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| Smoking Addiction and the Nature of Medicine | |
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| Tweet Topic Started: Jun 21 2005, 02:36 AM (207 Views) | |
| QuirtEvans | Jun 21 2005, 02:36 AM Post #1 |
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I Owe It All To John D'Oh
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Sometimes It's Better Just to Do Less Harm By RICHARD A. FRIEDMAN, M.D. Published: June 21, 2005 Hippocrates' injunction to physicians, "First, do no harm," is not always easy to follow. Sometimes doing the right thing medically means risking lesser harm to avoid greater harm. When I first met Larry, he was 40 pounds overweight, hypertensive and in a bind. His internist had just told him that if he could not kick his two-pack-a-day smoking habit, he would surely kill himself. His doctor was right, Larry said to me, but he also felt he could not live without cigarettes, either. Larry had already tried to quit and failed four times in the last five years. Now, he was desperate to succeed. The last time he supposedly quit, he was sneaking a cigarette on the porch in his bathrobe on a freezing winter morning so his wife would not discover that he had relapsed, when the door accidentally locked behind him. Shivering and chastened, he decided when his wife finally let him in that it really was time to quit. But from our first meeting, I knew that his habit would be hard to beat. Every aspect of his waking life, from morning coffee to nighttime television, was entwined with smoking. And when he described the effects of smoking, he lapsed into a dreamy adoration usually reserved for lovers. He waxed eloquent about its relaxant and pleasurable effects, as well as the positive effects it had on his concentration and alertness. To me, he was a walking textbook on the pharmacologic effects of nicotine. I wondered what therapy could even come close to such positive effects. A vast majority of medical therapies are intended to remove pain and discomfort, not replace a lethal pleasure with a healthier one. And patients accept treatments because, on the whole, they are better than the disease. In contrast, the central challenge of treating any addiction is that the treatment is almost never as pleasurable as the addiction itself. Like opiates and cocaine, nicotine is known to stimulate the release of dopamine in the reward pathways of the brain. This explains its pleasurable and powerfully self-reinforcing effects. Nicotine also releases an array of other neurotransmitters like serotonin, norepinephrine and vasopressin that mediate its other effects, like arousal, alertness and relaxation. Anyone who doubts the addictive power of nicotine should reflect on the fact that 50 percent of smokers who have heart attacks continue to smoke. One treatment for smoking addiction is bupropion, marketed as the antidepressant Wellbutrin, but also sold as Zyban for smoking cessation. Like nicotine, it increases dopamine transmission, but to a much lesser extent. It is thought to decrease the pleasurable effects of nicotine by pre-empting some of them. Zyban seemed like a good option for Larry. But its cost, or the cost of any smoking-cessation treatment, for that matter, is generally not covered by health insurance. On the other hand, Larry's insurance would generously reimburse him if I wrote a prescription for Wellbutrin - same molecule, different name. Because he was not depressed and felt that a record of having taken an antidepressant might be stigmatizing, he opted to pay out of pocket for Zyban, which proved minimally effective for him, anyway. Larry was also using nicotine replacement in the form of nicotine gum and the nicotine patch. But they did not come close to matching the pleasing effects of cigarettes. I decided to give him high-dose nicotine replacement, trying to outfox his smoking addiction. Only one form of nicotine replacement can approach the delivery system of a cigarette - nasal nicotine spray. Because it is absorbed rapidly into the bloodstream through the nasal mucosa, it produces a spike of nicotine in the brain, just as inhaled nicotine in tobacco smoke does. Using more sprays than cigarettes, he was finally able to quit smoking. It has been more than a year since his last cigarette, but each month he calls me to renew his nicotine spray. In the end, I simply switched Larry's nicotine system from lethal tobacco to a plastic spray bottle, but left his nicotine addiction untouched. And though little is known about the very long-term risks of nicotine in humans, I wager that they pale next to the certain lethality of cigarettes. After all, it's the smoke that kills, not the nicotine. Doing no harm is best, but sometimes harm reduction is as good as it gets. |
| It would be unwise to underestimate what large groups of ill-informed people acting together can achieve. -- John D'Oh, January 14, 2010. | |
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| big al | Jun 21 2005, 04:56 AM Post #2 |
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Bull-Carp
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Thanks, Quirt. That was an interesting article. I was unaware that nicotine nasal spray existed. I smoked for a long time before I finally successfully quit. One of the components of quiting for me was a group of people who met at a local hospital. I found it interesting to hear other people's habits and addictions. In particular, there was one man who was a trucking company dispatcher who smoked four packs a day, all during work, but nothing on the weekends. I, on the other hand, smoked less but craved a smoke if I went more than a couple of hours without. I also really liked a cigarette after eating or while drinking alcohol. Each person was unique in the form their particular habit or addiction took. If someone is trying to quit, my only advice would have to be, if one method doesn't work for you, try something else. Talk to your doctor, an ex-smoker, or some public health group. And good luck. Big Al |
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Location: Western PA "jesu, der simcha fun der man's farlangen." -bachophile | |
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| AlbertaCrude | Jun 21 2005, 10:10 AM Post #3 |
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Bull-Carp
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Ha, I tried that stuff a few years back. After the second day I was so freakin paranoid and anxious I was about ready to bar-b-cue the neighbour's dog. Took me ten minutes to muster the concentration to tie my shoe laces. Gathered up the prescription returned it to the pharmacy along with a letter to the pharmaceutical outfit and GP describing the side effects. Hot mints, round toothpicks and a bit of nicorette gum are the most effective means for me to quit other than cold turkey. |
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| Jolly | Jun 21 2005, 10:30 AM Post #4 |
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Geaux Tigers!
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Very true. The big push in medicine (darn, there I go with that nasty word again ) is an emphasis on wellness education, and early intervention. In short, they want you to have a nice long life, followed by a short, lethal illness.Therefore, the emphasis on daily glucose monitoring and glycosolated hemoglobins for diabetics; lipid, hsCRP and homocysteine for early indicators of cardiac wellness and vascular integrity, or there is even a new procedure out on the market to bust the alcoholics who fall off of the wagon and lie about it. Obesity will be the next great frontier. |
| The main obstacle to a stable and just world order is the United States.- George Soros | |
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| jon-nyc | Jun 21 2005, 10:34 AM Post #5 |
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Cheers
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In medicine and law, probably. |
| In my defense, I was left unsupervised. | |
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| ivorythumper | Jun 21 2005, 11:01 AM Post #6 |
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I am so adjective that I verb nouns!
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We could only wish for law. As long as the lawyers, politicians, lobbyists and law makers are getting fat and happy there is no incentive for putting America on a diet. |
| The dogma lives loudly within me. | |
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) is an emphasis on wellness education, and early intervention. In short, they want you to have a nice long life, followed by a short, lethal illness.

4:17 PM Jul 10