Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction

Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction

The clinical manifestations of impulsivity and compulsivity are diverse, and they frequently overlap with addiction disorders, which are diseases linked with a lack of impulse control. According to Goslar et al. (2019), obsessive and impulsive conduct difficulties are typically inextricably linked to substance misuse. In the reported example, a 53-year-old Puerto Rican female complains about an unpleasant situation. The patient admits to having alcohol problems since her father’s death when she was in her late teens. Despite having been a member of Alcoholics Anonymous for the previous 25 years, she reports having difficulty keeping her sobriety in the last two years since the opening of a new casino in her area. She also claims to enjoy drinking while gambling to help her relax during big-stakes games. She claims that she frequently loses control of her gambling and drinking habits. She also claims to have increased her smoking over the last two years and is concerned about the potential adverse health implications. She admits to having gained 7 pounds.

The patient is anxious since she borrowed over $50,000 from her retirement account to pay off her gambling obligations. Her mental status exam results suggest that she avoids eye contact, has a melancholy mood, and has poor impulse control. Eventually, the patient is diagnosed with alcohol use disorder and gambling disorder. Various patient characteristics may influence the decision-making process when prescribing medication to the presented patient. The presence of comorbid conditions, such as gambling disorder and alcohol use disorder, is the first issue to consider. This can have an impact on the pharmacological substances and other therapy approaches that are used. The type of drugs used for treatment can be influenced by the patient’s age, weight, and other health-related factors. The primary goal of this paper is to make three judgments regarding the patient’s pharmacologic therapy and the rationale for each decision, as well as to address the ethical considerations that may affect the treatment plan and communication with the patient.

First decision

The best course of action would be to begin treatment with a 380 mg intramuscular Naltrexone injection in the gluteal region every four weeks. According to Anton et al. (2018), Naltrexone, which is FDA-approved for the treatment of alcoholism, is effective in raising the chances of achieving complete abstinence from alcohol, reducing heavy drinking, and reducing the severity of gambling cravings, thoughts, and behavior. The medicine works by inhibiting opiate receptors in the brain, reducing alcohol cravings (Stahl, 2013). Furthermore, this choice is the most advantageous because it is provided only once a month, which increases compliance (Stahl, 2013). Moreover, the medicine would aid in treating nicotine addiction by lowering cravings.

Starting Antabuse (Disulfiram) 250 mg orally every morning is not a possibility at this time because the medicine causes adverse physical effects if alcohol is consumed within 12-24 hours of pharmaceutical use, and it usually is not utilized as first-line treatment (Antonelli et al., 2018). According to Stahl (2013), the medication is an irreversible aldehyde dehydrogenase inhibitor, causing acetaldehyde accumulation when alcohol is consumed. This causes unpleasant sensations such as nausea, flushing, vomiting, and hypotension and may make compliance difficult. Starting Campral (acamprosate), 666 mg orally TID is also not an option because it is only prescribed to treat alcohol addiction and can have unfavorable side effects when provided to those with obsessive habits (Antonelli et al., 2018). The medication also acts as an “artificial alcohol,” impairing a person’s thoughts and behavior (Stahl, 2013).

The patient was expected to report a decrease in her symptoms after starting Naltrexone, including a decreased desire to gamble and go to the casino and a reduced desire to drink alcohol, in addition to the ability to sustain sobriety. According to Anton et al. (2018), Naltrexone not only reduces alcohol intake by reducing reinforcing qualities such as rewarding effects and cravings, but also the severity of gambling drives, gambling behavior, and thoughts. Because she enjoys smoking while playing at the slot machines, the patient’s smoking behavior should improve when her desire to bet decreases. The medicine was also expected to be well tolerated by the patient, with no adverse effects.

Decision No. 2

At this time, the best course of action would be to recommend the patient to a counselor to treat her gambling problem. As can be observed, the patient responded well to Naltrexone after four weeks, as she reported alcohol abstinence and reduced gaming, as seen by the reduced frequency of visits to the casino. The choice to recommend the patient to a counselor is based on data that there are no recognized treatment options for gambling addiction, given that such addictive activities are psychological, and as such, behavioral approaches can considerably aid in their resolution (Grant et al., 2014; Goslar et al., 2019). Although the patient expresses anxiousness, which is a typical adverse effect of Naltrexone, this does not warrant stopping the drug, as Antonelli et al. (2018) say that this side effect is often temporary. Furthermore, even though the patient is still smoking, her smoking behavior is aggravated by gaming; thus, assisting her in abstaining from gambling may also help her reduce her tobacco use. I decided against adding Valium (diazepam) 5 mg orally TID as needed for anxiety because taking one medicine to treat the adverse effects of another is not suggested. Adding Chantix 1 mg PO BID is also not a good idea because the medication should be begun at 0.5 mg each day. As a result, with a larger medicine dosage, the patient is more likely to have adverse effects such as agitation, nausea, and nightmares. Furthermore, the treatment would not affect her gambling addiction, which is the fundamental reason for her increasing smoking behavior.

It was predicted that after continuing Naltrexone and referring the patient to a counselor to help her address her gambling concerns, the patient would report a steady decline in his gambling and drinking behavior. According to Stahl (2013), the effects of Naltrexone can be observed in a few days, but the maximum effects may not be seen for several weeks. As a result, I hoped to give the medicine a chance to assist the patient with his drinking and smoking issues. It was also expected that the patient would report less anxiousness. The patient said that her anxiety had subsided after four weeks and that she had visited a counselor who did not like her. She also stated that she had begun attending local Gamblers Anonymous meetings, which she found beneficial.

Decision#3

At this stage, the best action is to discuss the patient’s concerns with her counselor and encourage her to continue attending Gamblers Anonymous meetings. This is based on data indicating a good therapeutic alliance is critical for promoting treatment compliance, and an evil therapeutic partnership between patients and counselors can result in therapy discontinuation (Nienhuis et al., 2018). Given that counseling is the cornerstone treatment for gambling addiction, discontinuing therapy for the patient would reduce the likelihood of remission of the gambling problem. Furthermore, while the patient reports perceived positive support from the Gamblers Anonymous sessions, it would be advisable to encourage her to continue participating.

I decided not to encourage the patient to continue seeing the counselor while attending the support group because it was not the most excellent option. The patient raised worries about his disdain for the counselor, stating that continuing without addressing the issue would likely result in disobedience or termination of therapy. I also chose not to stop abuse and encouraged her to continue seeing the counselor and attending support group meetings because it would be inappropriate. First, there is no reason to discontinue the drug because the stated side effects were subsided, and the patient was already responding well. As a result, the most suitable approach would be to discuss and resolve the patient’s concern with the counselor to maximize treatment compliance.

Given that the patient is already responding favorably to the medication and support group, it was predicted that her desire to drink, smoke, and gamble would continue to decline. The ultimate goal of treatment would be to quit drinking and smoking and stop gambling (Martinac et al., 2019). The patient was also expected to stick with therapy and continue seeing the therapist. Finally, the patient was expected to continue to tolerate the drug well and without experiencing any adverse effects.

Moral considerations

Several ethical problems were examined during the patient’s treatment. First, the ethical principles of beneficence and nonmaleficence were reviewed in making the best treatment decisions. For example, it was verified that all pharmaceuticals were examined for their associated risks vs. benefits. The medications or therapies chosen would result in the best possible outcomes with the fewest adverse effects (Clarke, 2019). Furthermore, the bioethical concept of veracity requires that patients be given thorough, accurate, and impartial information regarding their medical situations (Clarke, 2019). In this scenario, it was critical to tell the patient about the efficacy of Naltrexone and the medication’s potential adverse effects. Various ethical considerations that could impact the treatment approach were also recognized. The patient kept borrowing money to pay off her bills hidden from her husband, which could jeopardize therapy. Given the importance of social support in treating mental and behavioral illnesses, the patient would have been better able to address her gambling problem if she had revealed the secret to her husband, who is part of her social support system. While the nurse wishes to assist the client in improving her social support system, she must also adhere to the principle of confidentiality and so keep the secret revealed to the client private (Clarke, 2019).

Conclusion

The case involved a 53-year-old Puerto Rican woman with drinking, gambling, and smoking issues. Based on an evaluation of the available treatment options, the first decision was to begin Naltrexone, which is beneficial in lowering alcohol cravings, addiction, and tobacco cravings (Anton et al., 2018). The drug worked effectively for the patient, who reported abstinence from alcohol following the first dose. The second decision involves recommending the patient to a counselor to assist her in dealing with her gambling issues. The core of gambling addiction therapy and counseling is (Goslar et al., 2019). Because the recommended drug addressed the other two cases, this was intended to assist the patient in addressing her gambling addiction.

The third decision involves discussing the patient’s problems with her therapist and urging her to continue attending Gamblers Anonymous sessions. This was done to identify and address difficulties in her relationship with her therapist to support treatment compliance (Nienhuis et al., 2018). Furthermore, because the patient reported positive support from her Gamblers Anonymous meeting peers, it was reasonable to urge her to continue participating. There was no need to discontinue the medicine because the patient claimed that the anxiety linked with Naltrexone had gone away and that he was responding well.

References

Anton, R. F., Latham, P. K., Voronin, K. E., Randall, P. K., Book, S. W., Hoffman, M., & Schacht, J. P. (2018). Nicotine use/smoking is associated with the efficacy of Naltrexone in the treatment of alcohol dependence. Alcoholism: Clinical and Experimental Research, 42(4), 751–760.

Antonelli, M., Ferrulli, A., Sestito, L., Vassallo, G. A., Tarli, C., Mosoni, C., … & Addolorato, (2018). Alcohol addiction-the safety of available approved treatment options. Expert opinion on drug safety, 17(2), 169-177.

Clarke, L. (2019). Challenging ideas in psychiatric nursing. Routledge.

Goslar, M., Leibetseder, M., Muench, H. M., Hofmann, S. G., & Laireiter, A. R. (2019). Pharmacological treatments for disordered gambling: a meta-analysis. Journal of Gambling Studies, 35(2), 415-445.

Grant, J. E., Odlaug, B. L., & Schreiber, L. R. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375-381.

Martinac, M., Karlović, D., & Babić, D. (2019). Alcohol and Gambling Addiction. In Neuroscience of Alcohol (pp. 529-535). Academic Press.

Nienhuis, J. B., Owen, J., Valentine, J. C., Winkeljohn Black, S., Halford, T. C., Parazak, S. E., … & Hilsenroth, M. (2018). A meta-analytic review of the therapeutic alliance, empathy, and genuineness in individual adult psychotherapy. Psychotherapy Research, 28(4), 593-605.

Stahl, S. M., & Stahl, S. M. (2013). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge University Press.

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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 for this client. Consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

You should evaluate all options at each decision point before deciding and moving throughout the exercise. Before deciding, ensure you have researched each vote and considered the conclusion you will select. Be sure to research each option using the primary literature.

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?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• 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.

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.
• 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.

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.
• 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.

Conclusion (1 page)

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