Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction

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Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction

The case under this assessment is of a 53-year-old female of Puerto Rican descent presenting to the clinic with complaints of experiencing an “embarrassing problem.” She has been having problems with alcohol since her late teenage; she has been struggling with alcohol since her 20s and has been on and off for over 25 years. Her onset of drinking followed the death of her father. In the past two years, and since the opening of a new casino in her neighborhood, she has been finding it difficult to maintain sobriety. She got “hooked” on gambling during the grand opening of the new casino. She further reported that she gets high during high-stakes games and requires a drink or two to maintain calmness. This, however, results in more drinking and reckless gambling. She also smokes. Her cigarette smoking has increased over the past two years. Nevertheless, she is afraid of the negative impacts of smoking on her health.

The client has made deliberate attempts to abstain but has not been successful, as she states that she gets high when gambling and that she often requires a couple of drinks to even out. She has gained weight since starting to drink too much alcohol. The client borrowed 50,000 dollars from her retirement account without telling her husband to finance her gambling debts and is now concerned that her husband may find out. Further, a mental status examination of the client revealed that she is alert and well-oriented to the event and time. Her self-reported mood was sad. Her eye contact was avoidant, as she looked away or down during the clinical interview. She denied experiencing any visual or auditory hallucinations or delusional thoughts. She also denied having any suicidal ideation or tendencies. Her impulse control is impaired, but her judgment and insight are intact. The presumptive diagnosis was gambling disorder and alcohol use disorder. Impairment in impulse control, financial mismanagement attributable to gambling, and alcohol dependence are some of the patient-specific factors that will impact decision-making when prescribing medications for the client.

Decision Point #1

The first decision point is to start the client with naltrexone 380mg injection administered intramuscularly (IM route) every four weeks. Naltrexone is an FDA-approved medication in the management of alcohol use disorder. Naltrexone depot injections given through the IM route allow for monthly use and are recommended for clients with moderate to severe alcohol use disorder due to their dosing flexibility and higher compliance (Avery, 2022). In this case, the client can benefit from using naltrexone 380mg depot injection.

The second option was to start the client on disulfiram. Disulfiram is also effective in treating alcohol use disorder and is FDA-approved for treating alcohol dependence. Its use, however, was not warranted in this case due to the low guarantee that the client would abstain from alcohol for at least 12 hours due to her gambling problem and her reason for taking alcohol. As Lanz et al. (2023) note, disulfiram should only be used where there is a guarantee that the client will abstain for at least 12 hours. The other option was to start the client on acamprosate. Acamprosate is another FDA-approved medication in the management of alcohol dependence. Its use was, however, not warranted due to its suboptimal effects in lowering heavy drinking. The client in the case is a heavy drinker.

The selected decision point (naltrexone 380mg injection administered intramuscularly every four weeks) was aimed at addressing the alcohol use disorder. Naltrexone is an FDA-approved medication for this indication. Its once-monthly use can help overcome the problem of noncompliance (Avery, 2022). Its effectiveness and pharmacokinetic parameters make it the preferred choice for the client. When communicating with the client, an ethical consideration that comes into play is beneficence. This principle obliges the caregivers to act for the benefit of their clients. This means providing the best care to them regardless of their state or background. Maintaining objectivity when handling the client is necessary in this respect.

Decision Point #2

The second decision point is to add diazepam 5mg, administered orally every 24 hours. This decision point was arrived at after the client returned to the clinic with complaints of anxiety. Anxiety is one of the side effects of naltrexone. Diazepam is an FDA-approved medication for treating anxiety. It maintains effectiveness in relieving anxiety symptoms by facilitating GABA activity (Melaragno, 2021). The client, in this case, can benefit from this medication.

The other option was to refer the client to the counselor to address her gambling issues. While addressing the gambling problem is a necessity in the case, its application was not warranted at the time as the client had more pressing issues. She had complaints of anxiety, which had her concerned. It was ethical for caregivers to first address the client’s concerns in line with the ethical provision of beneficence. The other option was to add varenicline. Varenicline is a medication used as a smoking cessation aid. Its use may, however, not be necessary as smoking cessation for the client can be achieved by other cost-effective measures such as gambling cessation. As evident in the case, the onset of smoking coincided with the onset of gambling.

The decision to add diazepam 5mg was aimed at addressing the anxiety complaints reported. Diazepam is effective in managing anxiety symptoms. At a 5mg dose, this medication is tolerable but still effective in alleviating anxiety manifestations (Melaragno, 2021). Its use is thus warranted in the case. While communicating with the client and making this decision point, the ethical principle of beneficence comes into play. Both competing options in this decision point are right. However, a consideration to be made is whether the options address the client’s immediate concerns. Beneficence requires caregivers to act in the best interest of the client. Not addressing her immediate concern of anxiety may be a contravention of this provision.

Decision Point #3

The third decision point is to continue the dose of naltrexone while tapering that of diazepam and referring the client to a counselor for the management of her gambling issue. This decision point is informed by the disappearance of the anxiety symptoms and positive clinical response to the ongoing naltrexone therapy. At this point, discontinuing diazepam is necessary. Gradual withdrawal through tapering is necessary during therapy with diazepam to prevent symptoms relapse and withdrawal symptoms (Reid Finlayson et al., 2022). Referring the client to a counselor, on the other hand, will help her manage her gambling addiction problem.

The other two options were to continue the current dose of naltrexone while increasing the dose of diazepam and to maintain the dose of naltrexone and diazepam. Increasing or maintaining the dose of diazepam is not warranted in this case. Diazepam, like other benzodiazepines, is used in the short-term management of anxiety disorders. Long-term use has been associated with tolerance, high abuse and dependence potential, and sometimes perceptual disturbances (Soyka et al., 2023). Furthermore, there was no manifestation in the case that pointed to the need to continue diazepam therapy.

The selected decision point was targeted at addressing the gambling problem while maintaining control over the alcohol abuse problem. Since optimal clinical response was noted with the initiation of naltrexone, maintaining the dose at 380mg was warranted. Discontinuation of diazepam was also necessitated as the anxiety was under control. Referral to the counselor sought to address the gambling problem. Besides, psychotherapeutic modalities such as CBT maintain effectiveness in addressing gambling disorders (Ribeiro et al., 2021). Referral to a counselor is thus warranted. An ethical consideration, in this case, is non-maleficence. This ethical obligation requires caregivers to do no harm to their clients. The two available options had the potential to cause harm to the client. Increasing or maintaining the dose of diazepam may have resulted in some harm to the client.

Conclusion

The case presented involved a 53-year-old female from Puerto Rico with comorbid addiction. The presumptive diagnoses were alcohol abuse disorder and gambling addiction. Subjective findings also revealed that she also smokes. The first point of managing this patient is to address the alcohol addiction due to its profound effects on the client’s health as well as its influence on her other activities, such as financial management. Disulfiram, acamprosate, and naltrexone are FDA-approved medications for the management of alcohol dependence. These modalities are equally effective in addressing alcohol dependence. In the case presented, naltrexone was the preferred agent due to its effectiveness in managing alcohol abuse disorder, tolerability, and cost-effectiveness. The depot injection through the IM route allows it to be used once monthly and confers considerable dosing advantages over the others.

The use of naltrexone has been associated with some side effects. Anxiety is a common side effect of naltrexone that is manageable using anti-anxiety medications. Benzodiazepines, such as diazepam, maintain effectiveness in alleviating anxiety symptoms. Their use is, however, restricted for long-term use due to their potential for tolerance, abuse, and dependence. Thus, these medications should be discontinued after 2-4 weeks. Tapering their doses while discontinuing them may help prevent withdrawal symptoms and symptom relapse.

Gambling addiction is another reported problem. Psychotherapeutic modalities such as CBT are the mainstay in the management of gambling addiction (Ribeiro et al., 2021). In this case, the client may benefit from CBT. Discussing smoking cessation options is also necessary in this case. At the point of care, it is incumbent for caregivers involved in managing the client to educate her on the risks of smoking and the available smoking cessation therapies. This will provide a better guarantee of wellness to the patients, in line with the ethical provisions of beneficence.

References

Avery, J. (2022). Naltrexone and alcohol use. American Journal of Psychiatry, 179(12), 886–887. https://doi.org/10.1176/appi.ajp.20220821

Lanz, J., Biniaz-Harris, N., Kuvaldina, M., Jain, S., Lewis, K., & Fallon, B. A. (2023). Disulfiram: Mechanisms, applications, and challenges. Antibiotics, 12(3), 524. https://doi.org/10.3390/antibiotics12030524

Melaragno, A. J. (2021). Pharmacotherapy for anxiety disorders: From First-line options to treatment resistance. FOCUS, 19(2), 145–160. https://doi.org/10.1176/appi.focus.20200048

Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D. E., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: An internet survey. Therapeutic Advances in Psychopharmacology, 12, 204512532210823. https://doi.org/10.1177/20451253221082386

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). https://doi.org/10.1186/s12888-021-03097-2

Soyka, M., Wild, I., Caulet, B., Leontiou, C., Lugoboni, F., & Hajak, G. (2023). Long-term use of benzodiazepines in chronic insomnia: A European perspective. Frontiers in Psychiatry, 14. https://doi.org/10.3389/

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Question

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)

Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction

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)

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.