Florence Nightingale was the first nurse researcher. What she brought to the table, from my perspective, is that nurses observe patients and treatments as well as the response to treatments. This observation then leads to questions that warrant further exploration. That is exactly what this issue of "Stories From the Field" covers. It is about a diligent staff nurse who observed practice, developed a hunch, and further explored her hunch. Bravo for taking the next step!

Opioid addiction continues to plaque our society at alarming rates. It inevitably is a pressing topic, and with the rise in overdose, it has been a matter that has politicians, lawmakers, government, police, educators, and even families at the dinner table talking. At this point, who is not talking about it? The question that still remains is what are we doing about it?

Medication-assisted therapies are more frequently being incorporated into residential substance abuse treatment facilities and outpatient treatment centers. More and more programs are incorporating the use of suboxone, naltrexone, and buprenorphine. Working in the field of addiction, I have been able to observe some successful interactions with patients and their use of medication-assisted treatment (MAT).

During clinical practice, I have noticed the physician and his persistent attempt to introduce nicotine cessation with the client while on MAT. Several themes were emerging after watching the physician-and-client interaction. A hunch was formulating, and I was eager to see if there was validity to his theory. His position was that clients who are still smoking will not have the greatest success with MAT. There were also incidental findings during our daily observations that those clients still smoking continued to have greater cravings and were seeking an increase in their treatment regimen. Was this coincidental? I decided to search the literature utilizing two key words in the search bar: "nicotine and opiates." Successfully, I found articles, one in particular, that supported the physician's treatment philosophy. After reading the abstract, I showed the physician that what he was seeing manifesting in some clients was indeed supported by the literature. In fact, with further research on academic search engines, one may find a correlation between nicotine use, persistent relapse, and increased drug cravings while on MAT.

Krishnan-Sarin, Rosen, and O'Malley (1999) examined the use of an opioid antagonist challenge procedure to evaluate responsivity of the endogenous opioid system in nicotine-dependent individuals. This was evidenced by naloxone-induced alterations in both behavioral (craving and withdrawal symptoms) and neuroendocrine (cortisol levels). The results demonstrated that nicotine-dependent subjects evidenced naloxone dose-dependent increases in withdrawal signs and symptoms. Lower doses of naloxone also produced increases in craving and the urge to smoke. The authors also noted tiredness in the smoking group. Smokers had lower prenaloxone baseline levels of cortisol and attenuated cortisol release in response to the challenge with naloxone compared with nonsmokers. The authors concluded that long-term exposure to cigarette smoke is associated with alterations in the responsivity of the endogenous opioid system. This research study supported what the physician and I were observing in the clinical setting. The clients were complaining of withdrawal symptoms and increased drug cravings more so than in those who were not smoking. The results of the study in the article mentioned above revealed that nicotine-dependent subjects evidenced naloxone dose-dependent withdrawal signs and symptoms. The article concluded that long-term exposure to cigarettes is associated with alterations in the responsivity of the endogenous opioid system (Sarin, 1999).

As a result of this finding, the doctor enhanced his care and treatment of his clients by sharing evidence-based information and initiating with the client a smoking cessation program. If the client showed willingness and interest, the doctor implemented immediate measures to begin nicotine replacement. The hope is to gain traction on recovery and sobriety with a successful combination treatment in the absence of the nicotine.

The reality is that many treatment centers do not focus on nicotine dependency as part of the treatment plan. The provision of holistic medical and nursing care should encompass discussion of smoking cessation for clients abusing opioids and those receiving MAT.

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