CLINICAL CASE 1:
Intense Craving for a Cigarette and Restlessness After Being Cigarette Deprived for 2 Hours
The patient was a 62-year-old male physician seeking definitive treatment for severe tobacco dependence and nicotine addiction. One year previously, he had been able to stop smoking for several months. After a left upper lobectomy for bronchogenic carcinoma, he had resumed smoking because of a severely stressful event in his life. Much to his frustration, he found that he simply could not stop smoking again. Craving for cigarettes was so severe that he could not effectively practice medicine. Thus, much to his frustration, despite several short-lived quitting attempts, he continued smoking.
On the day I first saw him, he had been in my offices for about 2 hours and asked if he could go outside to smoke a cigarette because he noticed he was beginning to have severe cigarette cravings accompanied by marked restlessness. I asked him to wait a few minutes, until after one of my nurses had instructed him in the proper use of nicotine nasal spray and had him demonstrate proper use of the active device. He agreed. When I walked by him in our clinic waiting room about 15 minutes later, he mentioned that, much to his surprise, within 90 seconds after he had given himself the test dose from the active nicotine nasal spray (1 mg of nicotine delivered), he felt his cigarette craving and restlessness simply “melt away.” He pointed out that in the past, only by smoking a cigarette had he been able to dissipate these symptoms so promptly. Not surprisingly, this experience gave him even greater confidence in the treatment plan I was about to outline and in his ability to stop smoking. It was also clinical “proof” to him of what he intellectually knew regarding the biology of nicotine addiction.
CLINICAL CASE 2:
Difficulty Concentrating After Stopping Smoking Cold Turkey
The patient was a 54-year-old white male accountant presenting for tobacco-dependence treatment. He had last tried to stop smoking about 3 years previously, stopping cold turkey on a Monday morning. Due to nicotine withdrawal, he lacked the concentration to understand basic financial spreadsheets, although he had been a practicing accountant for more than 20 years. When he tried to analyze the spreadsheet data, he “only saw a jumble of numbers.” After 4 days of struggling unsuccessfully to practice accountancy, he smoked one cigarette and found that he could immediately think clearly again. His mind was functioning in its usual keen fashion, and he could analyze financial data with his usual skill and ability.
As long as he continued to smoke, he could carry out his professional commitments. Because he really did want to stop smoking, he sought professional assistance to see if he could stop smoking without experiencing this horrendous and disruptive nicotine withdrawal symptom.
I reassured this patient at the initial visit, after he had told me about these concerns, that with current generation medications to treat tobacco dependence, he should be able to function normally, once he stopped smoking, without going through the ordeal he had several years earlier. (And he did.)
CLINICAL CASE 3:
Increased Irritability and Anger After Stopping Smoking Cold Turkey
The patient was a 34-year-old white female management consultant presenting for treatment of severe nicotine withdrawal symptoms of 3 weeks’ duration. The patient had successfully stopped smoking 3 weeks earlier, using a proprietary 1-week group-counseling program. Although she was pleased that she had been able to stop smoking on her own, she was concerned that she was about to lose all of her clients. She indicated that she had lost her usual tact and diplomacy when dealing with clients. Since stopping smoking, she noted that she had become hyperirritable, easily frustrated, and severely short-tempered. She had not been this way before stopping smoking. She had noticed no improvement in these symptoms since onset 3 weeks ago, when she stopped smoking. She decided she should seek treatment after the following episode occurred.
One of her clients was a large multinational hotel chain. She had just attended a daylong meeting with the board of directors to review their annual business development plan. When they made their presentation to her, she found their plan severely lacking. Rather than tactfully pointing out how it could be improved and strengthened, which she would have done before stopping smoking, she bluntly told them how poor it was. Moreover, she found herself shouting at them, telling them she was amazed at their stupidity and shortsightedness. She knew that if she continued in this hotheaded, short-tempered fashion, she would alienate and lose her clients, thus destroying her livelihood.
On the positive side, she noticed that even though she had been off cigarettes for only 3 weeks, her cough had nearly disappeared. Medically, she was feeling much improved, so she did not want to resume smoking. She knew, however, that if she could not regain her usual manner of dealing with her clients, she would have to resume smoking to avoid alienating them. Although the example she had just given me was unusually dramatic, she commented that since she had stopped smoking 3 weeks ago, she felt as if she were sitting on a keg of dynamite and that any little to blow up and start screaming.
I congratulated her on stopping smoking and being cigarette-free for 3 weeks. I also explained to her that she was suffering from classic nicotine withdrawal symptoms: being more irritable, getting frustrated more easily, and becoming short-tempered. Moreover, these symptoms of nicotine withdrawal could be easily treated with a nicotine medication. I prescribed nicotine polacrilex, 4 mg, one piece to be chewed according to package instructions, every hour while awake, aiming for a minimum of 16 pieces per day.
Although the patient was skeptical this would do anything for her, she agreed to try it for a week. When she returned 1 week later, she reported that the day after she saw me, she began using the prescribed nicotine polacrilex daily dosage (approximately 64 mg of nicotine per day, from polacrilex medication). By that afternoon, she felt “95% back to normal.” She reported that this level of mood and functioning had remained. Several days after she had started the medication, she had another major meeting with a different multinational client. At this meeting she felt she was functioning with her usual level of diplomacy, tact, skill, and creativity—all, of course, without needing a cigarette to restore her equanimity.
CLINICAL CASE 4:
Effective Medical Management of Cigarette Slips Due to Acute Work-Related Stress During Tobacco-Dependence Treatment
The patient was a 54-year-old male Silicon Valley CEO presenting for tobacco-dependence treatment because his shortness of breath was interfering with all aspects of his life. He had only mild obstructive airway disease (mixed emphysematous and chronic bronchitic type) by pulmonary function testing but had hypoxemia (SpO2 [oxygen saturation by pulse oximeter], 91%) on room air.
He was smoking one and one-half packs per day and was highly nicotine dependent, on the basis of the Fagerström Tolerance Questionnaire scale, scoring 8 points (maximum, 11 points). He set his Target Quit Date (TQD) for September 13, 1993, using three standard-strength nicotine patches (delivering 45 mg of nicotine per 16 hr). The patient was delighted at how well he did initially. For the first 2 days, he had no nicotine withdrawal symptoms of any kind, including craving for cigarettes. (He also had no signs or symptoms of nicotine toxicity.) As the first week wore on, however, he noticed that he was becoming progressively more irritable. Also, he was becoming plagued by intermittent, incredibly intense, and frequent cigarette urges.
Late in the afternoon of the fourth day after his TQD, in response to severe stress at work, he had three cigarettes in rapid succession. He had no more cigarettes before returning to the clinic about 24 hours later. Because of those slips, however, as well as the increased cigarette craving and irritability, his nicotine patch dose was increased by 33% to four nicotine patches delivering 60 mg of nicotine per 16 hours. Moreover, he was given a prescription for 4 mg of nicotine polacrilex as needed so that he could actively do something immediately to control intense cigarette urges.
Because of the medication changes and the patient’s smoking in response to an acute stress situation, he was seen 10 days later, on September 27, 1993. He had used the four nicotine patches as prescribed and without difficulty. He was also using approximately four pieces of the 4-mg nicotine polacrilex daily, with no side effects whatsoever. The patient reported that after his previous visit on September 17, 1993, within 1 hour of putting on the fourth patch later that day he noted a marked decrease in irritability, anger, and cravings for cigarettes. During the following 10 days, however, he slipped on four separate days, having one cigarette on each of those days. The trigger was generally work-related stress, but one morning he rushed out of his house, forgetting his four nicotine patches. He continued to have intermittent slips, nearly all due to sudden work-related stress, for 6 weeks after his TQD. Finally, after he increased his daily use of 4-mg nicotine polacrilex, while continuing to wear four nicotine patches per day, he was able to stop smoking completely on September 27, 1993. Over the next 6 months, while not decreasing this nicotine patch dose, he slowly tapered off nicotine polacrilex. Then, during the next 4 months, he slowly tapered off his four nicotine patches. Throughout this time, he was seen about every 4 weeks. He knew to call immediately if he had any flare-ups in nicotine withdrawal symptoms, such as cigarette craving, irritability, or anger, as this nicotine dose reduction process was going on. (Of course, if he had a slip and smoked even part of a cigarette, that would be reason for a STAT phone call!)
Finally, 11 months after his quit date, he successfully tapered off all his nicotine medications. He had definitely needed the steady-state serum nicotine level that the four nicotine patches provided, but he also needed to be able to provide his CNS with periodic nicotine boosts, which the 4-mg dose of nicotine polacrilex provided. For approximately 2 months, from October to December 1993, his therapeutic nicotine dose, from both medications, was about 90 mg/day. He needed this dose to control his nicotine withdrawal symptoms and to enable him to stop smoking successfully (dose to therapeutic effect). He had no nicotine toxicity symptoms or adverse events of any kind.