A Puerto Rican Woman With Comorbid Addiction

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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.(Comorbid Addiction Essay Example)

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.(Comorbid Addiction Essay Example)

Introduction to the case (1 page)

·       Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

·       Which decision did you select?(Comorbid Addiction Essay Example)

·       Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.(Comorbid Addiction Essay Example)

·       Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.(Comorbid Addiction Essay Example)

·       What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).(Comorbid Addiction Essay Example)

·       Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

·       Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.(Comorbid Addiction Essay Example)

·       Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.(Comorbid Addiction Essay Example)

·       What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

·       Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

·       Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.(Comorbid Addiction Essay Example)

·       Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

·       What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

·       Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.(Comorbid Addiction Essay Example)

Conclusion (1 page)

·       Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

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Comorbid Addiction Essay Example-solution

The present case involves a 53-year-old Puerto Rican female presenting an “embarrassing” problem. She has borrowed $ 50000 from her retirement account to ease her gambling debts without her husband knowing. The patient had a persistent problem with alcohol use since her teenage years when her father died. She reports struggling with alcohol abuse since her 20s. She reports being occasionally involved with Alcoholics Anonymous for the last 25 years. However, she has had trouble maintaining sobriety in the past two years with the opening of a casino near her home. She reports being hooked on the casino and getting high when gambling. She enjoys drinking while gambling to help her keep calm when she takes highly. With high stakes, she drinks more and gambles recklessly. Besides, she has increasingly smoked in the last two years and is worried about the health effects. Although she attempts to cease drinking, her gambling makes it difficult to avoid a few drinks. She reports less smoking with alcohol. She enjoys smoking while gambling at slot machines. She reports a 7 lb weight gain. During the mental examination, she avoids eye contact and has no significant gestures or ticks. She reports being sad and has impaired impulse control.(Comorbid Addiction Essay Example)

The client is diagnosed with gambling and alcohol use disorder (AUD). The presented symptoms meet the diagnostic criteria for gambling and alcohol use disorder. For an individual to be diagnosed with gambling disorder, they must present a recurring and persistent gambling behavior that causes distress and impairment in 12 months. Individuals present symptoms such as the desire to gamble with more money, restlessness associated with the need to stop gambling, unsuccessful attempts from stopping gambling, feelings of distress, the need to get even after loss, dependence on others to relieve desperate financial situations, loss/jeopardized social/occupational/academic relationships, and lies from hiding gambling. On the other hand, AUD is characterized by a pattern of alcohol consumption that causes distress and impairment in 12 months. Affected individuals present symptoms such as large amounts of alcohol consumption, unsuccessful attempts to cut down alcohol consumption, craving for alcohol, more time spent seeking to consume alcohol, tolerance for alcohol abuse, continued alcohol abuse despite known effects, and failure in social/occupational/recreational activities.(Comorbid Addiction Essay Example)

Decision #1

The first decision was Vivitrol (Naltrexone) injection, 380 mg intramuscularly, in the gluteal region every four weeks. The client presented primary alcohol use disorder (AUD) symptoms, and Naltrexone is FDA-approved for treating AUD. Naltrexone has been proven effective in treating individuals diagnosed with AUD (Malone et al., 2019). Naltrexone binds to mu-opioid receptors, blocking opioid effects, reinforcing the effect of alcohol, and reducing alcohol cravings. Moreover, studies have shown that Naltrexone reduces the number of drinking days and promotes beneficial effects with abstinence in individuals diagnosed with AUD (Suny, 2018).(Comorbid Addiction Essay Example)

The other two options, Antabuse (disulfiram) 250 mg orally daily and Campral (acamprosate) 666 mg orally three times/day, were not selected. Naltrexone and disulfiram are equally effective in reducing alcohol intake, managing alcohol cravings, and managing relapse in individuals diagnosed with AUD (Adhikari et al., 2020). Compared to Naltrexone, disulfiram is not equally tolerable among individuals diagnosed with AUD. On the other hand, acamprosate has lower efficacy in treating individuals with AUD compared to disulfiram and Naltrexone. Moreover, the efficacy of acamprosate cannot be improved by adding other active medications or psychosocial treatment (Kirkeby & Satre, 2019). Therefore, Naltrexone was the ideal choice of medication at this point.(Comorbid Addiction Essay Example)

Naltrexone was chosen to help the client lower her alcohol intake and reduce her craving for alcohol. The ethical consideration at this point is informed consent. As a PMHNP, it is crucial to explain to a client their condition, the available medication, the benefits, and the side effects. All forms of Naltrexone have an FDA black box warning related to their hypertonicity, which is associated with higher doses of Naltrexone (Ribeiro et al., 2021). Therefore, patients should be warned of the possible side effects and informed to seek medical attention whenever they experience specific symptoms associated with hepatic injury. Moreover, Naltrexone can exacerbate withdrawal symptoms from exogenous opioids. Therefore, a PMHNP should uphold nonmaleficence by ensuring that clients are free from opioids for at least seven days before initiating naltrexone therapy to reduce potential side effects.(Comorbid Addiction Essay Example)

Decision #2

At this stage, the decision is to refer the client to a counselor to address the gambling issues. There is no FDA-approved medication for gambling. Non-pharmacological interventions, including motivational interviewing and cognitive behavioral therapy, are primarily recommended. Through counseling, individuals can receive motivational intervention therapy that focuses on themselves, helping them discover and resolve gambling-related issues, and enhancing their willingness to change their behavior (Ribeiro et al., 2021). Traditionally, counselors do not embody judgments, confrontations, or adversaries toward affected individuals. Furthermore, the outcome of the initial decision showed an effective response to medication, as the patient reported not taking alcohol during the four weeks. However, the client reported persistent gambling at a high financial cost and smoking, which concerns her. She also reports anxiety.(Comorbid Addiction Essay Example)

The other decision, adding Valium (diazepam) 5 mg orally TID/PRN/anxiety or Chantix (Varenicline) 1 mg orally BID, was not ideal. Valium is a benzodiazepine that is contraindicated for individuals taking other central nervous system depressants, including alcohol (Bounds & Nelson, 2021). Moreover, benzodiazepines cannot be used in long-term treatment, the potential of abuse is high, and is associated with dosage increase to achieve desirable effect. Despite being effective in treating tobacco addiction (Burke et al., 2016), Varenicline was not ideal since the client reported smoking when gambling. Therefore, the concern at this point was to manage the client’s gambling issue. Besides, Varenicline is associated with side effects, including agitation, hostility, and depressed mood.(Comorbid Addiction Essay Example)

I hoped to help the client manage her gambling addiction by recommending a counselor. The appropriate ethical consideration at this point is patient autonomy and therapeutic alliance. Counselors promote collaboration, autonomy, and intrinsic motivation to promote the desire to quit alcohol consumption (Ribeiro et al., 2021). Informing the client that anxiety is a salient effect of medication that would diminish with time and the need to join a local Gamblers Anonymous group will help establish and maintain the therapeutic alliance.(Comorbid Addiction Essay Example)

Decision #3

The decision at this point was to explore the issue Mrs. Perez is having with her counselor and encourage her to continue attending the Gamblers Anonymous meetings. The client still responds well to medication, does not experience anxiety, and feels supported in the Gamblers Anonymous group. However, the client reports issues with her counselor, who suggests broken therapeutic. The therapeutic alliance is central to treatment adherence (Hartley et al., 2020). Therefore, exploring the issues with the client was paramount at this stage.(Comorbid Addiction Essay Example)

It was not ideal for encouraging the client to continue with her current counselor and the Gamblers Anonymous group without addressing her concerns with the counselor. Moreover, it was not ideal to discontinue Vivitrol, continue meeting with her counselor, and participate in the Gamblers Anonymous group without exploring her issues with the counselor. Other than exploring the client’s issues with her counselor, Gamblers Anonymous is associated with effectively managing to gamble (Schuler et al., 2016). Besides, it is cost-effective and widely available.(Comorbid Addiction Essay Example)

The decision to explore the client’s issues with the counselor was to improve therapeutic alliance and promote the benefit of seeking counseling for her gambling problem. Understanding that there is no pharmacological intervention for gambling (Malone et al., 2019), the client-counselor relationship was central to mitigating the client’s gambling issues. At this point, the ideal ethical considerations were maintaining the patient’s autonomy by providing them with relevant information to allow them to contribute to her care based on informed opinion. Besides, discussing smoking cessation options with the client is relevant in addressing all her addictions and promoting overall well-being.(Comorbid Addiction Essay Example)

Conclusion

The patient’s primary symptoms meet the diagnostic criteria for gambling and alcohol use disorder. The patient presents persistent gambling affecting her financial position and could interfere with her relationship with her husband. She finds it challenging to cease gambling. Besides, the client presents an alcohol abuse pattern characterized by large amounts of alcohol abuse and cravings for alcohol. Although not proposed, the client presents symptoms of tobacco addiction stemming from gambling issues.(Comorbid Addiction Essay Example)

In the first stage, Naltrexone was chosen, considering the FDA recommends it for managing s AUD. Besides, the medication has a high safety profile and effectiveness compared to other medications such as acamprosate and disulfiram. In the second stage, referring the client to a counselor was ideal, considering her persistent gambling problem. The client had responded positively to medication and had reported not taking alcohol during the period. Diazepam and Venerecilin were not considered at this stage since the presenting concern for the patient was gambling, resulting in smoking.(Comorbid Addiction Essay Example)

Lastly, exploring the client’s issues with the counselor was ideal to ensure an appropriate therapeutic alliance. At this stage, the therapeutic alliance was crucial to ensure the client benefited from counseling for her gambling issues. Moreover, discussing with the client on smoking cessation options was crucial in ensuring the client’s addictions were managed in totality. Ethical concerns, including informed consent, autonomy, and appropriate communication, were central to successfully treating the patient’s addictive disorders.(Comorbid Addiction Essay Example)

References

Adhikari, S., Tulachan, P., Ojha, S. P., Chapagai, M., Dhungana, S., & Pant, B. (2020). Comparison of Disulfiram and Naltrexone in Cases of Alcohol Dependence Syndrome. Ethnicity, 36(92.3), 0-602. https://doi.org/10.33314/jnhrc.v18i1.1921

American Psychiatric Association (APA). (2019). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing

Bounds, C. G., & Nelson, V. L. (2021). Benzodiazepines. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470159/

Burke, M. V., Hays, J. T., & Ebbert, J. O. (2016). Varenicline for smoking cessation: a narrative review of efficacy, adverse effects, use in at-risk populations, and adherence. Patient Preference and Adherence, 10, 435. https://doi.org/10.2147%2FPPA.S83469

Hartley, S., Raphael, J., Lovell, K., & Berry, K. (2020). Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance. International Journal of Nursing Studies, 102, 103490. https://doi.org/10.1016%2Fj.ijnurstu.2019.103490

Kirkeby, B., & Satre, T. (2019). Does the combination of Naltrexone and acamprosate relieve long-term abstinence rates over either treatment alone in patients with alcohol use disorder? Evidence-Based Practice, 22(5), 25. 10.1097/EBP.0000000000000270

Malone, M., McDonald, R., Vittitow, A., Chen, J., Obi, R., Schatz, D., … & Lee, J. D. (2019). Extended-release vs. oral Naltrexone for alcohol dependence treatment in primary care (XON). Contemporary Clinical Trials, 81, 102-109. https://doi.org/10.1016/j.cct.2019.04.006

Ribeiro, E. O., Afonso, N. H., & Morgado, P. (2021). Non-pharmacological treatment of gambling disorder: a systematic review of randomized controlled trials. BMC Psychiatry, 21(1), 1-15. https://doi.org/10.1186/s12888-021-03097-2

Schuler, A., Ferentzy, P., Turner, N. E., Skinner, W., McIsaac, K. E., Ziegler, C. P., & Matheson, F. I. (2016). Gamblers Anonymous as a recovery pathway: A scoping review. Journal of Gambling Studies, 32(4), 1261-1278. https://doi.org/10.1007%2Fs10899-016-9596-8

Suny, U. (2018). Naltrexone for the treatment of alcohol use disorder in the primary care setting. US Pharm, 43(8), 26-33. https://www.uspharmacist.com/article/naltrexone-for-the-treatment-of-alcohol-use-disorder-in-the-primary-care-setting