Tobacco Free, Drug Free

Elizabeth (Libby) Stuyt, MD is President of NADA (National Acupuncture Detoxification Association) and Medical Director, Circle Program, Colorado Mental Health Institute, Pueblo, CO. She is one of the few addiction experts in the country who has seen the benefits of tobacco cessation to improve outcome and maintain recovery during and after treatment for other addictive substances and has published her findings:

Dr. Stuyt found that of 140 patients who completed the follow-up, 86% were using tobacco daily upon program entry and 73% picked up tobacco again during the year after treatment. Most striking was the difference in relapse rates for other drugs between those who returned to tobacco use after leaving the program (69%) and those who refrained from returning to tobacco (45%). In significant numbers, those who remained tobacco-free after release were more likely to remain abstinent from their other former drugs of choice throughout following year.

By Dr. Elizabeth (Libby) Stuyt

Director, Circle Program, Colorado Mental Health Institute

President, National Acupuncture Detoxification Association

My patients in the Circle Program are in a controlled environment for 90 days and have to stop using everything, including tobacco. There is a high correlation between smoking tobacco and relapse to every other drug. So, I think it is of paramount importance to stop smoking during drug treatment.

Tobacco works like all the other addictive drugs. It suppresses neurogenesis in the hippocampus, which suppresses learning.

In animals, researchers study the effect of drugs by using a Morris water maze. It’s a big tank of water in the middle of the room with a little block of wood under the surface. They see how long it takes for the animal to find the block of wood, get on it, and say to themselves, “Finally, I’m saved.”

Animals, once on the wood, can figure out where it is inside the tank from pictures that are posted along the edges of the tank, and go directly to the block of wood the next time they are placed in the water. However, if you fill their brains with drugs, including nicotine, they cannot find the block of wood to save their lives. If you get them off of drugs, exercising and eating right, the rats can find the block of wood again.

If you have got someone in substance abuse treatment, regardless of the drug, and that person is still using tobacco throughout the entire treatment program, you have suppressed neurogenesis in their hippocampus which makes it difficult for them to learn anything new. The hippocampus is where you put memories of anything that is important.

When you use an addictive substance for the first time you get dopamine in the nucleus accumbens area of the brain that sends the message to the hippocampus, “This is really great!” The message includes, “Next time you see the guy that gave that to us, remember him!” It sends a message to the prefrontal cortex part of the brain too, where consequences are stored, but the prefrontal motor cortex isn’t fully developed until early adulthood, ages 21 to 25. Most patients started using addictive substances during adolescence. Use of addictive substances hijacks the proper development of the learning and memory part of the brain so even though they may be in their 30s or older the brain never was able to mature adequately in those areas. The next time you see that same guy all you remember is the good part of using so you go right up to him to get more drugs. The more times you do this on a regular basis then the more profound the suppression of neurogenesis in the hippocampus and the harder it is to learn from the consequences of your behavior.

It takes 90 days for stem cells to grow in your hippocampus to differentiate and allow for new learning tracks to be laid down. Alcoholics Anonymous has known this intuitively forever. They say, “If you stop drinking, go 90 for 90.” They mean you need to go to 90 meetings in 90 days.

One reason 12 Step programs alone don’t always work is that meetings include a cup of coffee in one hand and a cigarette in the other. The ideal is to stop every addictive substance. If you can go through a 90-day period to allow the brain to heal, new neurogenesis will happen, and you will be able to rewire new neurons and learn new things. Most people don’t have the beauty of getting locked up for 90 days and even if they do, most programs allow them to drink as much caffeine or smoke as many cigarettes as they like.

I am adamant that treatment has to be tobacco-free. Tobacco is a very powerful drug. It is the hardest drug to quit, even heroin addicts admit that. It’s the only one addicts of all kinds use all day every day so it is reinforced.

I’ve forbidden the use of tobacco both in the inpatient and outpatient settings I’ve directed. Initially, for the first week or so, they are angry, can’t stand it. Ear acupuncture is really helpful for people at this stage. Once they are past the bad withdrawal period, the NADA 5-point ear protocol can continue to help with cravings and allows them start thinking differently.

In our inpatient program, I also use a nicotine patch for the first three weeks, if they have been smoking a pack a day or more. They get a 21 mg patch the first week, every day a new one. The next week they are down to 14mg every day for a week, then down to a 7mg patch every day along with NADA ear acupuncture 5 days a week. My perception is that the worst cravings occur during the first three days and get slowly better after that. We definitely see the folks who participate in NADA’s ear acupuncture reporting very minimal cravings and those who don't, reporting more significant cravings. We have many people refusing the patch after the first 1-2 weeks so the patch isn't that necessary in an inpatient setting where no one is exposed to other people smoking or being triggered by cues to smoke.

In the outpatient setting it’s the same model but it is harder for them. I make the Intensive Outpatient (IOP) patients come for treatment three hours a day, and they can’t use any tobacco during those three hours. I give them a patch and offer NADA, but they go back to using when they leave. They can’t seem to hear anything about the drug while they are using the drug. They can’t incorporate that information. So, most don’t quit a substance until they have a consequence. If people wait until they get consequences from tobacco it could be a heart attack or cancer.

The beauty of forced tobacco cessation is that quickly they can run, breathe, and feel so much better. At least jails and prisons are tobacco-free. That gives people the experience that they cannot smoke. That is the best benefit, when sitting in jail three or four months not using anything, they have the ability for their brain to heal, and can start learning right away.

I have gone around the country talking to treatment programs about stopping smoking on their campuses and it is a hard sell because they have the false impression people aren’t going to come there if they don’t allow them to smoke. If they have a good program people will come! CeDAR (Center for Dependency, Addiction, and Rehabilitation), for example, is a beautiful inpatient program in Aurora, Colorado, affiliated with the University of Colorado. That was the first place we started doing a NADA training for nurses, back in 2008 or so. They have been doing NADA there ever since. When they took me on a tour I saw a big sign in front of their gorgeous administration building: “University of Colorado is a tobacco free campus.” I was so excited, but then they told me, “We are the only place that has a smoking exemption.”

Soon thereafter I met the medical director at a conference and told her, “We in Circle are treating all your CeDAR failures because they have spent all their money at CeDAR, relapsed right away, and are now in Circle. Since they are allowed to smoke in your program, they don’t learn anything new.”

They finally went tobacco-free about three years ago, on Valentine’s Day. We have not been seeing CeDAR failures in my program, since! The CeDAR medical director actually published a poster in another conference revealing that they have saved money, made more money, and have better outcomes since forbidding smoking.