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Smoking, neurodiversity, and pragmatism

July 8, 2010

Prompted by one of anne_corwin‘s posts on Dreamwidth. I’d been meaning to write something on the subject for a while.

I used to be truly obnoxious about tobacco smoking. The effect any kind of smoke had (and still has!) on my allergies made me even more hyper about it. I would go into exaggerated coughing fits, shoot smokers truly filthy looks, and generally act like a self-righteous drama queen about it. I just couldn’t understand why anyone would want to do that to themselves, and had serious trouble resisting telling them all about it. No doubt, I drove a number of people close to me batty with the judgmentalism and interference I was being led to believe elsewhere was a good thing if I cared about them and didn’t want them to die horrible lingering deaths through their own stupidity. It wasn’t just me, they were (and are) honestly telling kids this was a good thing.

Then I was on meds that made my dopamine levels plummet, and started smoking at 20. Talk about cognitive dissonance. I was seriously depressed*, with akathisia, and am still not sure what made accepting an offered cigarette a good idea at the time. But I was out buying some the next day, and haven’t successfully stopped smoking for more than a week in the 15 years since then. I do not seem to be otherwise prone to addiction at all, but this is a truly special case. And I am ashamed of the way I treated other people when I was younger, with no understanding of their experiences and totally dismissing the existence of valid motivations.

There is more focus on neuroleptics with this kind of thing, but SSRIs will do it too. (Mess with serotonin, you also mess with dopamine; it’s all connected.) I got EPS on them–akathisia and lasting bruxism, along with serious dopamine-linked prolactin weirdness–so it was definitely screwing with dopamine levels. I have known other people who had previously quit, but felt incredible urges to smoke again after starting on SSRIs, including my mother. She had quit smoking almost 20 years before, got on Prozac, and was soon back on the cigarettes; she also suffered from (unrecognized) akathisia on SSRIs, which improved when she started smoking again. I hadn’t started using tobacco yet at that point in time, so I still badgered her to stop killing herself and stinking up the car so that it choked me. *choke choke eyeroll gasp wheeze eyeroll*

There’s lots of research on this kind of thing. A decent summary? Dirk Hanson’s Why Do Schizophrenics Smoke Cigarettes?:

The review of studies through 1999, undertaken by Lyon and published in Psychiatric Services, shows unequivocally that schizophrenic smokers are self-medicating to improve processing of auditory stimuli and to reduce many of the cognitive symptoms of the disease…

A 2005 German study concluded that nicotine improved cognitive functions related to attention and memory. “There is substantial evidence that nicotine could be used by patients with schizophrenia as a ‘self-medication’ to improve deficits in attention, cognition, and information processing and to reduce side effects of antipsychotic medication,” the German researchers concluded.

In addition, the process known as “sensory gating,” which lowers response levels to repeated auditory stimuli, so that a schizophrenic’s response to a second stimulus is greater than a normal person’s, is also impacted by cigarettes. Sensory gating may be involved in the auditory hallucinations common to schizophrenics. Receptors for nicotine are involved in sensory gating, and several studies have shown that sensory gating among schizophrenics is markedly improved after smoking…

Smoking can lower the blood levels of some antipsychotics by as much as 50%

A similar, more comprehensive review: A Review of the Effects of Nicotine on Schizophrenia and Antipsychotic Medications (note that a lot of the touted benefits of atypical neuroleptics have not panned out clinically). I was not aware of the effects on sensory gating–one of my major day-to-day problems–until I started doing a bit of research today. It’s not entirely clear how this works with autistic sensory gating (I kept finding rather conflicting stuff), but there is also Reversal of Diminished Inhibitory Sensory Gating in Cocaine Addicts by a Nicotinic Cholinergic Mechanism and shedloads on PTSD and sensory gating, through similar mechanisms. Note that below it is mentioned that neuroleptics can cause sensory gating problems; mine are harder to manage since I was on those meds.

Directly reducing the blood levels of the medication can be a powerful draw, especially if you are feeling like a complete zombie. I crept up to three packs a day while on olanazapine, risperidone, quetiapine, and ziprasidone–not all at the same time, thank goodness! I also started swilling coffee like there was no tomorrow (see Alcohol & Drug Abuse: Caffeine and Schizophrenia; similar to nicotine). My reaction to caffeine is still totally different than it was before I was on these meds; before I got very hyper, now it just almost brings me back up to level, and doesn’t interfere with sleep or anything. When I got off that medication, my smoking decreased a lot on its own.

Besides the more direct dopamine connections, come to find out, from Nicotinic Receptor Mechanisms in Neuropsychiatric Disorders: Therapeutic Implications:

Nicotinic acetylcholine receptor (nAChR) dysfunction is believed to contribute to numerous neurpsychiatric disorders. nAChRs belong to the class of ligand-gated ion channels that are present in the central nervous system. The endogenous ligand for nAChRs is acetylcholine, and nicotine directly acts on this receptor. nAChR modulation may play a modulatory role in several neuropsychiatric disorders. It may improve clinical features such as depressive symptoms; parkinsonism; and cognitive dysfunction related to working and verbal memory, executive functions, and attention…

Antipsychotics (eg, haloperidol) can induce side effects like cognitive and sensory gating deficits, and it is hypothesized that people with schizophrenia may smoke to remedy their cognitive deficits and antipsychotic-induced side effects.27,28…

nAChR activation plays a crucial role in regulating striatal dopaminergic function, and these dopaminergic systems are critical in motor control, as evidenced by findings that their disruption results in movement disorders such as Parkinson’s disease.95

That would also apply to drug-induced extrapyramidal effects/movement disorders. As pointed out in the nicotinic receptor review, nicotine patches also helped reduce Tourette’s tics. Then there’s Treatment of spastic dystonia with transdermal nicotine; my own (painful) generalized tardive dystonia from the neuroleptics goes absolutely wild when I cut back much on nicotine consumption, which has cut more than one attempt at quitting short. Note: I have not been on these medications for years now, but movement disorders can continue forever, due to medications changing your brain (some research).

Not too surprisingly, nicotinic acetylcholine receptors also play a role in pain (I am not finding much specifically on pain amplification/gating/etc., but a connection makes sense, being a sensory experience interdependent with other sensory stuff) , and nicotine patches have been used for various| types of pain. People with chronic neuropathic pain are also more likely to smoke (assumption: “‘The possible physiologic relation between smoking and development of chronic neuropathic pain deserves further evaluation,’ the authors conclude…’I caution advocating smoking as a perceived treatment for neuropathic pain, since it is clear that the adverse risks of smoking outweigh any potential benefit.’ Little contradictory?) Then there’s the drift of Smokers With Chronic Pain Smoke More, But Show Desire To Quit: ‘”Like in similar research, those in our study who smoke to relieve pain are more likely to be depressed and disabled than those who do not use smoking for pain relief,” Hahn said. “Because of these findings, smoking cessation programs should incorporate treatment for psychological and physical problems common among smokers.”‘. Erm, could it be that they’re depressed and disabled because they’re in a lot of poorly-treated pain, and willing to try anything that helps? (Sounds familiar, actually.)

I’m not going super-comprehensive here (like when I went off on the prolactin kick), but there are a lot of reasons that people with neurological differences may smoke. It’s easier to go all moralistic and say “Waah! Look at all this unhealthiness–we need to find a way to make these people quit (killing themselves/everyone else/costing us a lot of money/etc.) with tobacco!” than to approach the matter from a genuine desire for harm reduction and looking at why they’re using it in the first place.

Carping at people, treating them like idiots who are just not aware that smoking is harmful, dismissing whatever benefits they may be deriving from it, and infantilizing them? It just does not help. Not only is the concern trolling highly disrespectful, it is highly unlikely to get people to change their behavior. Demand resistance, anyone? I would suspect that this could be an even more common response among groups of people who regularly get treated like everyone else knows better than they do what is good for them, such as longterm psych patients, other people with neurological differences, and disabled people in general. I know it gets right up my nose.

There is a huge honking difference between this kind of approach and respectful noninterference, which involves paying attention to what kind of help people might actually want. Getting talked down to? Very few people want that. It is not helpful.

I’d be absolutely amazed if, besides the direct metabolic effects, people on psych meds were not getting 25 years knocked off their life spans by smoking like smokestacks. Note that all of this extends to SSRIs and other antidepressants, and:

People with metabolic syndrome are twice as likely to die from, and three times as likely to have a heart attack or stroke compared to people without the disorder. They also have up to a nine-fold greater risk of developing type 2 diabetes…

All medication classes — antidepressants, mood stabilizers and “atypical,” or newer antipsychotics — appeared to increase the risks.

People diagnosed with depression lose 25 years or more of life expectancy, Taylor said.

Throw in smoking too? Not good at all. But it’s entirely too tempting to blame the individual for “perversely” self-medicating with tobacco.

I am very uncomfortable indeed, continuing to smoke. Not only am I well aware that it’s hurting my health in multiple ways, I do not like expensively supporting unethical tobacco companies. (Or the environmental damage from pesticide-laden monoculture, or…) Purposely inhaling smoke, especially with asthma and early-onset type 2 diabetes? Not a good plan. And, given some of my beliefs, I am unhappy about developing such an unbalanced and destructive relationship with a sacred plant.

But, for now, I don’t feel like I have much choice but to continue smoking. I have not had good luck with gum, patches, or lozenges, partly because I don’t think I was using enough of the gum or lozenges. (Lobelia? Ha! Though it really did help the asthma and muscle spasms.) An e-cigarette seemed like the perfect solution: burst of nicotine on demand, with a similar delivery mechanism. I tried to incrementally switch over to that, but ended up with worse sore throat, coughing, and asthma than from inhaling smouldering leaf smoke–which is saying something. (It was from immediate irritation, not the usual “cut back on tobacco, your cilia are no longer paralyzed” kind.) Switching to a glycerine-based nicotine liquid helped with the sore throat, but I haven’t yet figured out what might be causing the coughing and asthma so that I can work around it. I would like to use something with a lot less potentially harmful stuff packed along with the nicotine. After we move to somewhere it is not banned, I may try smokeless tobacco if I can’t figure out how to get the e-cigarette thing to work for me.**

I still work hard not to feel guilty about continuing to smoke, and had to wonder how much of the previous paragraph was “Look, I’ve tried really hard! Honest!”. Supremely unhelpful as that is.

In general, I think we could do with less moralism (Let’s not confuse health and morality) and more pragmatic harm reduction when it comes to smoking. Along with so many other things.

Edit 19:40: Fixed a sentence I had managed to garble into saying something very different indeed.
_____________

* How it was interpreted at the time, so the antidepressant doses got raised. What I was actually experiencing after I started on the medication was closer to “negative symptoms”, which have been linked to dopamine receptor availability in certain areas of the brain: “dopamine D2/D3 blockade in the striatum can mimic certain negative symptoms, such as affective flattening and avolition”. SSRIs can hijack dopamine transporters; “Also, they wrote that their findings may explain why treatment of children with fluoxetine can induce depressive symptoms in adulthood.” I strongly suspect that I’ve experienced so many lasting effects from earlier medication because my nervous system was still developing when I was started on SSRIs, at 14. I still have a lot of the “negative symptom”/zombie-feeling type problems.

** Somewhat amusing thing I ran across (Correlates of tobacco use among Native American women in western North Carolina: “The association of smokeless tobacco use with having consulted an Indian healer may help in understanding Cherokee women’s smokeless tobacco use.”: 8% of those studied. (Heck, in Prevalence and predictors of tobacco use among Lumbee Indian women in Robeson County, North Carolina (same page), “20.6% of women were current smokeless tobacco users”, mostly older women: “Intervention programs for tobacco use cessation should be sensitive to these differences.”) Yep, it’s a traditional way to stop smoking the stuff. And, from people I’ve known, more effective (and usually cheaper) than gum, patches, lozenges, etc. I suspect that chemicals in the tobacco other than nicotine alone play a role in dependency.

I also commented on the “condescension and classism…before we even start seeing racism and/or racist regional bias” when it comes to smokeless tobacco–much less women using it–about halfway down the page here. That applies to tobacco use in general, and living in the UK I have been interested to see the totally different public health approaches to tobacco (imported) and alcohol (long history of use). Tobacco is frequently fetishized as an inherently bad thing in the US, too. And Native people, women, etc. are assumed to need intervention to protect them from it. From the same site:”Tobacco is an integral part cultural traditions and the right to use it in a sacred this manner must be retained.” I would argue that nobody else has a right to tell people how they can use it, period. It’s just none of their business, so long as that use does not involve blowing smoke at them or spitting tobacco juice on their feet.

5 Comments leave one →
  1. July 8, 2010 6:31 pm

    brilliant and important work here, Urocyon!

    I’ve already got a post ready to go for tomorrow with a bit of commentary and link to here.

    thanks so much.

  2. July 10, 2010 11:42 am

    A fascinating article. Thank you. I too have found it impossible to stop smoking since medication. Olanzapine made me a coffee addict for exactly the same reason – I needed coffee to feel close to normal. I’m off Olanzapine now and on Duloxetine. I still smoke – and purposely avoid patterns of guilt thought about it – I’ll deal with the smoking if and when I can come off the duloxetine.

Trackbacks

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  3. Must read: Smoking while diagnosed mentally ill, testing thyroid and those who talk about serious issues are happier: Friday news and blogs – Beyond Meds

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