Tobacco Use Disorder

With the DSM-V, there is no longer a separate diagnosis of Opioid Dependence and Opioid Addiction. The two are combined into Opioid Use Disorder. Opioid Use disorder can be mild, moderate or severe. And all of the addictive substances have the same list. So here is Tobacco Use Disorder.

According to the DSM-5, there are three Criterion with 15 sub features, and four specifiers to diagnose Tobacco Use disorder. Use of tobacco products over one year has resulted in at least two of the following sub features:

A, Larger quantities of tobacco over a longer period then intended are consumed.

1. Unsuccessful efforts to quit or reduce intake of tobacco

2. Inordinate amount of time acquiring or using tobacco products

3. Cravings for tobacco

4. Failure to attend to responsibilities and obligations due to tobacco use

5. Continued use despite adverse social or interpersonal consequences

6, Forfeiture of social, occupational or recreational activities in favor of tobacco use

7. Tobacco use in hazardous situations

8. Continued use despite awareness of physical or psychological problems directly attributed to tobacco use

B. Tolerance for nicotine, as indicated by:

9. Need for increasingly larger doses of nicotine in order to obtain the desired effect

A noticeably diminished effect from using the same amounts of nicotine

C. Withdrawal symptoms upon cessation of use as indicated by

10. The onset of typical nicotine associated withdrawal symptoms is present

11. More nicotine or a substituted drug is taken to alleviate withdrawal symptoms

Additional specifiers indicate the level of severity of Tobacco use disorder

1. 305.1 (Z72.0) Mild: two or three symptoms are present.

2. 305.1 (F17.200) Moderate: four or five symptoms are present.

3. 305.1 (F17.200) Severe: Six or more Symptoms are present

(American Psychiatric Association, 2013).

from: https://www.theravive.com/therapedia/tobacco-use-disorder-dsm–5-305.1-(z72.0)-(f17.200)

We have much more stigma attached to Opioid Use Disorder, but list for Tobacco Use Disorder is the same. Most chronic pain patients on long term opioids qualify for at least mild Opioid Use Disorder. UW Telepain says that if they only have withdrawal and tolerance, then it is questionable if they qualify. They also have said that “we don’t know what to do with patients with mild opioid use disorder”.

I find our culture peculiar. People get accolades for saying “I am quitting smoking.” or “I am a recovering alcoholic.” But it’s not ok to say “I am a recovering opioid addict.” People will shun you. Demonize. Gossip. It’s all addiction, so we should stop the demonization and stigmatization and help people and each other.

The photograph is not a brain. I took this about a month ago: it’s a brain size mushroom that was in the church lawn…

disaster and withdrawal

When I watch the disaster news, what I think about is withdrawal.

Everyone who is on a substance that causes dependence or addiction is withdrawing.

They don’t seem to ever discuss that, but think…. if you are in Houston or Florida when everything floods, are your cigarettes dry? I don’t think so. And put multiple people in close contact in a shelter, with many withdrawing… I am not surprised that tempers flare.

Let’s look at numbers.

Tobacco: in 2013, 21.3% of the US population age 12 and older, smokes tobacco. Disasters are a reason to quit. It’s hard enough to quit tobacco, but imagine going cold turkey if we have our Pacific Northwest really massive earthquake. Quit smoking now, don’t wait for a disaster. And think about being in a stadium with one in five of the people over age 12 withdrawing from tobacco. Is that fun?

Alcohol: “In 2013, 30.2 percent of men and 16.0 percent of women 12 and older reported binge drinking in the past month. And 9.5 percent of men and 3.3 percent of women reported heavy alcohol use.” Ok, that’s rather vague. If you have a drink or two after work every day or with dinner, will you notice the lack? Yes, I think so, but maybe only 10% of the adults are really going into alcohol withdrawal. That’s a conservative estimate. 30% are probably grumpy.

Illicit drugs: 4-8% of the 40-70 year olds used something in the past month. Are they addicted? Well, some are. And the 18-15 year olds are the most active, around 20%. Methamphetamines, cocaine, crack, crank, heroin, eeee-yuk.

Prescription drugs: “More than half of new illicit drug users begin with marijuana. Next most common are prescription pain relievers, followed by inhalants (which is most common among younger teens).” So let’s see, what percentage of the population is on prescribed opioids, benzodiazepines and barbituates? Ooooo, 1/3 of the US population has been prescribed opioids (2). Chronic opioids are prescribed to 3-4% of the US population, but of course, that is the prescribed chronic pain ones, not the illicit ones. Now, those can have a withdrawal. Alcohol and benzodiazepine withdrawal are the most dangerous for the patient, but in opioid withdrawal the pain receptors go absolutely crazy, like a volcano blowing up. And the tweakers withdrawing from methamphetamines. The sleep medicines like sonata and ambien avoid the issue of whether they are addictive by saying they are for “short term use” — 6 weeks for the former and 2 weeks for the latter, but some people have been on them for years. And marijuana daily, I have seen great difficulty with anxiety and sleep when people are trying to quit.

Marijuana: 7.5% of the population over age 12. How many of those are addicted? I see varying numbers, ranging from 10% to 50%. If you use marijuana regularly, check. Stop it for a week. See if there is a problem. I’d try it before a disaster, because it would add to the stress during….

Caffeine: Ok, I would withdraw from caffeine. 90% of US people are addicted to caffeine. I get a massive headache for 24 hours and then I am ok. I have gone off it more than once….

With ADHD medicines for children, a “drug holiday” is sometimes recommended. If you are regularly using any potentially addictive substance, try a “drug holiday” of your own.

And I think it’s the best motivator ever to quit smoking. Friday I had a couple of dedicated smokers and when I talked about flooded cigarretes, they blanched. Quit now, before you quit in circumstances…

And prayers for everyone in the disaster areas.

1. https://www.drugabuse.gov/publications/drugfacts/nationwide-trends
2. https://www.cbsnews.com/news/more-than-one-third-americans-prescribed-opioids-in-2015/
3. https://www.cnbc.com/2016/04/27/americans-consume-almost-all-of-the-global-opioid-supply.html  Hey, 80% of the world opioid supply is eaten by the US population! Why are US citizens in so much pain? Or are we under the impression that we shouldn’t have to feel pain and by gosh, we can afford the drugs….
4. http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies.

So WHY doesn’t the news talk about this? Because the cigarette and alcohol and prescription drug companies would yank the advertising?

Emergency preparedness

In Venezuela now
some people get water once a week
and sicken from it

First, withdrawal
When we have our eathquake
Tsumani and roads and bridges are gone

If one in three adults in Utah
Got an opioid prescription in 2014
What are the numbers here?
Opioids
Alcohol
Benzos
Caffeine
After the first wave of death
and grief, withdrawal begins
Not just addictive drugs
from insulin
from blood pressure meds
anticoagulants
seizure medicine
chemo ground to a halt
I read that alcohol is best to trade in disaster
and chaos and loss
Guarded by guns in small gangs
We are told to store water
Where?
If the house falls down
and I can get out, where would I put water?
A bunker in the ground?
I stock straws for water
I wish I could buy 9000
for my town
I stock books for when the computers
go silent
I stock songs in my head
memorized all
I fight for all my patients
Who would I not fight for?
Maybe it would be better to die
or be captured early
I stock love not guns.

http://www.nytimes.com/slideshow/2016/05/26/world/americas/desperate-times-in-venezuela/s/27VENEZUELA-SS-slide-3ZIT.html?_r=0

http://www.theguardian.com/us-news/2016/may/26/utah-mormons-prescription-painkiller-addiction

http://www.newyorker.com/magazine/2015/07/20/the-really-big-one