I’ve completed a monograph that calls for change in the addiction treatment arena. It focuses on our need to modify our settings and services to a tobacco-free and smoke-free model of care.
This post is the fourth and final in a small series of excerpts from the monograph. The intent of posting these excerpts is to build interest among readers in the topic and in reading the monograph itself.
Below, as installment # 4 in the lead-up is small portion of a section called “Questions from the Field”. In that section of the monograph I respond to comments and questions from one reviewer. Following the small excerpt below I again provide the Acknowledgements and Disclaimer sections.
With this being the fourth and final installment in the lead-up series, the full monograph itself will come out on Tuesday August 26, 2025.
Questions from the Field
One of the reviewers of this document provided some possible concerns and questions.[1] I’ve adapted that material into the following list of questions, and provide answers for each.
Q: How important do you think it is to treat tobacco use at the same time one is being treated for other addictions? That’s a different question from the one you are asking, which was: “On a scale from 0 to 10 how important is it to treat tobacco use in a patient with a substance use disorder? And why?”
A: I like that proposed question because to me it goes to the idea of how to address co-occurring disorders.
The history of treating co-occurring disorders with best practices is rather long. And the literature on that topic is well developed and well worth studying. The co-occurring literature notes that methods for treatment of co-occurring conditions might be sequential (first one problem, then the other), or concurrent (two separate treatments in parallel), or integrated (one whole method by one whole team). The use of one of those methods or the other is driven by the presenting picture. And the methods can be fine-tuned, as appropriate, by the history, strengths, and current stage of treatment, change, and recovery management – each on a per-problem basis – that the particular person presents. Thus, on its own, “integrated” is not “better” per se than “concurrent” or “sequential”, per se.
Almost all of the time, co-occurring disorders are thought of as a substance use disorder and a mental health condition. But it can be interesting and helpful at times to consider two or more substance use disorders that are present simultaneously as co-occurring conditions – aside from the presence or absence of a mental health condition.
From a practical perspective, simultaneously present and separate SUDs may need separate management.
For example, concurrent medical withdrawal management of an alcohol use disorder and a tobacco use disorder in a hospital setting might need to be first in sequence. And once concluded, the residential addiction treatment that also includes specific attention to the person’s stimulant use disorder then begins.
Alternatively, a patient seeking residential treatment for a benzodiazepine use disorder might already be ten years into sustaining the recovery-management phase of their tobacco use disorder, and not need NRTs at this time.
Or, while on a methadone program, a stable patient may have an active alcohol use disorder that requires alcohol withdrawal management and residential treatment of their alcohol use disorder, while their methadone maintenance is continued during and following their residential AUD treatment.
A more common picture would be a person with an alcohol use disorder, a cannabis use disorder, and a tobacco use disorder, wherein medical withdrawal management for alcohol is not needed, treatment for one central “addiction illness” makes sense, and NRTs are in fact necessary for stabilization prior to withdrawal management from nicotine while they cease smoking cigarettes.
So “How important is it to treat tobacco use at the same time as other SUDs”? That would depend on the presenting picture. If the presenting picture indicated the tobacco use was current along with the other SUDs, I would say it is very important for the reasons outlined in the monograph.
[1] Bob Lynn. Personal communication. July 15, 2025
Acknowledgements
I would like to thank the following people for their review of earlier drafts of this manuscript and providing their feedback, suggestions and encouragement: Kim Bayha, Sandy Ellingson, Trina Fullard, Bob Lynn, Philip T. McCabe, David McCartney, Joseph Najdzion, Jason Schwartz, Mary H. Ward, and William L. White.
Disclaimer
Nothing in this document should be taken or held as clinical instruction, clinical supervision
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