PAC 330 Module 3 Nicotine and Cannabis Example

A Pack a Day and a Pen All Day: Nicotine, Cannabis and Treating Both in a Young Adult

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 330: Substance Abuse

Instructor Name

Month Day, Year

A Pack a Day and a Pen All Day: Nicotine, Cannabis and Treating Both in a Young Adult

Kayla is twenty-three and works as a line cook at a busy Omaha restaurant. She started smoking cigarettes at fourteen, with friends behind the school, and now smokes a pack a day. She started using cannabis at fifteen and, for the past two years, has used a vape pen filled with high-potency concentrate from the moment she wakes until she falls asleep. She came to Prairie Hope Recovery, the composite program in these papers, because her anxiety has worsened, she cannot sleep without cannabis and she coughs every morning. She wants help with cannabis but says cigarettes are "not a big deal." This paper profiles both substances and plans her treatment. Kayla and Prairie Hope are made up; the research is real.

How Nicotine Acts

Benowitz (2010) reviewed the pharmacology of nicotine addiction. Nicotine binds to nicotinic acetylcholine receptors in the brain, especially one subtype in the reward system, triggering the release of dopamine and other neurotransmitters. Smoking delivers nicotine to the brain within seconds, faster than almost any other route, which strengthens its reinforcing effect. Smokers experience mild stimulation, improved concentration and reduced tension. With repeated use, receptors adapt, and smokers become tolerant and dependent; between cigarettes, they experience withdrawal, including irritability, anxiety, difficulty concentrating and increased appetite. Many smokers smoke largely to relieve this withdrawal, which they experience as stress relief. Benowitz noted that most smokers want to quit and that effective medications exist.

How Dependence Compares

Anthony et al. (1994) used a national survey to estimate, for each substance, the proportion of people who had ever used it and who had become dependent. Tobacco had the highest proportion: about a third of people who had ever smoked had become dependent. For heroin, the proportion was about a quarter; for cocaine, about one in six; for alcohol, about one in seven; and for cannabis, about one in eleven. The figures show that tobacco, often regarded as less serious than other drugs, is in fact the substance most likely to produce dependence among those who try it.

Cannabis Effects and Risks

Volkow et al. (2014) reviewed the adverse health effects of cannabis. Its main psychoactive ingredient, THC, acts on cannabinoid receptors throughout the brain, affecting memory, attention, coordination and reward. The authors reported that about nine percent of people who use cannabis become addicted, rising to about one in six among those who start in adolescence and to between a quarter and a half among daily users. Regular use beginning in adolescence was associated with changes in brain development and with poorer educational outcomes. Acute use impairs driving. Heavy use went along with greater psychosis risk in vulnerable people and with worsening anxiety and depression in some users. The authors noted that the potency of cannabis had risen substantially over recent decades, increasing these risks, and that concentrates can be far more potent than the plant.

Kayla's early onset, daily use and use of high-potency concentrate place her in the groups at highest risk. Her worsening anxiety may be related to her use.

Comparing the Two

Medication for Smoking Cessation

The EAGLES trial, reported by Anthenelli et al. (2016), enrolled more than eight thousand smokers, roughly half of whom had a psychiatric diagnosis such as depression, anxiety or bipolar disorder, and gave each person twelve weeks of one of four treatments chosen at random: varenicline, bupropion, a nicotine patch or a placebo. Concerns had been raised that varenicline and bupropion might cause neuropsychiatric side effects. The trial found no significant increase in such events with either medication compared with the patch or placebo, in people with or without psychiatric disorders. Varenicline produced the highest abstinence rates, followed by bupropion and the patch, all of which outperformed placebo.

For Kayla, whose anxiety had made her prescriber cautious, the trial supports varenicline as both effective and safe.

Treating Both at Once

Kayla's counselor raised a common question: should she quit both substances at once? Many clinicians once advised treating one addiction at a time, but research on people in treatment for other substance use disorders has generally found that addressing smoking at the same time does not harm, and may help, other outcomes. Both substances are also intertwined in Kayla's routine: she smokes and vapes at the same breaks. The counselor will present the evidence and let Kayla decide, while making the case that her morning cough and her anxiety give her reasons to address both.

The Plan

With her agreement, Kayla's prescriber will start varenicline, beginning a week before a chosen quit date for cigarettes. For cannabis, she will receive weekly counseling combining motivational enhancement and cognitive-behavioral therapy, the approach with the strongest evidence for cannabis use disorder, focused on her triggers at work and at night. Because she cannot sleep without cannabis, she will receive help with sleep, including a sleep routine and, if needed, an assessment by her prescriber. Her anxiety will be assessed separately once her use decreases, since some of it may be withdrawal and some may need its own treatment.

Conclusion

Kayla came for help with cannabis and dismissed cigarettes, but the research suggests both deserve attention. Benowitz explains nicotine's powerful reinforcing effects, Anthony, Warner and Kessler show that tobacco produces dependence more often than any other substance, Volkow and colleagues document cannabis's risks for early, daily users of high-potency products and the EAGLES trial supports varenicline even in people with anxiety. Treating both, with medication for one and counseling for both, gives Kayla the best chance of breathing and sleeping easier.

References

Anthenelli, R. M., Benowitz, N. L., West, R., St Aubin, L., McRae, T., Lawrence, D., Ascher, J., Russ, C., Krishen, A., & Evins, A. E. (2016). Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): A double-blind, randomised, placebo-controlled clinical trial. The Lancet, 387(10037), 2507-2520. https://doi.org/10.1016/S0140-6736(16)30272-0

Anthony, J. C., Warner, L. A., & Kessler, R. C. (1994). Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology, 2(3), 244-268. https://doi.org/10.1037/1064-1297.2.3.244

Benowitz, N. L. (2010). Nicotine addiction. New England Journal of Medicine, 362(24), 2295-2303. https://doi.org/10.1056/NEJMra0809890

Volkow, N. D., Baler, R. D., Compton, W. M., & Weiss, S. R. B. (2014). Adverse health effects of marijuana use. New England Journal of Medicine, 370(23), 2219-2227. https://doi.org/10.1056/NEJMra1402309