Journal of Psychoactive Drugs
ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20
Treating Cigarette Smoking in Methadone Maintenance Clients Jim Story & Michael J. Stark To cite this article: Jim Story & Michael J. Stark (1991) Treating Cigarette Smoking in Methadone Maintenance Clients, Journal of Psychoactive Drugs, 23:2, 203-215, DOI: 10.1080/02791072.1991.10472237 To link to this article: http://dx.doi.org/10.1080/02791072.1991.10472237
Published online: 20 Jan 2012.
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Jim Story, M.S.* & Michael J. Stark, Ph.D.** Abstract- Substance abusers in treatment have cigarette-smoking rates about three times that found in the general adult population, yet there is a paucity of published studies exarnining smoking-cessation programs for these clients. Accordingly, a behaviorally based smoking-cessation program for methadone maintenance clients was developed. and the efficacy of a methadone dose increase as a pharmacological adjunct was tested in a doubleblind placebo-controlled study. While no significant difference between experimental and control subjects in reported abstinence rates was found, subjects receiving a methadone increase reported significantly more nicotine craving and other withdrawal symptoms during the first week of abstinence than did controls. Measures of smoking rates indicated that experimental subjects smoked significantly more than controls throughout the 10-week study period. Although the initial smoking abstinence rate of 65% was encouraging, most subjects returned to smoking by the end of the study period. These fmdings indicate that the development of smoking-cessation programs for methadone clients merits further study and that such programs should stress relapse prevention techniques tailored to the specific needs of this population. Also, while the use of a methadone dose increase as a pharmacological adjunct has not been found to be efficacious, other pharmacological strategies involving the use of nicotine should not be ruled out.
Keywords -methadone, nicotine, substance abuse, smoking cessation, tobacco
Since the late 1960s, when information concerning the negative consequences of smoking was beginning to be made available to the general public, the percentage of adults 20 years of age and older in the United States who smoke cigarettes has declined from around 40% to under 30% in 1990. During this time there has been a steady decrease in the prevalence of adult smokers in all age, sex, and race categories, with the exception of women aged 65 years and older (U.S. Department of Health and Hwnan Services 1988). In spite of promising trends, smoking rates are still very high for certain segments of the population, notably the poor, unemployed, divorced, less educated, and bluecollar workers. Not surprisingly, people who abuse other substances also have the highest tobacco-smoking rates. A host of investigators have reported smoking rates rang-
ing from 85% to 100% in abusers of alcohol, opioids, and cocaine (DiFranza & Guerrera 1990; Ginne 1989; Burling & Ziff 1988; Rounsaville etal. 1985; Istvan & Matarazzo 1984; Simpson et al. 1978). Marijuana use is also associated with increased cigarette smoking. For example, Cheek and colleagues (1973) found that among college students they surveyed, 73% of heavy marijuana users (three or more times/week) were tobacco smokers, compared to tobacco-smoking rates of 50% for regular marijuana users (once or twice/week) and 36% for occasional users (less than once/week). Not only are the rates of cigarette smoking among substance-abusing clients extremely high, but the inverse is also true; that is, people who smoke cigarettes have a much greater propensity to use other substances than their nonsmoking counterparts. Results of a national survey on drug abuse revealed that within each age cohort, cigarette smokers were more likely than nonsmokers to have used alcohol, marijuana, psychotherapeutic pills, and "stronger drugs" (i.e., heroin, cocaine, hallucinogens), and that this difference was greatest among youths and young adults (U.S. Department of Health and Human Services 1980). In a survey of 565 college students, Goode (1972) found
•Department of P1ychology, University of New Mexico, Albuquerque, New Mexico. ••Graduate Program in Counseling Psychology, Lewis & Clark College, Ponland, Oregon. Please address reprint requeJU to Michael I. Stark, Ph.D., Graduate Program in Counseling Psychology, Box 93, Lewis & Oark College, Ponland, Oregon 97219.
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Trea ting Cigarette Smo king
that cigarette smokers were far more likely to use illicit drugs- including marijuana, heroin , and methamphetamine - than nonsmoking students. In this study, 39% of nonsmokers had not used illegal drugs in the six months preceding the survey, while the corresponding numbers were 13% for light smokers, 14% for moderate smokers, and II% for heavy smokers. Goode concluded that smoking any number of cigarettes was related to illicit drug use, and students who smoked just once a day were as likely to use other substances as those smoking a pack a day or more. Finally, daily use of marijuana was found to be 20 times higher and daily use of other illicit drugs was 13 times higher in high-school seniors who smoked cigarettes compared to those who did not smoke (U.S. Department of Health and Human Services 1980). It is not surprising that substance abusers have high rates of cigarette smoking given that multiple drug use is the common pattern of drug abuse (Miller & Mirin 1989; Jekel & Allen 1987; Kreek 1987). Furthermore, acute administration of ethanol (Mello et al. 1980a; Griffiths, Bigelow & Liebson 1976), heroin (Mello etal. 1980b), psychomotor stimulants (Benningfield & Griffiths 1981; Schuster, Lucchesi & Emley 1979), and sedatives (Benningfield, Chait & Griffiths 1983) produces robust and dose-related increases in smoking behavior. However, the acute effects of psychoactive substances may be insufficient to account for the relation between their use and cigarette smoking. For example, there is a positive correlation between marijuana use and cigarette smoking even though acute administration of marijuana does not affect (Mello & Mendelson 1986; Mello et al. 1980a) or actually reduce cigarette smoking (Kelly et al. 1990). Difficulties in quilling is another possible reason for the high smoking rates among substance abu sers . DiFranza and Guerrera (1990) compared the natural history of smoking in 77 inpatient alcoholics to that of 124 controls seeking care at family practice settings. Theresults of a 64-item survey indicated that once having become regular smokers there was no significant difference between the groups in numbers who had tried to quit (81% of alcoholics and 91% of controls). However, there was a significant difference between those who had been successful in quilling (defined as no smoking for at least three months prior to the study), with 49% of the controls having successfully quit but only 7% of the alcoholics having been able to do so. Inasmuch as one out of five smoking relapses occurs when people have been drinking (Shiffman 1982), it is logical that drinkers would be less successful in sustaining smoking cessation. This is consistent with the fact that substance abusers have difficulty quitting all forms of drug abuse, including their primary substance of abuse (Marian 1979; Hunt, Barnett & Branch 1971 ). Finally, substance abusers in community clinics JourfW.I of Psychoactiv~ Drwgs
have many of the demographic characteristics (e. g. , low income, less education) that are risk factors for smoking. CIGARETTE SMOKING AND METHADONE MAINTENANCE
For many methadone maintenance treatment (MMT) clients, cigarette smoking is undoubtedly their oldest, most difficult to quit, and potentially most lethal drug dependence. The smoking rates among clients in MMT are very high, with rates of82% (Stark & Campbell In press) and 98% (Berger & Schweigler 1972) having been reported. Undeniably, these high rates are due to the prevalence of smoking among opioid abusers, but methadone itself may also cause increases in smoking. Chait and Griffiths (1984) examined the interaction of acute methadone administration and smoking in five subjects with histories of opioid abuse who were being maintained on methadone. The subjects, all of whom smoked from one to two packs of cigarettes per day, were allowed to smoke ad libitum 90 minutes after receiving either a placebo, dextromethorphan (a taste blind) or one of three doses of methadone (onehalf, one or two times their normal maintenance dose). It was found that methadone pretreatment resulted in sign ificant dose-related increases for the group in the number of cigarettes smoked per session, fro m a mean of 2.8 after placebo to 5.6 after the highest methadone dose . The time spent by subjects puffing cigarettes, the level of carbon monoxide (CO) expired by subjects, and subjective ratings of smoking satisfaction were also found to increase significantly with increasing methadone dose. Investigators in an earlier study (Bigelow et al. 1981) reported that subjects undergoing methadone detoxification reduced the number of cigarettes smoked per day as their dose decreased. In this study, nine male MMT clients un derwent a daily clinic-controlled blind methadone detoxification. The average dose for these clients was 43.3 mg of methadone, which was reduced to 0 mg during a 10- to 3 1-day period. It was found that during detoxification, cigarette smoking correlated with methadone dose level (r=0.64), and that the smoking rate declined at a mean rate of 0.35 cigarettes for every milligram of methadone dose reduction. Mello and colleagues (1980b) employed a methadone-detoxification condition as part of their study of the effects of heroin on smoking. They did not fi nd an increase in smoking during methadone administration, but it is possible that the doses were too small to produce an effect, as methadone dose levels were not reported. The mechanism by which opioid use increases smoking behavior is in question, but several explanations have been offered. Mello and colleagues ( 1980b) suggested that the effects of nicotine and opioids may complement and mutually facilitate each other or that for a smoker under the influence of opioids, nicotine's effects are either more 204
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reinforcing or attenuated. requiring more cigarettes to produce the desired effect. These researchers also raised the possibility that the increase in smoking is a reflection of a generalized increase in activity levels following opioid administration. Chait and Griffiths ( 1984) suggested that opioid administration functions as a discriminative stimulus for smoking, at least for subjects who have a history of increased smoking after opioid administration, or that opioids increase smoking by blocking or attenuating the aversive effects of cigarettes, which may tend to limit smoking in the absence of these substances. With regard to the latter hypothesis, the analgesic and cough suppressant properties of opioids may serve to eliminate some negative effects of smoking, such as throat irritation and coughing.
who had successfully quit smoking after their alcoholism treatment, compared to those who made unsuccessful attempts at smoking cessation. Miller, Hendrick and Taylor (1983) found that among problem drinkers undergoing behavioral self-control training, smoking cessation by pretreatment smokers was in all cases associated with successful control of drinking even though pretreatment nonsmoking was not. These authors hypothesized that in spite of the traditional lore that smoking-cessation attempts during treatment for alcohol abuse are countertherapeutic and increase the risk of relapse, programs aimed at dual control of smoking and drinking may yield synergistic effects. Finally, Henningfield (1984) hypothesized that cigarette smoking might be a significant relapse factor for other drug use, although this has not yet been studied.
SMOKING CESSATION WITH SUBSTANCE ABUSERS
SMOKING CESSATION WITH METHADONE MAINTENANCE CLIENTS
In spite of the very high cigarette-smoking rates among substance abusers and the devastating health consequences of cigarette smoking, there is a paucity of published studies examining smoking cessation with these clients. Clinicians fear that smoking cessation will interfere with clients' efforts to abstain from using other drugs and are reluctant to press them to stop smoking. Bobo and Gilchrist (1983) found that 22.6% of an alcoholism treatment staff said they never favor urging alcoholic clients to quit smoking; 45.5% reported never encouraging alcoholic clients to quit. Clients are also reluctant to participate in smoking-cessation programs as part of their treatment for other substance abuse. Kozlowski and colleagues (1989a) surveyed 289 alcohol and other drug abuse clients and found that only 31% of the smokers were interested in receiving treatment for smoking at the same time as their alcohol or other drug abuse treatment. It is understandable that clients seeking substance abuse treatment would be less concerned about smoking than their primary substance of abuse. Kozlowski and colleagues likened this to people having had their car towed in for repairs and fmding out that in addition to the current emergency, the rust on the car's body will ruin it in 10 years. Clients are naturally concerned about their immediate drug abuse problems and less worried about the health consequences of tobacco smoking that might affect them in the future. It is also reasonable that treatment staff would be concerned about the fragility of their clients' abstinence and would not want to risk treatment gains with additional demands on clients. Although staff and clients are concerned about concurrent smoking and other substance abuse treatment, the limited evidence available does not present cause to worry. Bobo and colleagues (1987) found a somewhat higher rate of abstinence from alcohol among recovering alcoholics
MMT clients are a likely target population for smoking cessation because once stabilized, they are not undergoing the anxieties associated with withdrawal and initial abstinence. Additionally, they have better retention rates than clients in other treatment modalities (Grey, Osborn & Reznikoff 1986; Craig, Rogalski & Veltri 1982; Simpson, Savage & Lloyd 1979). Methadone maintenance clients are often seen by counseling, dispensary or medical staff on a daily basis, a fact that could greatly facilitate a smoking-cessation program. Finally, as an exogenous opioid, methadone itself could be used as a pharmacological adjunct to treatment, with increases in doses employed to ameliorate the nicotine withdrawal syndrome. The justification to use methadone to lessen the nicotine withdrawal syndrome is derived from research suggesting that increased production of endogenous opioids as a result of nicotine intake is one of the mechanisms by which smoking behavior is reinforced (Pomerleau & Pomerleau 1984). Nicotine intake has been found to be significantly and positively correlated to plasma ~-endor phin levels in human subjects. In one study (Pomerleau et al. 1983), smokers who were deprived of cigarettes for several hours were then allowed to smoke either two lownicotine (0.48 mg/cigarette) or two high-nicotine (2.87 mg/cigarette) cigarettes. For the subjects smoking the highnicotine cigarettes, a strong positive correlation was found between plasma nicotine and plasma ~-endorphin ~-lipotropin levels (r=0.977). The increase over baseline of ~-endorphin-~-lipotropin levels was approximately 100% for these subjects. It has also been shown that an opioid withdrawal response induced by administration of the narcotic antagonist naloxone in morphine-dependent mice can be prevented by injecting the mice with nicotine (Brase et al. 1974). Furthermore, Karras and Kane (1980) found that
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HYPOTHESES
naloxone reduced the amount smoked and the corresponding desire to smoke in seven volunteer subjects, all of whom were long-term cigarette smokers who smoked at least a pack per day. However, in one well-designed study with seven subjects, Nemeth-Coslett and Griffiths (1986) did not find naloxone to affect smoking, nor did Mello and colleagues (1980b) with a single subject The fact that the effects of narcotic antagonists have only been studied in a total of 15 subjects in three different laboratories (Mello & Mendelson 1986) indicates that the inconsistent findings with naloxone are insufficient to call the endogenous opioid theory of smoking reinforcement into question . It has been suggested that combinations of multicomponent behavioral treatment and pharmacological intervention may be well suited for highly dependent smokers (U.S. Department of Health and Human Services 1988). As MMT clients are likely to fit the profile of heavy smokers who see themselves as being addicted to cigarettes, they may be attracted to a smoking-cessation program that allows them to attempt quitting in two stages. If ph ysiological withdrawal from nicotine can be postponed by increasing ~-endorphins with an exogenous opioid (i.e., methadone), then the initial intervention can focus on extinguishing smoking behaviors and learning nonsmoking skills. Once these skills are established, nicotine withdrawal could begin and clients would be more likely to continue to not smoke than if faced with learning new skills and undergoing nicotine withdrawal simultaneously. This is the logic behind the use of nicotine gum in smoking cessation, which has proven to be a consistently effective addition to multicomponent cessation programs (U.S. Department of Health and Human Services 1988; Hughes & Hatsukami 1985; Schneider, Jarvik & Forsythe 1984 ). Clients in MMT programs are accustomed to the use of methadone to prevent withdrawal symptoms. As a pharmacological treatment for smoking, the use of methadone provides a way of joining clients' belief systems (Lichtenstein 1982), and dose increases might also motivate clients to participate in a smoking-cessation program. The present authors decided to combine the methadone dose increase with a multicomponent behavioral approach that incorporates the use of a baseline period and quit date, modification of reinforcement contingencies, self-management techniques, coping-skills training, and relapse prevention. 1be efficacy of these procedures is well-documented and a number of studies of multicomponent programs have reported one-year abstinence rates ranging from 40% to nearly 60%, about double the rates found with single-component programs (U.S . Department of Health and Human Services 1988).
Journal of Psychoactive Drugs
If an increase in methadone dose proves effective in easing nicotine withdrawal symptoms and facilitating smoking cessation, it would be expected that subjects who receive such an increase and quit smoking would report less craving and fewer withdrawal symptoms in the early stage of abstinence than would subjects in a placebo-control condition. A higher quit rate for the experimental group would also be expected. In addition, if methadone substitutes for depleted ~-endorphin due to nicotine deprivation, then subjects receiving the methadone increase who quit smoking should not experience the effects of the dose increase as much as those who continue to smoke. On the other hand, according to the experimental evidence mentioned above (Chait & Griffiths 1984; Mello et al. 1980b), administration of opioids has been found to result in increases in smoking behavior and satisfaction . Whatever the mechanism involved here, it may be more difficult for subjects in the increased methadone dose condition to quit smoking. If these effects prevail over any amelioration of withdrawal symptoms due to a methadone dose increase, a lower quit rate for the experimental group than the placebo-control group would be expected. Also, if a methadone dose increase results in increased desire to smoke, more reported craving and withdrawal symptoms should be reported by this group. A randomized, double-blind, placebo-control design could provide a test for these two different hypotheses .
METHODS AND PROCEDURES A smoking-cessation program developed for MMT clients was offered at Skills Training for Adult Recovery (STAR), a 300-client methadone clinic, which is part of Comprehensive Options for Drug Abusers (CODA) , Oregon's largest drug abuse treatment center. The STAR program consists of three phases that offer clients training in educational, recreational, and personal skills (Stark 1989). In order to be eligible for the smoking-cessation program, clients had to be in Phase II of STAR. Clients enter Phase II after an eight-week orientation and stabilization phase. Once in Phase II, clients are offered a variety of treatment options from such subject areas as vocational development, stress management, communication, nutrition, and recreation and leisure as well as required courses on addiction. Beginning about one month prior to the start of the STAR 1989 summer term, the smoking-cessation course "Quit Smoking" was advertised in the clinic by posters and fliers, and by word of mouth through CODA counselors. At an orientation session before the start of the course, clients were informed that by taking the course and participating in a scientific study they would (a) get an in206
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health concerns as their main reason for signing up for the course.
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crease in their methadone dose (unless they declined to do so), (b) receive a$25 participation stipend, and (c) fulfill their STAR requirement in the first three weeks of a 10-week quarter.
Dosing Procedure During the orientation session, subjects were told that they would receive an increase in their methadone dose -with the maximum possible increase being 20% of their present dose- but that they would not be told how much they had received until the final session to be held 10 weeks after the start of the study. At the end of the study period. subjects who received the maximum dose increase would be given the choice of remaining at this dose level or undergoing a gradual reduction to their previous level. Those receiving less than the maximum dose increase would be given the option of increasing their dose to a level 20% above their original (preexperimental) dose. Methadone dose levels for the 17 subjects before the increases ranged from 34 mg to 71 mg (J..Ii=49). After the increases, doses for the control group ranged from 41 mg to 71 mg (JJ;=54), while the experimental group ranged from 52 mg to 85 mg (JJ;=62). Subjects were told that the dose increases would be administered beginning on Monday morning, one week after the orientation session, and that this would also be their target quit date for beginning abstinence from cigarettes as well as the date of their first evening session of the Quit Smoking class. Baseline data on smoking rates, methadone dose effects, and nicotine withdrawal symptoms were gathered from subjects on questionnaires taken daily during the week prior to the target date for quitting.
Subjects Of the 33 clients who preregistered for the Quit Smoking course, 22 attended the orientation session and signed up for the class. 1bese subjects were then randomly assigned to either an experimental group, which would receive a 20% methadone dose increase, or a placelxH:ontrol group receiving a one milligram dose increase. Both subjects and researchers were blind to the dosing assignments. Of the 11 subjects originally assigned to the experimental group, one subsequently asked not to be included in the study because she wanted a decrease in her methadone dose but wished to remain in the course. Of the 11 subjects assigned to the control group, two dropped out during the first week of the course and two others decided that they wanted decreases in their methadone doses but wished to remain in the course. A total of 20 clients remained in the course, and 17 of these remained subjects in the study. The 10 subjects in the experimental group and seven in the control group remained throughout the study. All of the participants (five men and 12 women) were White and ranged in age from 25 to 43 (J.F36). The highest educational grade completed by subjects ranged from 10 to 16 (J,J;=12), and their monthly income ranged from none to $1,745 (J..Ii=$431). Three subjects reported being employed full time and two in part-time jobs; nine subjects said they were receiving some form of public assistance, either welfare or social security income. Nine subjects reported being married, three single, one widowed, and four divorced. All of the subjects had a history of opioid use (all but one were heroin users) before coming to CODA, and their age at first use ranged from 14 to 29 (JJ;=20). The length of time of subjects' current stay in CODA's MMT program ranged from eight to 91 months (JJ;=32). Nine had previously been maintained on methadone either at CODA or at another clinic. Subjects' total time on methadone maintenance ranged from 12 to 97 months (J..Ii=40.12). The following information on subjects' smoking history was taken from a Smoking Proflle Questionnaire. The age at which subjects started smoking ranged from four to 22 (J.F 15) and the length of time they had been smoking ranged from seven to 35 years (JJ;=21). Subjects reported smoking from one to two and a half packs of cigarettes per day, with the mean being just over one and three-quarter packs per day (jJ;= 1.84). Five of the subjects reported that they had never attempted to quit smoking, nine of the 17 said they had never given up cigarettes for more than three days since they began smoking, and five had never quit for more than one day. All17 felt that they were "extremely addicted" to cigarettes, and 14 of them reported JowrMl of Psychoactive Drwgs
Smoking-Cessation Procedure MMT clients at CODA are obligated to participate a minimum of 10 hours during each 10-week term in STAR program courses. The Quit Smoking course was therefore designed to take up a total of 10 hours, including one hour for the orientation session and one hour for a fmal session. The course began on a Monday evening, following the week used for baseline data gathering, and consisted of four consecutive, 90-minute evening sessions led by one of the researchers. Back-to-back sessions on each of these evenings were conducted both to accommodate clients' schedules and to decrease the number of subjects present at each session. The size of the groups varied, ranging from seven to 12 subjects (JJ;=10). The four-session intervention trained subjects in the use of behavioral and cognitive smoking-cessation techniques that focused on coping with withdrawal symptoms, eliminating environmental smoking triggers, and substituting new behaviors to take the place of smoking responses. The first evening was the target quit date and subjects were asked to turn in their cigarettes to the researcher at the beginning of the session. Subjects were then told what they could expect to experience in the first few days of nicotine withdrawal. Group cohesion and support was 207
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encouraged by asking subjects to put their names on a phone list or to pick one other group member (a buddy) and to exchange phone numbers (U.S. Department of Health and Human Services 1988). On the two consecutive Mondays following the first week of the Quit Smoking class, hour-long sessions were held that focused on preventing relapse. After these sessions, the subjects' 10-hour obligation to STAR was fulfilled, but an optional third relapse prevention session was made available to them two weeks after the last required session. However, this optional session was only auended by one subject. The approach taken in relapse prevention sessions was basically that used in Kaiser Hospital's Freedom from Cigarettes program (Stevens & Hollis 1989), which is based on Marlatt's model of the relapse process (Marlatt & Gordon 1985).
usual dose was added to the questionnaire. Subjects were also asked to describe specifically any effects (i.e., drowsiness, euphoria, and increased energy) they had noticed from their dose increase. This revised questionnaire was then used, beginning on the morning of their methadone dose increase and target quit-smoking date, for continued data gathering over a four-week period. On the evening of the last required relapse prevention session, the subjects were asked to fill out a Strategies and Expectations Questionnaire. This instrument was developed to assess subjects' use of the skills and coping strategies they had learned during the course, and to see if this correlated with success in achieving abstinence from cigarettes (Shiffman 1984, 1982). It also included the same questions regarding auributions and expectancies that were asked on the Smoking Profile Questionnaire. At the final session, held during week 10 of the STAR summer quarter, subjects were asked to fill out a final questionnaire. This instrument included questions regarding subjects' current smoking status and their smoking rates since the last session auended. Subjects who had achieved abstinence from cigarettes for a week or more during the course were asked to rate several factors as to their importance in contributing to their success. Those who did not quit smoking for a week were asked to what degree these same factors contributed to their inability to do so. The final questionnaire asked subjects whether or not they expected to auempt quilling smolcing again in the near future, and if so, what was their expectation of success. Subjects were asked what aspects of the course and which people were most helpful to them in their attempt to quit smoking, and whether or not they believed that the methadone dose increase was useful. They were also asked to estimate the amount of their dose increase. After com pleting the questionnaires, subjects were told what their actual dose increases had been.
Data Collection and Instruments At the orientation session, subjects were asked to fill out a Smoking Proflle Questionnaire developed by theresearchers to gather information on current smoking status and smoking history, including previous quit auempts and subjects' motivation for signing up for this course and for wanting to quit smoking at this time. They were also asked questions regarding their expectancies of success in this and future cessation attempts and the degree to which they perceived themselves to be addicted to tobacco. A second questionnaire was developed to gather baseline data for smoking rates, nicotine withdrawal symptoms, and methadone dose effects. This questionnaire included a revised version of the Smoker Complaint Scale (Schneider & Jarvik 1985, 1984), which measures the severity of subjectively reported nicotine withdrawal symptoms. The version used in this study was shortened and contained Likert-scaled items assessing nicotine withdrawal symptoms and craving for cigarettes (Hatsukami, Hughes & Pickens 1985; Shiffman & Phil1979; Shiffman & Jarvik 1976). Subjects were also asked to report the number of cigareues smoked each day during the baseline period. All but three of the study subjects received their methadone doses at the CODA clinic on a daily basis and were asked to fill out the baseline data questionnaire each morning before or within a few minutes after taking their dose. The questionnaires were given to subjects and collected by dispensary personnel each morning. The other three subjects received their doses at a local pharmacy and were given enough questionnaires for the baseline week, with instructions to fill them out each day before taking their dose and to bring them all to the Monday evening class. After a week of baseline data gathering, a further question asking subjects to compare (using a four-point Likert scale) their increased methadone dose with their Journal of Psychoactive Drugs
RESULTS
Abstinence and Smoking Rates Abstinence. Of the 17 study subjects, 11 (65 %) reported achieving abstinence for five days or more (quitters). Seven of the 10 subjects (70%) in the methadone dose increase (experimental) group and four of the seven (57%) in the control group quit smoking for the five days. The difference in quit rates was not significant (Fisher 's Exact Test,p=0.64) . At the end of the 10-week study, two of the 17 subjects ( 12%) reported abstinence from cigarettes; both were in the control group. The difference in 10-week abstinence rates between experimental and control subjects was not significant (Fisher's Exact Test, p=O.ll ). At I 0 months from the end of the class, participants were asked to fill out a questionnaire to assess their present 208
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time that most of these subjects had resumed smoking (day 11) to the end of the fourth week of the study found that control quitters smoked significantly less than experimental quitters (F=40.39; df=1,34; p
ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20
Treating Cigarette Smoking in Methadone Maintenance Clients Jim Story & Michael J. Stark To cite this article: Jim Story & Michael J. Stark (1991) Treating Cigarette Smoking in Methadone Maintenance Clients, Journal of Psychoactive Drugs, 23:2, 203-215, DOI: 10.1080/02791072.1991.10472237 To link to this article: http://dx.doi.org/10.1080/02791072.1991.10472237
Published online: 20 Jan 2012.
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Jim Story, M.S.* & Michael J. Stark, Ph.D.** Abstract- Substance abusers in treatment have cigarette-smoking rates about three times that found in the general adult population, yet there is a paucity of published studies exarnining smoking-cessation programs for these clients. Accordingly, a behaviorally based smoking-cessation program for methadone maintenance clients was developed. and the efficacy of a methadone dose increase as a pharmacological adjunct was tested in a doubleblind placebo-controlled study. While no significant difference between experimental and control subjects in reported abstinence rates was found, subjects receiving a methadone increase reported significantly more nicotine craving and other withdrawal symptoms during the first week of abstinence than did controls. Measures of smoking rates indicated that experimental subjects smoked significantly more than controls throughout the 10-week study period. Although the initial smoking abstinence rate of 65% was encouraging, most subjects returned to smoking by the end of the study period. These fmdings indicate that the development of smoking-cessation programs for methadone clients merits further study and that such programs should stress relapse prevention techniques tailored to the specific needs of this population. Also, while the use of a methadone dose increase as a pharmacological adjunct has not been found to be efficacious, other pharmacological strategies involving the use of nicotine should not be ruled out.
Keywords -methadone, nicotine, substance abuse, smoking cessation, tobacco
Since the late 1960s, when information concerning the negative consequences of smoking was beginning to be made available to the general public, the percentage of adults 20 years of age and older in the United States who smoke cigarettes has declined from around 40% to under 30% in 1990. During this time there has been a steady decrease in the prevalence of adult smokers in all age, sex, and race categories, with the exception of women aged 65 years and older (U.S. Department of Health and Hwnan Services 1988). In spite of promising trends, smoking rates are still very high for certain segments of the population, notably the poor, unemployed, divorced, less educated, and bluecollar workers. Not surprisingly, people who abuse other substances also have the highest tobacco-smoking rates. A host of investigators have reported smoking rates rang-
ing from 85% to 100% in abusers of alcohol, opioids, and cocaine (DiFranza & Guerrera 1990; Ginne 1989; Burling & Ziff 1988; Rounsaville etal. 1985; Istvan & Matarazzo 1984; Simpson et al. 1978). Marijuana use is also associated with increased cigarette smoking. For example, Cheek and colleagues (1973) found that among college students they surveyed, 73% of heavy marijuana users (three or more times/week) were tobacco smokers, compared to tobacco-smoking rates of 50% for regular marijuana users (once or twice/week) and 36% for occasional users (less than once/week). Not only are the rates of cigarette smoking among substance-abusing clients extremely high, but the inverse is also true; that is, people who smoke cigarettes have a much greater propensity to use other substances than their nonsmoking counterparts. Results of a national survey on drug abuse revealed that within each age cohort, cigarette smokers were more likely than nonsmokers to have used alcohol, marijuana, psychotherapeutic pills, and "stronger drugs" (i.e., heroin, cocaine, hallucinogens), and that this difference was greatest among youths and young adults (U.S. Department of Health and Human Services 1980). In a survey of 565 college students, Goode (1972) found
•Department of P1ychology, University of New Mexico, Albuquerque, New Mexico. ••Graduate Program in Counseling Psychology, Lewis & Clark College, Ponland, Oregon. Please address reprint requeJU to Michael I. Stark, Ph.D., Graduate Program in Counseling Psychology, Box 93, Lewis & Oark College, Ponland, Oregon 97219.
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that cigarette smokers were far more likely to use illicit drugs- including marijuana, heroin , and methamphetamine - than nonsmoking students. In this study, 39% of nonsmokers had not used illegal drugs in the six months preceding the survey, while the corresponding numbers were 13% for light smokers, 14% for moderate smokers, and II% for heavy smokers. Goode concluded that smoking any number of cigarettes was related to illicit drug use, and students who smoked just once a day were as likely to use other substances as those smoking a pack a day or more. Finally, daily use of marijuana was found to be 20 times higher and daily use of other illicit drugs was 13 times higher in high-school seniors who smoked cigarettes compared to those who did not smoke (U.S. Department of Health and Human Services 1980). It is not surprising that substance abusers have high rates of cigarette smoking given that multiple drug use is the common pattern of drug abuse (Miller & Mirin 1989; Jekel & Allen 1987; Kreek 1987). Furthermore, acute administration of ethanol (Mello et al. 1980a; Griffiths, Bigelow & Liebson 1976), heroin (Mello etal. 1980b), psychomotor stimulants (Benningfield & Griffiths 1981; Schuster, Lucchesi & Emley 1979), and sedatives (Benningfield, Chait & Griffiths 1983) produces robust and dose-related increases in smoking behavior. However, the acute effects of psychoactive substances may be insufficient to account for the relation between their use and cigarette smoking. For example, there is a positive correlation between marijuana use and cigarette smoking even though acute administration of marijuana does not affect (Mello & Mendelson 1986; Mello et al. 1980a) or actually reduce cigarette smoking (Kelly et al. 1990). Difficulties in quilling is another possible reason for the high smoking rates among substance abu sers . DiFranza and Guerrera (1990) compared the natural history of smoking in 77 inpatient alcoholics to that of 124 controls seeking care at family practice settings. Theresults of a 64-item survey indicated that once having become regular smokers there was no significant difference between the groups in numbers who had tried to quit (81% of alcoholics and 91% of controls). However, there was a significant difference between those who had been successful in quilling (defined as no smoking for at least three months prior to the study), with 49% of the controls having successfully quit but only 7% of the alcoholics having been able to do so. Inasmuch as one out of five smoking relapses occurs when people have been drinking (Shiffman 1982), it is logical that drinkers would be less successful in sustaining smoking cessation. This is consistent with the fact that substance abusers have difficulty quitting all forms of drug abuse, including their primary substance of abuse (Marian 1979; Hunt, Barnett & Branch 1971 ). Finally, substance abusers in community clinics JourfW.I of Psychoactiv~ Drwgs
have many of the demographic characteristics (e. g. , low income, less education) that are risk factors for smoking. CIGARETTE SMOKING AND METHADONE MAINTENANCE
For many methadone maintenance treatment (MMT) clients, cigarette smoking is undoubtedly their oldest, most difficult to quit, and potentially most lethal drug dependence. The smoking rates among clients in MMT are very high, with rates of82% (Stark & Campbell In press) and 98% (Berger & Schweigler 1972) having been reported. Undeniably, these high rates are due to the prevalence of smoking among opioid abusers, but methadone itself may also cause increases in smoking. Chait and Griffiths (1984) examined the interaction of acute methadone administration and smoking in five subjects with histories of opioid abuse who were being maintained on methadone. The subjects, all of whom smoked from one to two packs of cigarettes per day, were allowed to smoke ad libitum 90 minutes after receiving either a placebo, dextromethorphan (a taste blind) or one of three doses of methadone (onehalf, one or two times their normal maintenance dose). It was found that methadone pretreatment resulted in sign ificant dose-related increases for the group in the number of cigarettes smoked per session, fro m a mean of 2.8 after placebo to 5.6 after the highest methadone dose . The time spent by subjects puffing cigarettes, the level of carbon monoxide (CO) expired by subjects, and subjective ratings of smoking satisfaction were also found to increase significantly with increasing methadone dose. Investigators in an earlier study (Bigelow et al. 1981) reported that subjects undergoing methadone detoxification reduced the number of cigarettes smoked per day as their dose decreased. In this study, nine male MMT clients un derwent a daily clinic-controlled blind methadone detoxification. The average dose for these clients was 43.3 mg of methadone, which was reduced to 0 mg during a 10- to 3 1-day period. It was found that during detoxification, cigarette smoking correlated with methadone dose level (r=0.64), and that the smoking rate declined at a mean rate of 0.35 cigarettes for every milligram of methadone dose reduction. Mello and colleagues (1980b) employed a methadone-detoxification condition as part of their study of the effects of heroin on smoking. They did not fi nd an increase in smoking during methadone administration, but it is possible that the doses were too small to produce an effect, as methadone dose levels were not reported. The mechanism by which opioid use increases smoking behavior is in question, but several explanations have been offered. Mello and colleagues ( 1980b) suggested that the effects of nicotine and opioids may complement and mutually facilitate each other or that for a smoker under the influence of opioids, nicotine's effects are either more 204
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reinforcing or attenuated. requiring more cigarettes to produce the desired effect. These researchers also raised the possibility that the increase in smoking is a reflection of a generalized increase in activity levels following opioid administration. Chait and Griffiths ( 1984) suggested that opioid administration functions as a discriminative stimulus for smoking, at least for subjects who have a history of increased smoking after opioid administration, or that opioids increase smoking by blocking or attenuating the aversive effects of cigarettes, which may tend to limit smoking in the absence of these substances. With regard to the latter hypothesis, the analgesic and cough suppressant properties of opioids may serve to eliminate some negative effects of smoking, such as throat irritation and coughing.
who had successfully quit smoking after their alcoholism treatment, compared to those who made unsuccessful attempts at smoking cessation. Miller, Hendrick and Taylor (1983) found that among problem drinkers undergoing behavioral self-control training, smoking cessation by pretreatment smokers was in all cases associated with successful control of drinking even though pretreatment nonsmoking was not. These authors hypothesized that in spite of the traditional lore that smoking-cessation attempts during treatment for alcohol abuse are countertherapeutic and increase the risk of relapse, programs aimed at dual control of smoking and drinking may yield synergistic effects. Finally, Henningfield (1984) hypothesized that cigarette smoking might be a significant relapse factor for other drug use, although this has not yet been studied.
SMOKING CESSATION WITH SUBSTANCE ABUSERS
SMOKING CESSATION WITH METHADONE MAINTENANCE CLIENTS
In spite of the very high cigarette-smoking rates among substance abusers and the devastating health consequences of cigarette smoking, there is a paucity of published studies examining smoking cessation with these clients. Clinicians fear that smoking cessation will interfere with clients' efforts to abstain from using other drugs and are reluctant to press them to stop smoking. Bobo and Gilchrist (1983) found that 22.6% of an alcoholism treatment staff said they never favor urging alcoholic clients to quit smoking; 45.5% reported never encouraging alcoholic clients to quit. Clients are also reluctant to participate in smoking-cessation programs as part of their treatment for other substance abuse. Kozlowski and colleagues (1989a) surveyed 289 alcohol and other drug abuse clients and found that only 31% of the smokers were interested in receiving treatment for smoking at the same time as their alcohol or other drug abuse treatment. It is understandable that clients seeking substance abuse treatment would be less concerned about smoking than their primary substance of abuse. Kozlowski and colleagues likened this to people having had their car towed in for repairs and fmding out that in addition to the current emergency, the rust on the car's body will ruin it in 10 years. Clients are naturally concerned about their immediate drug abuse problems and less worried about the health consequences of tobacco smoking that might affect them in the future. It is also reasonable that treatment staff would be concerned about the fragility of their clients' abstinence and would not want to risk treatment gains with additional demands on clients. Although staff and clients are concerned about concurrent smoking and other substance abuse treatment, the limited evidence available does not present cause to worry. Bobo and colleagues (1987) found a somewhat higher rate of abstinence from alcohol among recovering alcoholics
MMT clients are a likely target population for smoking cessation because once stabilized, they are not undergoing the anxieties associated with withdrawal and initial abstinence. Additionally, they have better retention rates than clients in other treatment modalities (Grey, Osborn & Reznikoff 1986; Craig, Rogalski & Veltri 1982; Simpson, Savage & Lloyd 1979). Methadone maintenance clients are often seen by counseling, dispensary or medical staff on a daily basis, a fact that could greatly facilitate a smoking-cessation program. Finally, as an exogenous opioid, methadone itself could be used as a pharmacological adjunct to treatment, with increases in doses employed to ameliorate the nicotine withdrawal syndrome. The justification to use methadone to lessen the nicotine withdrawal syndrome is derived from research suggesting that increased production of endogenous opioids as a result of nicotine intake is one of the mechanisms by which smoking behavior is reinforced (Pomerleau & Pomerleau 1984). Nicotine intake has been found to be significantly and positively correlated to plasma ~-endor phin levels in human subjects. In one study (Pomerleau et al. 1983), smokers who were deprived of cigarettes for several hours were then allowed to smoke either two lownicotine (0.48 mg/cigarette) or two high-nicotine (2.87 mg/cigarette) cigarettes. For the subjects smoking the highnicotine cigarettes, a strong positive correlation was found between plasma nicotine and plasma ~-endorphin ~-lipotropin levels (r=0.977). The increase over baseline of ~-endorphin-~-lipotropin levels was approximately 100% for these subjects. It has also been shown that an opioid withdrawal response induced by administration of the narcotic antagonist naloxone in morphine-dependent mice can be prevented by injecting the mice with nicotine (Brase et al. 1974). Furthermore, Karras and Kane (1980) found that
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HYPOTHESES
naloxone reduced the amount smoked and the corresponding desire to smoke in seven volunteer subjects, all of whom were long-term cigarette smokers who smoked at least a pack per day. However, in one well-designed study with seven subjects, Nemeth-Coslett and Griffiths (1986) did not find naloxone to affect smoking, nor did Mello and colleagues (1980b) with a single subject The fact that the effects of narcotic antagonists have only been studied in a total of 15 subjects in three different laboratories (Mello & Mendelson 1986) indicates that the inconsistent findings with naloxone are insufficient to call the endogenous opioid theory of smoking reinforcement into question . It has been suggested that combinations of multicomponent behavioral treatment and pharmacological intervention may be well suited for highly dependent smokers (U.S. Department of Health and Human Services 1988). As MMT clients are likely to fit the profile of heavy smokers who see themselves as being addicted to cigarettes, they may be attracted to a smoking-cessation program that allows them to attempt quitting in two stages. If ph ysiological withdrawal from nicotine can be postponed by increasing ~-endorphins with an exogenous opioid (i.e., methadone), then the initial intervention can focus on extinguishing smoking behaviors and learning nonsmoking skills. Once these skills are established, nicotine withdrawal could begin and clients would be more likely to continue to not smoke than if faced with learning new skills and undergoing nicotine withdrawal simultaneously. This is the logic behind the use of nicotine gum in smoking cessation, which has proven to be a consistently effective addition to multicomponent cessation programs (U.S. Department of Health and Human Services 1988; Hughes & Hatsukami 1985; Schneider, Jarvik & Forsythe 1984 ). Clients in MMT programs are accustomed to the use of methadone to prevent withdrawal symptoms. As a pharmacological treatment for smoking, the use of methadone provides a way of joining clients' belief systems (Lichtenstein 1982), and dose increases might also motivate clients to participate in a smoking-cessation program. The present authors decided to combine the methadone dose increase with a multicomponent behavioral approach that incorporates the use of a baseline period and quit date, modification of reinforcement contingencies, self-management techniques, coping-skills training, and relapse prevention. 1be efficacy of these procedures is well-documented and a number of studies of multicomponent programs have reported one-year abstinence rates ranging from 40% to nearly 60%, about double the rates found with single-component programs (U.S . Department of Health and Human Services 1988).
Journal of Psychoactive Drugs
If an increase in methadone dose proves effective in easing nicotine withdrawal symptoms and facilitating smoking cessation, it would be expected that subjects who receive such an increase and quit smoking would report less craving and fewer withdrawal symptoms in the early stage of abstinence than would subjects in a placebo-control condition. A higher quit rate for the experimental group would also be expected. In addition, if methadone substitutes for depleted ~-endorphin due to nicotine deprivation, then subjects receiving the methadone increase who quit smoking should not experience the effects of the dose increase as much as those who continue to smoke. On the other hand, according to the experimental evidence mentioned above (Chait & Griffiths 1984; Mello et al. 1980b), administration of opioids has been found to result in increases in smoking behavior and satisfaction . Whatever the mechanism involved here, it may be more difficult for subjects in the increased methadone dose condition to quit smoking. If these effects prevail over any amelioration of withdrawal symptoms due to a methadone dose increase, a lower quit rate for the experimental group than the placebo-control group would be expected. Also, if a methadone dose increase results in increased desire to smoke, more reported craving and withdrawal symptoms should be reported by this group. A randomized, double-blind, placebo-control design could provide a test for these two different hypotheses .
METHODS AND PROCEDURES A smoking-cessation program developed for MMT clients was offered at Skills Training for Adult Recovery (STAR), a 300-client methadone clinic, which is part of Comprehensive Options for Drug Abusers (CODA) , Oregon's largest drug abuse treatment center. The STAR program consists of three phases that offer clients training in educational, recreational, and personal skills (Stark 1989). In order to be eligible for the smoking-cessation program, clients had to be in Phase II of STAR. Clients enter Phase II after an eight-week orientation and stabilization phase. Once in Phase II, clients are offered a variety of treatment options from such subject areas as vocational development, stress management, communication, nutrition, and recreation and leisure as well as required courses on addiction. Beginning about one month prior to the start of the STAR 1989 summer term, the smoking-cessation course "Quit Smoking" was advertised in the clinic by posters and fliers, and by word of mouth through CODA counselors. At an orientation session before the start of the course, clients were informed that by taking the course and participating in a scientific study they would (a) get an in206
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crease in their methadone dose (unless they declined to do so), (b) receive a$25 participation stipend, and (c) fulfill their STAR requirement in the first three weeks of a 10-week quarter.
Dosing Procedure During the orientation session, subjects were told that they would receive an increase in their methadone dose -with the maximum possible increase being 20% of their present dose- but that they would not be told how much they had received until the final session to be held 10 weeks after the start of the study. At the end of the study period. subjects who received the maximum dose increase would be given the choice of remaining at this dose level or undergoing a gradual reduction to their previous level. Those receiving less than the maximum dose increase would be given the option of increasing their dose to a level 20% above their original (preexperimental) dose. Methadone dose levels for the 17 subjects before the increases ranged from 34 mg to 71 mg (J..Ii=49). After the increases, doses for the control group ranged from 41 mg to 71 mg (JJ;=54), while the experimental group ranged from 52 mg to 85 mg (JJ;=62). Subjects were told that the dose increases would be administered beginning on Monday morning, one week after the orientation session, and that this would also be their target quit date for beginning abstinence from cigarettes as well as the date of their first evening session of the Quit Smoking class. Baseline data on smoking rates, methadone dose effects, and nicotine withdrawal symptoms were gathered from subjects on questionnaires taken daily during the week prior to the target date for quitting.
Subjects Of the 33 clients who preregistered for the Quit Smoking course, 22 attended the orientation session and signed up for the class. 1bese subjects were then randomly assigned to either an experimental group, which would receive a 20% methadone dose increase, or a placelxH:ontrol group receiving a one milligram dose increase. Both subjects and researchers were blind to the dosing assignments. Of the 11 subjects originally assigned to the experimental group, one subsequently asked not to be included in the study because she wanted a decrease in her methadone dose but wished to remain in the course. Of the 11 subjects assigned to the control group, two dropped out during the first week of the course and two others decided that they wanted decreases in their methadone doses but wished to remain in the course. A total of 20 clients remained in the course, and 17 of these remained subjects in the study. The 10 subjects in the experimental group and seven in the control group remained throughout the study. All of the participants (five men and 12 women) were White and ranged in age from 25 to 43 (J.F36). The highest educational grade completed by subjects ranged from 10 to 16 (J,J;=12), and their monthly income ranged from none to $1,745 (J..Ii=$431). Three subjects reported being employed full time and two in part-time jobs; nine subjects said they were receiving some form of public assistance, either welfare or social security income. Nine subjects reported being married, three single, one widowed, and four divorced. All of the subjects had a history of opioid use (all but one were heroin users) before coming to CODA, and their age at first use ranged from 14 to 29 (JJ;=20). The length of time of subjects' current stay in CODA's MMT program ranged from eight to 91 months (JJ;=32). Nine had previously been maintained on methadone either at CODA or at another clinic. Subjects' total time on methadone maintenance ranged from 12 to 97 months (J..Ii=40.12). The following information on subjects' smoking history was taken from a Smoking Proflle Questionnaire. The age at which subjects started smoking ranged from four to 22 (J.F 15) and the length of time they had been smoking ranged from seven to 35 years (JJ;=21). Subjects reported smoking from one to two and a half packs of cigarettes per day, with the mean being just over one and three-quarter packs per day (jJ;= 1.84). Five of the subjects reported that they had never attempted to quit smoking, nine of the 17 said they had never given up cigarettes for more than three days since they began smoking, and five had never quit for more than one day. All17 felt that they were "extremely addicted" to cigarettes, and 14 of them reported JowrMl of Psychoactive Drwgs
Smoking-Cessation Procedure MMT clients at CODA are obligated to participate a minimum of 10 hours during each 10-week term in STAR program courses. The Quit Smoking course was therefore designed to take up a total of 10 hours, including one hour for the orientation session and one hour for a fmal session. The course began on a Monday evening, following the week used for baseline data gathering, and consisted of four consecutive, 90-minute evening sessions led by one of the researchers. Back-to-back sessions on each of these evenings were conducted both to accommodate clients' schedules and to decrease the number of subjects present at each session. The size of the groups varied, ranging from seven to 12 subjects (JJ;=10). The four-session intervention trained subjects in the use of behavioral and cognitive smoking-cessation techniques that focused on coping with withdrawal symptoms, eliminating environmental smoking triggers, and substituting new behaviors to take the place of smoking responses. The first evening was the target quit date and subjects were asked to turn in their cigarettes to the researcher at the beginning of the session. Subjects were then told what they could expect to experience in the first few days of nicotine withdrawal. Group cohesion and support was 207
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encouraged by asking subjects to put their names on a phone list or to pick one other group member (a buddy) and to exchange phone numbers (U.S. Department of Health and Human Services 1988). On the two consecutive Mondays following the first week of the Quit Smoking class, hour-long sessions were held that focused on preventing relapse. After these sessions, the subjects' 10-hour obligation to STAR was fulfilled, but an optional third relapse prevention session was made available to them two weeks after the last required session. However, this optional session was only auended by one subject. The approach taken in relapse prevention sessions was basically that used in Kaiser Hospital's Freedom from Cigarettes program (Stevens & Hollis 1989), which is based on Marlatt's model of the relapse process (Marlatt & Gordon 1985).
usual dose was added to the questionnaire. Subjects were also asked to describe specifically any effects (i.e., drowsiness, euphoria, and increased energy) they had noticed from their dose increase. This revised questionnaire was then used, beginning on the morning of their methadone dose increase and target quit-smoking date, for continued data gathering over a four-week period. On the evening of the last required relapse prevention session, the subjects were asked to fill out a Strategies and Expectations Questionnaire. This instrument was developed to assess subjects' use of the skills and coping strategies they had learned during the course, and to see if this correlated with success in achieving abstinence from cigarettes (Shiffman 1984, 1982). It also included the same questions regarding auributions and expectancies that were asked on the Smoking Profile Questionnaire. At the final session, held during week 10 of the STAR summer quarter, subjects were asked to fill out a final questionnaire. This instrument included questions regarding subjects' current smoking status and their smoking rates since the last session auended. Subjects who had achieved abstinence from cigarettes for a week or more during the course were asked to rate several factors as to their importance in contributing to their success. Those who did not quit smoking for a week were asked to what degree these same factors contributed to their inability to do so. The final questionnaire asked subjects whether or not they expected to auempt quilling smolcing again in the near future, and if so, what was their expectation of success. Subjects were asked what aspects of the course and which people were most helpful to them in their attempt to quit smoking, and whether or not they believed that the methadone dose increase was useful. They were also asked to estimate the amount of their dose increase. After com pleting the questionnaires, subjects were told what their actual dose increases had been.
Data Collection and Instruments At the orientation session, subjects were asked to fill out a Smoking Proflle Questionnaire developed by theresearchers to gather information on current smoking status and smoking history, including previous quit auempts and subjects' motivation for signing up for this course and for wanting to quit smoking at this time. They were also asked questions regarding their expectancies of success in this and future cessation attempts and the degree to which they perceived themselves to be addicted to tobacco. A second questionnaire was developed to gather baseline data for smoking rates, nicotine withdrawal symptoms, and methadone dose effects. This questionnaire included a revised version of the Smoker Complaint Scale (Schneider & Jarvik 1985, 1984), which measures the severity of subjectively reported nicotine withdrawal symptoms. The version used in this study was shortened and contained Likert-scaled items assessing nicotine withdrawal symptoms and craving for cigarettes (Hatsukami, Hughes & Pickens 1985; Shiffman & Phil1979; Shiffman & Jarvik 1976). Subjects were also asked to report the number of cigareues smoked each day during the baseline period. All but three of the study subjects received their methadone doses at the CODA clinic on a daily basis and were asked to fill out the baseline data questionnaire each morning before or within a few minutes after taking their dose. The questionnaires were given to subjects and collected by dispensary personnel each morning. The other three subjects received their doses at a local pharmacy and were given enough questionnaires for the baseline week, with instructions to fill them out each day before taking their dose and to bring them all to the Monday evening class. After a week of baseline data gathering, a further question asking subjects to compare (using a four-point Likert scale) their increased methadone dose with their Journal of Psychoactive Drugs
RESULTS
Abstinence and Smoking Rates Abstinence. Of the 17 study subjects, 11 (65 %) reported achieving abstinence for five days or more (quitters). Seven of the 10 subjects (70%) in the methadone dose increase (experimental) group and four of the seven (57%) in the control group quit smoking for the five days. The difference in quit rates was not significant (Fisher 's Exact Test,p=0.64) . At the end of the 10-week study, two of the 17 subjects ( 12%) reported abstinence from cigarettes; both were in the control group. The difference in 10-week abstinence rates between experimental and control subjects was not significant (Fisher's Exact Test, p=O.ll ). At I 0 months from the end of the class, participants were asked to fill out a questionnaire to assess their present 208
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time that most of these subjects had resumed smoking (day 11) to the end of the fourth week of the study found that control quitters smoked significantly less than experimental quitters (F=40.39; df=1,34; p
