Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female

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

Select what the PMHNP should do:

• 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
Decision Point One

Campral (acamprosate) 666 mg orally TID
RESULTS OF DECISION POINT ONE

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
Select what the PMHNP should do next:

• Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms
• Discontinue Campral and begin Antabuse (disulfiram) 250 mg orally daily
• Decrease Campral to 666 mg orally BID
Decision Point Two
Decrease Campral to 666 mg orally BID
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Mrs. Perez reports that the suicidal ideation is “still there” but not as bad. She reports that she is still afraid to go to the casino for fear that she may drink, which may cause those “horrible” side effects to come back
Client’s anxiety has also decreased quite a bit since decreasing the dose to twice a day. She reports that she is still smoking cigarettes
Decision Point Three
Select what the PMHNP should do next:
• Discontinue Campral and begin Antabuse 250 mg orally daily
• Discontinue Campral and recommend psychotherapy for her gambling issue
• Add on Wellbutrin (bupropion) XL 150 mg orally daily
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.


Assignment: Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction

Impulsivity, compulsivity, and addiction are challenging disorders for clients across the lifespan. These disorders often manifest as negative behaviors, resulting in adverse outcomes for clients. In your role as the psychiatric mental health nurse practitioner, you have the opportunity to help clients address underlying causes of the disorders and overcome these behaviors. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with impulsivity, compulsivity, and addiction.

Learning Objectives
Students will:
Assess client factors and history to develop personalized therapy plans for clients with impulsivity, compulsivity, and addiction
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for impulsivity, compulsivity, and addiction
Evaluate efficacy of treatment plans
Analyze ethical and legal implications related to prescribing therapy for clients with impulsivity, compulsivity, and addiction
Learning Resources

Required Readings

Note: All Stahl resources can be accessed through this link provided.

https://stahlonline-cambridge-org.ezp.waldenulibrary.org/common_home.jsf

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 14, “Impulsivity, Compulsivity, and Addiction”
https://stahlonline-cambridge-org.ezp.waldenulibrary.org/essential_4th_chapter.jsf?page=chapter14_introduction.htm&name=Chapter%2014&title=Overview%20of%20impulsive-compulsive%20%20disorders#c02598-14-1

Stahl, S. M., & Grady, M. (2012). Stahl’s illustrated substance use and impulsive disorder New York, NY: Cambridge University Press.

To access the following chapter, click on the Illustrated Guides tab and then the Substance Use and Impulsive Disorders tab.

Chapter 10, “Disorders of Impulsivity and Compulsivity”
https://stahlonline-cambridge-org.ezp.waldenulibrary.org/illustrated_images.jsf?page=sudc10_fig.html&name=SUD&imgType=Figure&title=Chapter%2010

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

https://stahlonline-cambridge-org.ezp.waldenulibrary.org/prescribers_guide.jsf

Review the following medications:

For insomnia

For obsessive-compulsive disorder

Citalopram
clomipramine
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
venlafaxine
vilazodone

For alcohol withdrawal

chlordiazepoxide
clonidine
clorazepate
diazepam
lorazepam
oxazepam

For bulimia nervosa and binge eating

fluoxetine
topiramate
zonisamide

For alcohol abstinence

acamprosate
disulfiram

For alcohol dependence

nalmefene
naltrexone

For opioid dependence

buprenorphine
naltrexone

For nicotine addiction

bupropion
varenicline

Book Excerpt: Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders. Treatment Improvement Protocol Series, No. 32. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64350/

Chapter 1, “Substance Use Among Adolescents”
Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”
Chapter 7, “Youths with Distinctive Treatment Needs”

Childhood trauma linked to worse impulse control. (2016). Journal of Psychosocial Nursing & Mental Health Services, 54(4), 15.

https://search-proquest-com.ezp.waldenulibrary.org/docview/1782829190/fulltextPDF/F849A1EAC9664174PQ/1?accountid=14872

Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375-381. doi:10.1111/j.1365-2125.2012.04457.x

https://www-ncbi-nlm-nih-gov.ezp.waldenulibrary.org/pmc/articles/PMC4014021/

Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing, 42(4), 10-15. doi:http://dx.doi.org/10.3928/00989134-20160314-04

https://search-proquest-com.ezp.waldenulibrary.org/docview/1810341157?accountid=14872

Salmon, J. M., & Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in older adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis, 8(1), 74-84. doi:10.1080/15504263.2012.648439

https://web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/detail/detail?vid=0&sid=219f7aa1-3e96-491c-9a46-1439c6767d01%40sessionmgr4007&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=71678483&db=sih

Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., & … Soares, J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry, 55(6), 1337-1341.

https://www-sciencedirect-com.ezp.waldenulibrary.org/science/article/pii/S0010440X14001059?via%3Dihub

Required Media

Laureate Education (2016c). Case study: A Puerto Rican woman with comorbid addiction [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this week’s Assignment.

To prepare for this Assignment:

Review this week’s Learning Resources. Consider how to assess and treat adolescent clients requiring therapy for impulsivity, compulsivity, and addiction.
The Assignment

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?
Quality of Work Submitted:
The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.

Excellent 27 (27%) – 30 (30%)
Good 24 (24%) – 26 (26%)
Fair 21 (21%) – 23 (23%)
Poor 0 (0%) – 20 (20%)
Quality of Work Submitted:
The purpose of the paper is clear.

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