It's like, on one hand you need the patient to understand this is often a long uncomfortable road, but without them giving up.
The psychological truly is the longest lasting, and for that reason for many, hardest part. Once the physical withdrawal wears off, yes, the patient will find themselves going hours without thinking about using, which before would have been unthinkable. But because of the psychological aspects that usually isn't the end of it quite that quickly for many.
I was a "habit" or ritual smoker, so for me dozens of little normal things you do every day I had associated with tobacco, from driving to after a meal to going to bed at night. I had to remind myself that my brain had once been capable of doing all these things without tobacco in the past, and could certainly "re-learn" to do all those things again without in the future. But it takes time.
In the case of self-medicating for anxiety or other issues, this may be more difficult because time alone may not lead to a waning and an adaptation to "normal" life, where eventually all the discomfort associated with quitting goes away on its own with time.
This happens frequently with drinking as well.
You may have to formulate this as giving up one problem (the substance and all it does) for another. I think it's key to let people know a few things in this case. The substance was covering up the issue, while making the underlying issue itself worse (withdrawal anxiety), as well as giving you all the other problems from the substance. Now you are experiencing more discomfort as you re-learn to live without, note the underlying issue, and have to learn to cope not only without that substance in "normal life" (like eating without using the substance) but also cope with discomforts like anxiety. If there's an organic piece to that, you may need some other medication, and certainly there are psychological elements that may response to cognitive therapy and the like.
It's important to note, that the increased discomfort and anxiety often lessens greatly with time and nothing else, and you have to sort of wait and see how much you're left with and is persistent. For the persistent piece, you have a choice to go back to smoking, or treat the persistent piece.
Treating the persistent piece of anxiety continuing is outside my wheelhouse.
Also, the continued NRT can also be contributing to this, actually. For whatever reason the patient had self titrated to eighty some odd milligrams a day, and that may not just be coincidental. It may take that much for them not to be uncomfortable on this drug.
Also, if someone is having issues with cravings and rebound anxiety, this may never be fully resolved as long as they take any amount of the drug that isn't "enough." Sometimes the only way to break the cycle is to get off NRT entirely, because being on NRT doesn't change the pharmacodynamics of the very short half life and tolerance and micro-withdrawal and all the rest.
If you want the brain to really adapt to life without nicotine, then at some point you have to be without nicotine. The big issue here is it obviously carries with it the huge danger of total relapse back to full blown tobacco use.
If someone can maintain on NRT, then sure, do that. If they can't, and are at significant risk of relapse, or, if you think that you could get them back to NRT without them going back to tobacco if total nicotine abstinence doesn't work, then you might want to try total abstinence at some point, if the NRT really really isn't cutting it.
This is similar to how many people find they do better with absolutely zero alcohol than with mild or moderate use.
It's not just about a totalitarian response for psychological reasons. Some people's brains are better able to learn to adapt on a molecular basis, to being without a substance, if they are totally without the substance. The problem is that it can take up to years sometimes to see how much recovery will take place, as it does for other neurologically based issues. While most recovery is made within a short time of an event like quitting smoking or stroke, it doesn't end there.
Someone with underlying anxiety issues may never be comfortable with only little tastes of the drug they self medicate with, is the point. Something else may need to be done at some point, and total abstinence may be a piece of that.
It's a problem that isn't solved just with replacement therapy, or abstinence, or even time. It can take lots of time and it can take other treatments to deal with underlying mood issues and psychological coping issues. Much like recovery from say stroke or something, frequently it takes a lot of things to adjust (therapy, changing the environment, tolerating discomforts, etc). There may be a role for pharmacology and there certainly probably is one for other therapies.
