BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”

SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health.

She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

Diagnosis: Gambling disorder, alcohol use disorder

Decision Point One

Antabuse (Disulfiram) 250 mg orally every morning ON 

Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

Antabuse (Disulfiram) 250 mg orally daily

Campral (Acamprosate) 666 mg orally three times/day

E

·  Client returns to clinic in four weeks

·  Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

·  Clientis She is also reporting that she is having “out of control” anxiety.. 

Decision Point Two

Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms

RESULTS OF DECISION POINT TWO Decision Point Two

Select what the PMHNP should do next:

Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety

Refer to a counselor to address gambling issues

Add on Chantix (varenicline) 1 mg orally BID

• Client returns to clinic      in four weeks
• Mrs. Perez reports that      when she first received the valium, it helped her tremendously. She states      “I was like a new person- this is a miracle drug!” However, she reports      that she has trouble “waiting” between drug administration times and      sometimes takes her valium early. She is asking today for you to increase      the valium dose or frequency
• Although she reports that      her anxiety is gone, she still reports suicidal ideation, but states “with      that valium stuff, who cares?”;;;;;;;; 
• Decision Point Three
•  
   
• Add on Wellbutrin (bupropion) XL 150 mg orally daily
• Guidance to Student

   

• Given her weight (less than 60      kg), Campral should have been started at 666 mg orally BID. It is possible      that the higher dose may be responsible for the severity of the symptoms      that Mrs. Perez is experiencing.
• Technically, the drug should      have been stopped (not simply decreased) once Mrs. Perez reported suicidal      ideation. Even with the decrease in dose, she is still having suicidal      ideation, which indicates the need to discontinue the drug. Although      controversy exists regarding how long to use pharmacologic approaches to      treatment of alcohol dependence, 8 weeks is probably insufficient,      therefore, the drug should not simply be discontinued without using a      different agent in its place.
• Mrs. Perez should be started on      Antabuse at 250 mg orally daily and referred to psychotherapy to address      her gambling issue.
• In all cases, the PMHNP needs      to discuss smoking cessation options with Mrs. Perez in order to address      the totality of addictions and to enhance her overall health. The decision      to begin Wellbutrin XL 150 mg orally daily may help achieve this goal, but      this choice does not address her abstinence from alcohol.
• Additionally, it should be      noted that although Mrs. Perez reports that she has been avoiding the      casino secondary to her fear that she will drink, this “fear” has not      actually treated her gambling addiction. This particular addiction has      resulted in considerable personal financial cost to Ms. Perez. Mrs. Perez      needs to be referred to a counselor who specializes in the treatment of      gambling disorder, and she should also be encouraged to establish herself      with a local chapter of Gamblers Anonymous.
• Examine Case Study: A      Puerto Rican Woman With Comorbid Addiction. You will be asked to make      three decisions concerning the medication to prescribe to this client. Be      sure to consider factors that might impact the client’s pharmacokinetic      and pharmacodynamic processes.
• At each decision point stop to      complete the following:
• Decision #1
• Which decision did you select?
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #1 and the results of the      decision. Why were they different?
• Decision #2
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #2 and the results of the      decision. Why were they different?
• Decision #3
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #3 and the results of the      decision. Why were they different?

edit this or redo other assignment. 

Assessing and Treating Clients with Impulsivity, Compulsivity and Addiction 

Pharmacotherapy practice to treating substance use disorders is often referred to as medication assisted treatment (MAT) (Sharp et al., 2018). In this practice, specific medications approved by Federal Drug Administration (FDA) are used in combination with counseling and behavioral therapies in treatment of a substance use disorder (Sharp et al, 2018) Medications can reduce the cravings and other symptoms associated with withdrawal from a substance by occupying receptors in the brain associated with using that drug (agonists or partial agonists), block the rewarding sensation that comes with using a substance (antagonists), or induce negative feelings when a substance is taken ( SAMHSA, 2016). MAT has been primarily used for the treatment of opioid use disorder but is also used for alcohol use disorder and the treatment of some other substance use disorders. This paper focuses on pharmacotherapy approaches to treatment of alcohol use disorder, gambling disorder and smoking addiction in a 53 year- old female of Puerto origin. 

Case Scenario 

Decision Number One

Naltraxone (Vivitrol) injection, 380 mg intramuscularly in gluteal region every four weeks.

Rationale: Pharmacotherapy should be used in patients with alcohol use disorder who have current, heavy use and ongoing risk for consequences from use, motivated to reduce alcohol intake and do not have medical contraindications to the individual drug choice (SAMHSA, 2016). As the 53 year-old female has acknowledged that she has a drinking problem and has tried psychosocial approach with alcoholic anonymous(AA) without success, adding medication such as naltrexone would be warranted as next step. In random clinical trials (RCTs) naltrexone medication has been shown to reduce heavy drinking and enhance the likelihood of abstinence ( Garbutt et al.,  2014)

 Naltraxone is mu opioid receptor antagonist, can be in form of oral ( Revia) and injection( Vivitrol) ( Stahl, 2017). Naltraxone is FDA approved to treat alcohol dependence, blockade of effects of exogenously administered opioids (oral) and prevention of relapse to opioid dependence (Stahl, 2017).  Naltrexone reduces alcohol consumption through modulation of opioid systems, thereby reducing the reinforcing effects of alcohol and opioids (cravings, rewarding effects). Moreover, naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress ethanol consumption. 

The recommended naltrexone injectable (vivitrol) suspension is 380mg and should be administered via intramuscular (IM)injection to the gluteal area using the provided 1.5 inch 20-gauge needle(Drugs.com, 2017).  Vivitrol is extensively metabolized in humans, and elimination half-life of naltrexone via injection is 5–10 days (Drugs. com, 2017) Common side effects of naltrexone are nausea, headache, and dizziness, joint or muscle pain which subside with continued use. Special considerations include that vivitrol should not be given to patients taking opioids, and if opioids are required to treat pain, naltrexone should be discontinued. Naltrexone is contraindicated in acute hepatitis or liver failure. 

The advantage usage is that naltrexone can be initiated while the individual is still drinking (Canidate et al., 2017) This allows treatment for alcohol use disorder to be provided in community-based practice at the point of maximum crisis without the need for enforced abstinence or detoxification, thus beneficial for the client. Additionally, depot preparations of naltrexone may improve adherence by reducing the frequency of medication administration from daily to monthly and by achieving a steady therapeutic level of medication, thus avoiding peak effects that can exacerbate adverse events.

  The reason I did not select disulfiram (Antabuse) which by intent leads to adverse effects ( nausea, vomiting, metallic taste, tachycardia) when combined with alcohol intake, was that it  should only be used by abstinent patients in the context of treatment intended to maintain abstinence. In regards of Acamprosate, I did not select the medication because research indicates that Acamprosate should be used once abstinence is achieved (Yahn, Witterson, & Olive, 2013). 

The main goal of prescribing medication for treatment for alcohol use disorder is abstinence, which remains a primary treatment focus. However, decrease of heavy drinking can be accepted as an alternative treatment goal, especially if unwanted risks (health, social and financial) are reduced. 

The client returns four weeks after the injections, she has been sober since receiving injection, she denies any side effects from medications. The main chief complaint is gambling, but client is also concerned about her smoking and anxiety. 

  Decision Two

  Refer to a Counselor for Gambling Issues 

Rationale:  Several different types of therapy are used to treat gambling disorder, including cognitive behavior therapy, psychodynamic therapy, group therapy and family therapy (American Psychiatric Association, 2016) As recent, there is no FDA approved pharmacotherapy for gambling disorder. But, pharmacotherapy approaches for problem gambling can be effective when directed toward the patient’s comorbid psychiatric condition such as bipolar disorder, obsessive compulsive disorder(OCD), and substance abuse.  

  The client was concerned about her smoking and appeared to be motivated to stop smoking, hence adding medication to assist her to quit would have been a reasonable approach to avoid health complications (e.g cardiovascular, pulmonary) associated with smoking. However, I did not select the answer as the starting dosage (Varenicline 1mg PO BID) was slightly higher than recommended starting dose. Initial 0.5 mg/day; after 3 days increase to 1 mg/day in two divided doses; after 4 days can increase to 2 mg/day in two divided dose(Stahl, 2017) . Starting at a higher would have increased the possibilities of adverse effects such nausea, vomiting and even agitation.  

  Adding Diazepam (Valium) would not be a good option, as Valium is an addictive benzodiazepine with longer-lasting effects than other drugs in its class. In the light of the client’s history substance use disorder and addiction, adding another addictive substance such as valium would cause more harm. 

The client returns in four weeks, reports that anxiety has gone. Client reports not liking the therapist, but she has joined gambling anonymous group.

Decision Number Three

 Explore the issue that Mrs Lopez is having with her counselor, and encourage her to continue attending Gamblers Anonymous meetings

Rationale: Despite that Mrs. Lopez did not have a good relationship with the counselor, but she remained committed to fighting her addiction by joining Gamblers Anonymous group. Still, counseling remains the main approach in gambling addiction treatment, hence exploring the issues that Mrs. Lopez had with counselor would help to guide the next step in treatment. Also, smoking cessation needs to be explored at this time. Assessing the client’s willingness to quit is the first step as smokers differ in their readiness to change their tobacco use (Niaura, 2017). Understanding the smokers’ perspectives is essential to providing useful assistance. 

Ethical and Legal Implications in Prescribing Medications to Treat Substance Use Disorders.

 In order to optimize care of clients with substance use disorder, health professionals are encouraged to learn  and appropriately use routine screening techniques, clinical laboratory tests, brief interventions, and treatment referrals ( Garbutt, 2014). Using screening tools such as CAGE Questionnaire for alcohol use dependence, would be ideal in guiding treatment approach. Additionally, client’s autonomy and confidentiality must be maintained before prescribing medications to treat an addiction. When a legal or medical obligation exists for  a health professional to test clients for substance use disorder, there is an ethical responsibility to notify clients of this testing and make a reasonable effort to obtain informed consent ( Garbutt, 2014)

References

American Psychiatric Association. (2016). What Is Gambling Disorder? Retrieved from https://www.psychiatry.org/patients-families/gambling-disorder/what-is-gambling-disorder

Canidate, S. S., Carnaby, G. D., Cook, C. L., & Cook, R. L. (2017). A Systematic Review of Naltrexone for Attenuating Alcohol Consumption in Women with Alcohol Use Disorders. Alcoholism: Clinical and Experimental Research, 41(3), 466-472. Retrieved from https://web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=14&sid=183cffb8-9da8-48b2-a1b7-66c14f735856%40sessionmgr101

Drugs.com. (2017). Vivitrol Dosage Guide – Drugs.com. Retrieved from https://www.drugs.com/dosage/vivitrol.html

Garbutt, J. C., Greenblatt, A. M., West, S. L., Morgan, L. C., Kampov-Polevoy, A., Jordan, H. S., & Bobashev, G. V. (2014). Clinical and biological moderators of response to naltrexone in alcohol dependence: a systematic review of the evidence. Addiction, 109(8), 1274-1284. Retrieved from https://web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=8&sid=41ca863e-175d-45ae-ba36-43317c3c58e5%40sessionmgr4008

Niaura, R. (2017). Learning From Our Failures in Smoking Cessation Research | Nicotine & Tobacco Research | Oxford Academic. Retrieved from https://academic.oup.com/ntr/article/19/8/889/3888613

SAMHSA. (2016). Treatments for Substance Use Disorders | SAMHSA – Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/treatment/substance-use-disorders

Sharp, A., Jones, A., Sherwood, J., Kutsa, O., Honermann, B., & Millett, G. (2018). Impact of Medicaid Expansion on Access to Opioid Analgesic Medications and Medication-Assisted Treatment. American Journal of Public Health, 108(5), 642-648. Retrieved from https://web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=5&sid=21e9426c-0afa-475e-9a9a-e1872d98830d%40sess

Stahl, S. M. (2017). Essential psychopharmacology: The prescriber’s guide : antipsychotics and mood stabilizers. Cambridge: Cambridge University Press.

Yahn, S. L., Watterson, L. R., & Olive, M. F. (2013). Safety and Efficacy of Acamprosate for the Treatment of Alcohol Dependence. Substance Abuse: Research and Treatment, 7. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3565569/

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