To the Editor: As nicotine is presumed to maintain tobacco addiction, nicotine replacement therapies have been found useful during smoking cessation. Available forms of nicotine replacement include chewing gum, patches, nasal sprays, and vapor inhalers. These forms of treatment avoid the toxins and carcinogens associated with cigarette use. We present an interesting case of nicotine nasal spray misuse.
Mr. A was a 54-year-old man with diagnoses of major depression and alcohol dependence in remission. After being followed for 6 months in the psychiatric clinic, he requested help in discontinuing use of a nicotine nasal spray that he had been using for the past year. Because he could not afford prescription nasal spray, Mr. A had found a commercial source for nicotine on the Internet, which was sold as an insecticide, and he was able to purchase 25 g (1 g/ml solution) for $30.00. Mr. A diluted the nicotine solution with distilled water to 10 mg/ml and then placed the solution into empty spray bottles. He reported that he had used no tobacco since he had begun using the homemade nicotine nasal spray. However, his use of the nasal spray had increased over the past 9 months to two sprays per nostril every hour unless he was asleep, and attempts to decrease use resulted in intense nicotine craving and nicotine withdrawal symptoms such as irritability and mood instability.
Mr. A had had several past antidepressant trials to treat his depressive symptoms and had been stable on a regimen of sertraline, 200 mg/day, and trazodone, 400 mg/day, for the past 3 months. Relevant to his comorbid depression and nicotine dependence was the prior failure of a trial of bupropion to treat his mood disorder. Over 3 days gabapentin was titrated from 300 mg/day to 300 mg t.i.d. to decrease his nicotine withdrawal symptoms. At his next appointment, Mr. A surprisingly reported decreased use of the nasal spray, a decrease in his nicotine craving, and diminished nicotine withdrawal symptoms. He has remained abstinent from the nasal spray for the past 10 weeks at a final dose of 2400 mg/day of gabapentin.
We are unaware of any other reports of the misuse of homemade nicotine nasal spray. Although there is evidence that acute nasal nicotine intake in some smokers may be reinforcing (1), the current case is especially worrisome given the escalating doses of nicotine and ease with which it was obtained. Gabapentin is structurally related to γ-aminobutyric acid (GABA), and in addition to its mood-stabilizing effects, its GABA-ergic activity may help decrease the relapse to nicotine use by blocking the intense withdrawal symptoms and craving that often lead smokers back into tobacco use. Preclinical studies have suggested that agents that can increase GABA may be effective in the pharmacologic treatment of cocaine addiction (2). Further investigation of the use of gabapentin in nicotine dependence is suggested.