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How Cigarette Nicotine Affects The Brain

I was recently asked to review a new textbook on Nicotine Psychopharmacology, containing 18 very thorough chapters describing the latest evidence on the effects of smoking and nicotine on the brain and behavior. Much of it, though interesting, was a very heavy read. But it occurred to me that it might be useful to try to summarize what the 544 pages in this new book suggests about the effects of nicotine and the reasons smokers get addicted. So here is an attempt to describe how nicotine addiction works, in simplified terms.

When a smoker inhales nicotine from a cigarette, the drug is carried to the brain in highly concentrated form within around 10-15 seconds. The drug then binds to a variety of different types of nicotinic receptors in different parts of the brain, producing psychological and behavioral effects. One of the most important effects is that it stimulates release of dopamine, the ╥reward neurotransmitter╒ in the pleasure center of the brain. This effect appears to be experienced as a subtle ╥satisfaction╙ effect, and causes the smoker to want to smoke again in order to experience the effect. Nicotine has effects on other parts of the brain that effect ╥arousal╙ and the ability to focus our attention and concentration.

Thus smoking a cigarette can help a smoker to think clearly, in ways that are similar to the effects of caffeine. Nicotine also appears to help the smoker form associations between the things they were doing and the situation they were in at the time they were smoking, and the psychological effects of the drug. These learned associations mean that when the smoker is back in a situation in which he or she previously smoked, the brain triggers a memory of the sensations previously experienced and a desire to repeat them. (Often experienced as a desire or craving to smoke).

In addition, the more a person smokes, the more nicotinic receptors grow in his/her brain. Most of these receptors are desensitized when stimulated by nicotine, but when the person stops taking nicotine, more and more of these receptors become sensitized but not activated by nicotine. This leads to effects that are the opposite of the primary effects of nicotine: reduced release of dopamine in the reward center of the brain (experienced as a bad mood), and other effects such as poor concentration and increased appetite caused by lack of the usual nicotine levels in the brain. These symptoms are experienced as unpleasant and prompt the smoker to try to take nicotine (typically by smoking) in order to be able to feel ╥normal╙ again. Thus the abstaining smoker will smoke for a calm and less irritable mood, and to be able to focus their attention without being so distracted by thoughts of smoking or hunger for food.

People differ in the way their body and their brain reacts to nicotine. Many of these differences are influenced by genetic factors, some of which are starting to be understood. For example, some people metabolize nicotine much more quickly than others, meaning that they experience nicotine withdrawal sooner after their last cigarette. Some people are more sensitive to nicotine’s psychological effects and experience withdrawal symptoms more strongly than others.

In addition, there appear to be other substances in cigarette smoke that also have psychological effects. For example, some other substance in cigarette smoke slows down the speed with which dopamine is broken down in the brain. This means that as well as the nicotine causing dopamine to be released, this other substance causes the dopamine to “hang around” in the reward center of the brain a bit longer. For many smokers who try to quit, they experience a relatively brief period of moodiness and cravings, before starting to feel “normal” as a non-smoker.

But for some, stopping smoking produces a more severe withdrawal syndrome, involving a more global loss of satisfaction with life, inability to concentrate, and more severe cravings for a cigarette. These people will find it harder to quit smoking and may obtain greater benefit from use of the FDA-approved smoking cessation medicines.

Here is a link which explains some of these processes in video format:

This post, How Cigarette Nicotine Affects The Brain, was originally published on by Jonathan Foulds, Ph.D..

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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