On the Road to Recovery, Leave the Cigarettes Behind

Shadi Nahvi, MD, MS

The rate of smoking among the country’s opiate-dependent population is extremely high, and despite effective treatments for opioid use disorders with methadone and buprenorphine, many will successfully stop their drug abuse only to die of tobacco-related causes. 

Early in her career, Dr. Shadi Nahvi, Assistant Professor of Medicine (General Internal Medicine) and of Psychiatry and Behavioral Sciences, worked closely with a patient in Einstein's Division of Substance Abuse (DoSA) clinic, treating her depression and helping her initiate and maintain antiretroviral therapy for her HIV, only to see the same patient die of laryngeal cancer due to tobacco use. Losing this patient turned Dr. Nahvi's attention to the dearth of research on smoking cessation interventions tailored to the HIV-positive and opiate-dependent population, and helped her formulate a direction for her own work.

Einstein's DoSA clinic at 1510 Waters Place.

At the same time, Dr. Nahvi and colleagues were analyzing results of a 2006 survey of 389 methadone maintenance patients in four Einstein Division of Substance Abuse clinics. They found that 83% of the patients surveyed were current smokers (vs. approximately 16% of the overall New York City population). Nearly half of the smokers surveyed were contemplating quitting, and an additional 22% were immediately ready to quit (within the next month), and had made a serious attempt to quit within the previous month. 

"Given our opiate-dependent patients' complex social, economic, psychiatric, and medical needs, we knew that we needed to consider what could impact their smoking behavior and update our clinical practice with the current evidence-based smoking cessation treatments," Dr. Nahvi said. "Our first step was to train providers to provide this treatment to our methadone maintenance patients alongside their substance abuse treatment."

She conducted an observational study that assessed the effectiveness of varenicline, a prescription medication that reduces cravings and decreases the pleasurable effects of cigarettes and tobacco products, in treating a cohort of seventy opioid-dependent smokers. These smokers, who received integrated substance abuse, medical care, and psychiatric care, responded well to varenicline with few adverse effects, according to results of the study published in the journal Drug and Alcohol Dependence. A subsequent randomized, placebo-controlled trial of 112 patients tested the drug's effectiveness as an aid to smoking cessation in methadone-maintained smokers delivered varenicline with in-person and telephone counseling and showed promising results (published in the journal Addiction), with a high long-term retention rate (90 percent at 24 weeks) and an overall reduction in smoking behavior.

Reception area of Einstein's DoSA clinic at 1510 Waters Place.

Patients receiving office-based buprenorphrine treatment for opioid dependence at a community health center also had  high rates of tobacco use (a possible 89% of 319 surveyed). In an examination of tobacco use and smoking cessation treatment patterns among these patients (results were published in the Journal of Substance Abuse Treatment in April 2014), Dr. Nahvi and colleagues observed inconsistencies in these patients being offered smoking cessation treatment, identifying a missed opportunity to impact their high tobacco use.

"We are working to overcome the traditional bias that treating tobacco use in these settings might harm the recovery process," Dr. Nahvi said. "We have found that there is real interest in quitting, and that treating smoking improves drug outcomes. Our studies have modest success rates, so we really need to learn more about what will successfully help people quit smoking permanently." 

Dr. Nahvi's work has been recognized with numerous grants and awards, and is currently supported by a National Institute on Drug Abuse Mentored Patient-Oriented Research Career Development Award (K23), which she received in 2010. Through a She is also co-investigator of a New York State Department of Health-funded program, she has also to promotede provider smoking cessation training and smoking cessation program development throughout the Bronx.