A Lesser Evil is Still Evil
Within the chemical dependency treatment field, it is widely accepted that clients greatly improve their odds of remaining in recovery when they adhere to a strict policy of total abstinence. For instance, it is never advisable to suggest to a heroin addict that switching to alcohol is an acceptable path to recovery. By various neurochemical processes, all substances of abuse make it easier to either suppress or avoid unpleasant and distressing emotions, or to artificially alter one’s perceptual experience. Some clients prefer the feeling of intoxication from alcohol to that from methamphetamine or heroin. Furthermore, certain clients possess neurotransmitter dysregulations that predispose them to affinities for their respective drugs of choice. Regardless, real recovery from addiction of any sort cannot truly begin until all barriers between clients and reality have been removed.
Despite the difficulty ahead, clients—and we alongside them—have good reasons to strive for recovery: families can reunite, jobs can be retained or secured, outlooks can shift, and health can improve. Failing in this endeavor can precipitate many negative consequences, but the one that looms largest in many substance abusers’ minds is accidental and premature death. There is a lot of talk at the moment around the increase in intravenous (IV) heroin use and the concomitant increase in deaths from overdose and the very worrying increase in the rates of human immunodeficiency virus (HIV) transmission within this subset of the addiction community. For this and many other reasons, it is important that we work to foreshorten addicts’ use of this and any other substance of abuse, using any and all prudent means available.
Since the Minnesota Model and other modern approaches to chemical dependency treatment came into being in the 1950s, there have been many advances in intervention modalities, treatments designed to address mental illnesses that occur in conjunction with substance use disorders (co-occurring disorders), and medication-assisted treatment (MAT). As we see it, the problem is that, although we are doing a better job of helping clients to move from active addiction to recovery, we still stand to lose over half of the clients who enter some form of chemical dependency treatment protocol to premature death. Why? It’s because we do not adequately address their concurrent addictions to tobacco (Richter, Ahluwalia, Mosier, Nazir, & Ahluwalia, 2002).
Based on studies published in 1996 and 2002, persons with substance use disorders are three times more likely to smoke cigarettes than those with no substance use disorder (P = 3.07) (Richter et al., 2002); when they quit, smokers who are either alcoholic or drug-addicted quit at less than half the rate of the rest of the population; and, lastly, over half of the deaths recorded in the earlier, retrospective study were attributed to tobacco-related causes (50.9 percent). The next closest cause of premature death was attributable to alcohol (34.1 percent) (Hurt et al., 1996). Now, this does not mean that there were no cases of successful recovery in this population, nor do we mean to say that participants’ lives did not improve, but with so many deaths attributed to preventable causes, how successful is treatment that does not address abstinence from tobacco products?
With these data, it would make sense for those of us in the chemical dependency treatment field to focus more on smoking cessation than we do at present. Unfortunately, it will take more than an increase in focus to change these trends and outcomes. To explain why we believe this, let’s talk a bit about the idea of risk in the population of those with substance use disorders. Generally speaking, heroin is often seen as “riskier” than alcohol, and alcohol, despite being legal in all fifty states, is usually considered to be “riskier” than marijuana. Put more simply: heroin dependence > alcohol dependence > cannabis dependence. In our experience, clients and their families see the risk of overdose from heroin as more likely than the risk of acute alcohol poisoning; the same population also perceives alcoholism to be more physically and psychologically debilitating than dependence—physical and/or psychological—on marijuana. Let’s say, for the sake of argument, they are exactly right. Consider this scenario: a twenty-three-year-old male comes to our practice for help with severe opioid dependence. He tells us he’s tried to quit “cold turkey,” tried to wean himself off slowly, even tried using Suboxone, but every attempt ends with the same result: a few weeks pass, he gets a craving, texts his dealer, and the whole pattern begins again. After he has spent some time getting to know a member of our staff, and seems comfortable, an alternative he might not have considered is suggested: “Have you ever thought about whiskey?” one of us asks.
This is, of course, only an example of that wry wit for which we substance abuse counselors are known, and we would never offer such a suggestion to a client. It is our belief, too, that no client would take this suggestion seriously. In fact, as most of you know, statistically excessive alcohol use is much more dangerous than the use or abuse of any other mind-altering chemical. As of the most recent data, excessive alcohol consumption is responsible for more than eighty-eight thousand deaths each year in the US (Kaplan, 2014), whereas heroin deaths, even after doubling between 2010 and 2012 to 3,635, are far fewer (CDC, 2014). So why do we believe one drug to be better or worse than another? And why, when measured in actual lives lost, do we get it so wrong?
Assertions about Alcohol vs. Heroin
More alcohol is consumed at more places and times by many more people than is the case for heroin, and this increase in the frequency of consumption, even for a heavy drinker, has the effect of reducing the perceived risk of each discrete act of consumption.
Many people have consumed alcohol, and many people have experienced the sensation of alcohol intoxication—a comparatively minuscule number of people can say the same of heroin. Alcohol is a known quantity by a much larger population; we are more secure with the cause of premature death standing in broad daylight than we are with the one obscured by the twin shadows of fear and ignorance.
It may take years or even decades for a person to develop what would be diagnosed as alcohol dependence, whereas heroin dependence can occur in a period of weeks. In other words, “I’ll be able to quit drinking before it becomes a real problem.”
A client in the very early stages of recovery may not have fully accepted the fact that he has a disease, or he may believe his disease to be specific only to his particular drug of choice. In either of these scenarios, the client is likely still in the “bargaining” phase of the Kübler-Ross Stages of Grief: he agrees to give up heroin if he can acquire alcohol because, though statistically deadlier, it is preferable to nothing.
Weight loss, personality changes, severe symptoms of acute withdrawal, and other signs of dependence may be observable earlier in one’s addiction to heroin than to alcohol. Further, because of its legal status and ubiquitous availability, problematic alcohol use may go undetected far longer than what is possible with heroin use.
If these assertions are accurate, then they go a long way in explaining why tobacco use—and primarily cigarette smoking—so often continues into recovery.
According to the Centers for Disease Control and Prevention (CDC), cigarette smoking accounts for more than 480,000 deaths in the US each year, dwarfing the mortality figures for all drugs of abuse—legal and illegal—combined (CDC, 2014). When viewed rationally, the case for quitting smoking is overwhelmingly plain, but the disease of addiction is anything but rational. Addicts and alcoholics are apt, during attempts to moderate or cease their use of one substance, to switch drugs of choice. They may figure, “I need something to help me with stress, but I can’t risk another DUI, so I’ll stop drinking and only smoke pot.” We believe that those with substance use disorders are not so much addicted to one particular substance as they are addicted to intoxication: if they are not committed to total abstinence, then they will use whatever is available to change the way they perceive themselves and the world around them, and the fewer negative experiences they have had with a substance, the more likely they are to switch to it.
Cigarettes—and tobacco products in general—do not possess the same intoxicating properties as other drugs of abuse; they do not break families apart; they do not contribute to job loss; they do not have the same capacity to exacerbate the symptoms of mental illnesses. In short, they do create or perpetuate the kinds of negative consequences and problematic thinking and behavior that addicts and alcoholics in early recovery are most trying to avoid. If anything, many clients in early recovery see cigarettes as a positive:
- “They help with anxiety.”
- “It gives me something to do when I’m bored.”
- “I’ve given up everything else. Can’t I hold on to this one thing?”
Unfortunately, at many treatment facilities around the country, they are told that, yes, they can.
Despite widely available data on the dangers of cigarette smoking, many treatment facilities continue to allow their clients to smoke, believing it more prudent to focus on one addiction at a time. While it is highly likely that a newly arrived client’s presenting alcohol or other substance use disorder constitutes a more immediate risk to that client’s physical and mental health, there is strong evidence to suggest that starting a smoking cessation plan or a regimen of nicotine replacement therapy in early recovery will, contrary to prevailing opinions, improve said client’s chances of longer term recovery.
Writing for the National Institute on Drug Abuse (NIDA), Eric Sarlin, MEd, MA, citing a 2014 paper published in Psychological Medicine, states, “Smoking cessation appears unlikely to hinder and may even help recovery from substance use disorders and from mood and anxiety disorders (M/AD)” (Sarlin, 2014). He goes on to say that, of the study participants who quit smoking entirely, 69 percent “reported fewer continuing or recurrent DUDs (Drug Use Disorders),” at follow-up. Similar reductions were noted by those suffering from alcohol use disorders (AUD) and M/AD (reductions of 36 percent and 30 percent, respectively). Because of several factors, the report stops short of saying whether there is a causal link between smoking cessation and better treatment outcomes, but the data bear out the fact that “smoking cessation is highly compatible with recovery from mental disorders” and “was still significantly associated with reduced risk for a new-onset DUD” (Sarlin, 2014).
Based on these data, we now know that it is not just possible but prudent to engage in smoking cessation at a time concurrent to normal chemical dependency treatment. This does not, however, mean it will be easy. Approaching an irrational problem rationally rarely yields the results we might envision. Instead, we prefer to take a more conceptual view of the transition to and maintenance of recovery.
Many clients approach recovery with the understanding that they will have to rid their lives of certain negative influences: mind-altering chemicals, dysfunctional patterns of thought and behavior, problematic relationships, and habits that no longer serve them. These are the “People, Places, and Things” we talk about, and those new to recovery are not wrong about this part of the process. This particular explanation of change, though, is a better recipe for abstinence than it is for recovery, as the implication is that once the negative influences, behaviors, and tendencies have been removed, what remains is all that is required for a sustainable recovery. As many of you know, this is patently untrue. Addictive behavior cannot simply be removed; it must be displaced.
Hence, when discussing substance abuse or, in the case of this article, cigarette smoking, we choose to focus on what clients stand to gain rather than on what they may have to give up. Cigarettes may appear to help clients with anxiety in the moment, but they do nothing to affect the cause of the anxiety. When we work with clients who are still in active addiction, it is as though they are drowning: the desire to use can be as strong as the desire to take a breath. To try to draw breath underwater is to die, but they are powerless to do anything else. Should they deny this instinctual desire and manage to reach the surface, they are, at first, just happy to be alive. But after they have had a few moments to orient themselves to their surroundings, they are told to start swimming, lest they again risk drowning. Extending this metaphor to recovery, we would talk of the freedom clients might experience in the swim alone; or we might say that, upon reaching the distant shore, they will have the autonomy to plot their new lives’ courses. We discuss gratitude and humility. We remind them that knowing one’s limitations is honesty, not restriction. Just because something seems impossible doesn’t make it so.
The decision to continue smoking cigarettes in recovery is a manifestation of clients’ desire to believe again that which they have already declared a fallacy: the idea that addiction is a continuum, that one addiction is better or worse than any other. We can no longer dismiss an addiction to tobacco as “less bad” than other addictions. If we do this, we are only helping clients to create an abbreviated, circumscribed version of recovery, cut short not by relapse but by death.
Center for Disease Control and Prevention (CDC). (2014). Increases in heroin overdose deaths – twenty-eight states, 2010 to 2012. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a1.htm
Hurt, R. D., Offord, K. P., Croghan, I. T., Gomez-Dhal, L., Kottke, T. E., Morse, R. M., & Melton, L. J. III. (1996). Mortality following inpatient addictions treatment. Journal of the American Medical Association, 275(14), 1097–103.
Kaplan, K. (2014). About 88,000 US deaths each year traced to alcohol use, study says. LA Times. Retrieved from http://www.latimes.com/science/sciencenow/la-sci-sn-alcohol-related-deaths-years-lost-sxsw-20140313-story.html
Richter, K. P., Ahluwalia, H. K., Mosier, M. C., Nazir, N., & Ahluwalia, J. S. (2002). A population-based study of cigarette smoking among illicit drug users in the United States. Addiction, 97(7), 861–9.
Sarlin, E. (2014). Smoking cessation does not interfere with recovery from substance use. Retrieved from http://www.drugabuse.gov/news-events/nida-notes/2014/10/smoking-cessation-does-not-interfere-recovery-substance-use