dependence
• Left untreated 60% of smokers die from a tobacco-
caused disease
Hurt RD, Robertson CR JAMA 280:1173, 1998
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The cigarette should be conceived not as a product but as a package. The product is nicotine.
Think of the cigarette pack as a storage container for a day’s supply of nicotine:
Think of the cigarette as a dispenser for a dose unit of nicotine:
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“Low Tar Low Nicotine” Cigarettes FTC Method
• Determines relative yield of individual cigarettes
by smoking them in a smoking machine
• Machine draws 35ml puff of 2 seconds duration
every minute
• Cigarette smoked down to 23mm butt length
• Cambridge filter collects the particulate matter
• Does not measure the gas phase “free nicotine”
• 2008 no longer used and as of June 2010 no
longer can use “light” terminology
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“Low Tar Low Nicotine” Cigarettes Ventilation
• Ventilation holes one of key technologies to
manipulate tar and nicotine yields
• Electrostatic or laser perforations of the filter or
paper
• Ventilation holes in most brands are not visible
• 2/3’s of U.S. smokers are unaware of ventilation
holes or that blocking then increases tar/nicotine
yield
• Many smokers block (consciously or not) the
ventilation holes with their lips on fingers © 2012 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED
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Carcinogens Excreted by Smokers of
Regular or “Light” Cigarettes • 150 smokers of regular or “light”
cigarettes
• Nicotine metabolites-Serum cotinine and urine NNAL, NNAL-Gluc, and 4 aminobiphenyl hemoglobin adducts measured
• Essentially the same concentrations of were present in “light” as in regular cigarette smokers.
Bernert J.T., et. al. Nic & Tob Res 7:729, 2005 © 2012 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED
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Nicotine neurophysiology
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Nicotine effect on the brain
• Brain imaging studies show nicotine
acutely increases activity in the prefrontal
cortex, thalamus and visual system brain
circuits—
• There is stimulation of central
acetylcholine receptors (nAChRs) which
results in release of several
neurotransmitters most important -
Dopamine © 2012 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED
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Mesolimbic system
• Ventral Tegmental area (VTA)-collection of
nerve cells located midline on the floor of
the midbrain
• Neurons of the VTA send projections to
target the Nucleus Accumbens in the
prefrontal region of the brain
• The Nucleus Accumbens –reward center
for most drugs of abuse
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Central Nervous System
“Reward Center”
Dopamine (DA) release in the nucleus accumbens is thought to be
the “final common pathway” for the rewarding effects of most drugs
of abuse © 2012 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED
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Mesolimbic system
• VTA contains “dopaminergic neurons” that
respond to external rewarding stimuli such
as food, sex and social interaction as well
as aversive stimuli and stress.
• VTA stimulation promotes a generalized
behavioral arousal under both positive and
negative stimuli.
• “seeking of safety”
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Neurophysiology of nicotine
• VTA’s inputs are transmitted by cholinergic
pathways and receptors.
• Nicotine “hijacks” these receptors and
compels them to produce dopamine,
creating a powerful but artificial “safety”
signal.
• Most potent drug—more potent than
cocaine, amphetamine and morphine to
compel repetitive behavior © 2012 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED
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Different types of nAChr
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Nicotine addiction-animal study
• Powerful motivator of behavior
• Animal studies
– Prolonged “foot shock” behavior extinction
– Lever pressing of nicotine exposed monkeys
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NICOTINE
DOPAMINE Pleasure, Appetite Suppression
NOREPINEPHRINE Arousal, Appetite Suppression
ACETYLCHOLINE Arousal, Cognitive Enhancement
GLUTAMATE Learning, Memory Enhancement
SEROTONIN Mood Modulation,
Appetite Suppression
BETA-ENDORPHIN Reduction of Anxiety and Tension
GABA Reduction of Anxiety and Tension
Nicotine Stimulates Release of
Many Different Neurotransmitters
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Nicotine actions
• Induces stimulation and pleasure
• Reduces stress/anxiety
• Improves concentration, reaction time and
task performance
• Prevents withdrawal symptoms by keeping
nAChRs in desensitized state
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Smoking Saturates Nicotinic
Receptors • Radioligand allows for visualization
of α4β2 nAChRs
• Position Emission Tomography (PET) Scans
• 11 smokers had 14 PET scan sessions
• Smoked: none, 1 puff, 3 puffs, 1 cigarette or 2-3 cigarettes (satiety)
Brody, A.L. Arch Gen Psychiatry. 63;907-915, 2006 © 2012 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED
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Smoking Saturates Nicotinic
Receptors Results
• 1-2 puffs of a cigarette → 50%
occupancy of α4β2 nAChRs for 3 hours
after smoking
• One cigarette → 88% receptor
occupancy and ↓ cigarette craving
Brody, A.L. Arch Gen Psychiatry. 63;907-915, 2006
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Smoking Saturates Nicotinic
Receptors
Brody, A.L. Arch Gen Psychiatry. 63;907-915, 2006
0.0 Cigarette 0.1 Cigarette 0.3 Cigarette 1.0 Cigarette 3.0 Cigarette
kBq/mL
9
0
Nondisplaceable
MRI
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Neuroadaptation
• Repetitive Nicotine exposure
– Upregulation -Increase in nAChRs
– Response to nicotine-mediated
desensitization of receptors which may lead to
tolerance/dependence
– Daily smoking maintains near-complete
saturation and desensitization of nAChRs
– Avoids withdrawal
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Conditioning
environmental factors (cues) contribute to
urge to smoke (after meals, with coffee,
with friends)
Cue often is to avoid “irritability
• Association between cues and anticipated
drug effect drives urge
• May maintain nicotine use while nAChRs
are desensitized
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Nicotine Addiction
• Physical Dependence
Psychological Dependence:
– “Conditioned Response” to Cues • The Five Senses
• Emotions (positive and negative)
– Cues trigger neurotransmitter release
– Anticipation of Nicotinic receptor activation and
Dopamine release
Craving/Urges
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Withdrawal Syndrome or "Abstinence Syndrome"
Pathophysiologic disturbances
which result when a drug to
which an organism is physically
dependent is stopped.
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Craving
• An intense desire to fulfill an unsatisfied
state
– As opposed to ‘like’
• Positively correlated with relapse in two
ways
– Intensity during early quit
– Momentary craving associated with immediate
relapse long after initial quit
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The experience:
Withdrawal Symptoms
• Insomnia
• Restlessness
• Anxiety, Irritability,
Frustration, Anger
• Difficulty concentrating
• Sad, depressed mood,
anhedonia
• Increased appetite
• Decreased heart rate
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Other Common
Withdrawal Symptoms
• Headache
• Mouth ulcers
• Nausea
• Constipation
• Diarrhea
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Timeline of Nicotine Withdrawal For most smokers, withdrawal symptoms
last for a few weeks and then resolve.
Cravings can be frequent and intense early,
but become less intense and less frequent
over time Stop Date
Inte
nsit
y
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Medication:
Effects on Withdrawal &
Urges Stop Date
Intensity
Without Medication
With Medication
Time
Intensity
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High Relapse
• Most people who smoke want to stop
• 80% of smokers who try to quit on their own
relapse within 1 month
• Only 3% remain abstinent at 6 months
• Nicotine addiction=chronic disease
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Dealing with frustration
• Patient’s internal conflictambivilance
• Our responsibility is to help patients
resolve ambivalence
– Motivational interviewing which enhances
motivation to change through reflective
listening without confrontation or judging
– Ellicit trust by demonstrating
• Empathy-develop a sense of “shared experience”
• Joining –develop shared goals
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Dealing with Frustration
• Validation –confirm that the patient’s
experience/frustration with quitting has a
“biologic/physiologic basis”, but don’t
undermine “self-efficacy” by over
emphasizing “how difficult quitting can be”
• Hope-hopelessness is a common barrier
to behavior change in addiction.
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Dealing with frustration
• Hope –Work to reinvigorate hope by
maintaining a positive non judgmental
attitude, emphasizing creative solutions to
common problems.
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“Not a Bad Person with a Bad Habit, but a
Good Person with a Difficult Disease” --Tom Gauvin, NDC Counselor
It Is A Disease
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References
• 1. “Neurobiology of Nicotine Addiction:
Implications for smoking cessation
Treatment” Neal L Benowitz, MD
– American Journal of Medicine (supplement)
vol. 121 (4A) S3-S10
April, 2008
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References
• 2. Leone, FT et el; “Developing a Rational
Approach to Tobacco use Treatment in
Pulmonary Practice: A review of the
Biological Basis of Nicotine Addiction”;
Clinical Pulmonary Medicine,
Vol 19, No. 2, March, 2012
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Association for the Treatment of
Tobacco Use and Dependence
An organization of providers
dedicated to the promotion of and
increased access to evidence-based
tobacco treatment for the tobacco user.
www.attud.org
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