Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay
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.”
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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. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
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. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. 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. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
Diagnosis: Gambling disorder, alcohol use disorder
Decision Point One
Select what the PMHNP should do:
Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the
Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
gluteal region every 4 weeks
Antabuse (Disulfiram) 250 mg orally daily
Antabuse (Disulfiram) 250 mg orally daily
Campral (Acamprosate) 666 mg orally three times/day
Campral (Acamprosate) 666 mg orally three times/day
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
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. Why were they different?
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
In each decision please discuss reason why the other 2 medication were not used, there should be an introduction and a conclusion.
Assessing and Treating Clients with Impulsivity, Compulsivity, and Addiction
Introduction
The focus of this assignment is on Mrs. Maria Perez is a 53-year-old Puerto Rican female who was diagnosed with a gambling disorder, alcohol use disorder. Gambling disorder refers to the repetitive and persistent maladaptive gambling behavior as manifested by preoccupation with gambling; has to gamble with larger sums of money to attain the anticipated excitement; constant unsuccessful efforts to stop or control gambling; irritability when trying to stop gambling; goes back to gambling even after losing money; lies to family and endangers relationships, work, education etc. to gamble, among other symptoms (Calado & Griffiths, 2016). On the other hand, alcohol use disorder is the inability of a person to manage or control their alcohol-intake behaviors in spite of the desire to stop or the alcohol intake jeopardizing their relationships, work, education etc. (Yau & Marc, 2015). The client reported of alcohol and gambling addiction and is also worried about her increased tobacco smoking. MSE for the client indicates that the client is avoiding direct eye contact and is sad as well. Accordingly, in this paper, three decisions will be made on the client’s treatment while considering the pharmacokinetic and pharmacodynamics effects on the client. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
Decision Point One
The first decision that was selected is to administer the client with Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks. The rationale for selecting this decision is based on the fact that naltrexone is a competitive antagonist at addiction/alcohol receptors and therefore inhibits alcohol agonist-induced effects, including the effects the alcohol abusers desire. The medication also represses the desire for alcohol intake (Sullivan et al, 2014). Therefore, Naltrexone (Vivitrol) is an appropriate choice to treat alcohol addiction for the client. Additionally, clinical trials demonstrate the efficacy of Naltrexone in treating alcoholism (Alanis-Hirsch et al, 2016). Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. Moreover, the medication has minimal side effects and therefore the client is likely to tolerate the administered dose with the targeted efficacy.
The option of Antabuse (Disulfiram) 250 mg orally daily was not selected because the medication is associated with numerous serious side effects such as a headache, dyspnea, sympathetic over-activity, palpitations, vomiting, seizure, coma, and even death. Moreover, there is a high risk of toxicity with the medication in addition to the high rate of non-adherence with Disulfiram (Crowley, 2015). On the other hand, the option of Campral (Acamprosate) was not selected because evidence recommends Campral to be used in combination with psychological and social treatment as a component of a full alcohol addiction treatment (Crowley, 2015). In addition, guidelines recommend the medication to be started 5-7 days after the last drink yet the client has not withdrawn from the alcohol. In addition, the 3-times daily dosing regimen with Campral can reduce its adherence (Crowley, 2015). Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
With this decision, the expectation was that the client will gradually reduce her alcohol abuse, and stop craving for alcohol and desire to gamble as well. This is because studies demonstrate the efficacy of Naltrexone (Vivitrol) in lowering the desire to take alcohol as well as in reducing gambling cravings in individuals with gambling disorder. The other expectation was that the client would tolerate the medication and therefore she would not experience any adverse event.
The outcome that was hoped for and the results of the decision were almost similar. This is because after starting Naltrexone (Vivitrol) injection, the client did stop alcohol intake and also there was a reduction in gambling. The only difference is that the client reported complaints about anxiety. The anxiety is a common side effect of Naltrexone (Vivitrol) medication.
Decision Point Two
For decision 2, the decision that was chosen is to add valium (diazepam) 5 mg. This reason for choosing this decision is to treat the anxiety for the client. The medication was selected because valium influences GABA receptors within the brain; the receptors regulate anxiety. Valium influences GABA receptors by slowing the central nervous system which reduced the feelings of anxiety and produces a calming effect and therefore reduced anxiety symptoms (Calcaterra & Barrow, 2014). A study conducted by Warren et al (2016) indicated the efficacy of valium in the treatment of anxiety symptoms. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
The choice to have the client attend counseling for gambling issue was not chosen because this option would not address the anxiety the client is currently manifesting and also the client is already manifesting improvement in regard to gambling. The option of adding Chantix (varenicline) was not chosen due to the many adverse and side effects associated with varenicline, for example, suicide, sleep disturbance, cardiovascular events etc. (Davies et al, 2015).
Selection of this decision aimed to ensure that the symptoms of anxiety that the client is manifesting would improve. This is because the evidence demonstrates the efficacy of valium in improving anxiety symptoms (Warren et al, 2016). Another expectation was that the client would not have a dependency on the medication.
There were no notable differences between the expected results and the actual outcome of the decision. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. The actual outcome was that the symptoms of anxiety considerably improved. The only difference is that the client was asking for higher and frequent doses of the medication indicating a dependency on the medication. The dependency the client is manifesting on valium is because of the addictive effect of valium as a benzodiazepine (Tvete et al, 2016).
Decision Point Three
The chosen decision point three is for the client to continue with Vivitrol dose; taper Valium with the aim to discontinue the medication within the next two weeks and to have the client to counseling for the gambling issue. The reason for selecting the decision to taper valium is to gradually withdraw the medication and discontinue it in two weeks because the client is showing symptoms of dependency on the medication. According to Tvete et al (2016) benzodiazepines such as valium are not supposed to be taken for more than two-four weeks of continuous use since individuals can develop dependency and tolerance even after a short period. The decision to not discontinue valium immediately is because sudden withdraw might have led to the client developing withdrawal symptoms. Evidence and guidelines recommend gradual withdrawal of benzodiazepines in order to avoid patients from experiencing withdrawal symptoms (Fluyau et al, 2018). In addition, this option also involved the client being referred to counseling to help in her gambling addiction. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. Evidence shows that counseling is effective in managing gambling addiction and therefore counseling would have addressed gambling addiction for the client (Choliz, 2018).
Options to continue with the existing Vivitrol dose and maintain or increase the current valium dose were not chosen because the client needs to be tapered off the valium medication because she is already showing dependency on the medication and therefore there is need to gradually withdraw the medication (Warren et al, 2016).
Selecting the decision to continue with Vivitrol dose and taper Valium medication hoped to gradually withdrawal valium for the patient and ensure the client does not develop any valium dependency. Another expectation was that the counseling would address the gambling issue for the client and help reduce the gambling addiction. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
Conclusion
The first decision point for the client was to administer Naltrexone (Vivitrol) injection every four weeks. This decision was selected because Vivitrol has been shown to be effective in the treatment of alcohol addiction. Just like it was expected, the client stopped drinking alcohol and also she stop gambling as frequently as before. Nonetheless, the client manifested anxiety and this was attributable to the side effects of Vivitrol. The second decision was the addition of valium (diazepam) for the treatment of the client’s anxiety symptoms. Just as expected, the anxiety levels for the client reduced. However, the client exhibited a dependency on valium as indicated by her request to increase the valium dose. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. Due to the evidence dependency on valium, the third decision that was selected was to have the current dose of naltrexone maintained while gradually tapering valium dose. This decision was chosen because even though the client is showing dependency on the medication, sudden withdrawal would result in withdrawal symptoms for the client. The third decision also involved referring the client to a counselor to have her gambling addiction issue addressed. Finally, the therapist should maintain the confidentiality of all information that the client disclosed and not divulge the information to any other party without the client’s consent. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
References
Alanis-Hirsch K, Coff R, Ford J, Johnson K, Mady C, Laura S & Dennis M. (2016). Extended-release naltrexone: A qualitative analysis of barriers to routine use. J Subst Abuse Treat. 1(62), 68–73
Calado F & Griffiths M. (2016). Problem gambling worldwide: An update and systematic review of empirical research (2000–2015). J Behav Addict. 1; 5(4), 592–613.
Calcaterra N & Barrow J. (2014). Classics in Chemical Neuroscience: Diazepam (Valium). ACS Chem Neurosci. 5(4), 253–260. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
Choliz M. (2018). Ethical Gambling: A Necessary New Point of View of Gambling in Public Health Policies. Front Public Health. 6(12).
Crowley P. (2015). Long-term drug treatment of patients with alcohol dependence. Aust Prescr. 38(2), 41–43.
Davies N, Taylor G, Taylor A, Thomas K, Frank W, Martin R & Munafo M. (2015). What are the effects of varenicline compared with nicotine replacement therapy on long-term smoking cessation and clinically important outcomes? Protocol for a prospective cohort study. BMJ Open. 5(11): e009665. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.
Fluyau D, Revadigar N & Brittany M. (2018). Challenges of the pharmacological management of benzodiazepine withdrawal, dependence, and discontinuation. Ther Adv Psychopharmacology. 8(5), 147–168.
Sullivan M, Adam B, Mariani J, Glass A, Levin F, Comer S & Nunes E. (2014). Naltrexone treatment for opioid dependence: Does its effectiveness depend on testing the blockade? Drug Alcohol Depend. 133(1), 80–85.
Tvete I, Trine B & Tor S. (2016). A 5-year follow-up study of users of benzodiazepine: starting with diazepam versus oxazepam. Br J Gen Pract. 66(645), e241–e247.
Warren A, Cowen G & Harmer C. (2016). Cognitive mechanisms of diazepam administration: a healthy volunteer model of emotional processing. Psychopharmacology (Berl). 1(233), 2221–2228.
Yau Y & Marc P. (2015). Gambling Disorder and Other Behavioral Addictions: Recognition and Treatment. Harv Rev Psychiatry. 23(2), 134–146. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.