Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction

A 53-year-old Puerto Rican female, MWe’llaria Perez, presented herself today to the clinic with what she termed an “embarrassing problem.” She had alcohol problems in her late teenage years after her father died and has struggled with alcohol since her 20s. For the past 2client, she has been inconsistently involved with Alcoholics Anonymous. In the last two years, she has worked to keep sober after a new casino opened near her home. She got hooked when she visited the casino with a friend during its opening. She enjoys gambling and drinks one or two bottles to calm her in high-stake bets. This leads to more drinking and uncontrolled gambling. In the past two years, she has also developed a cigarette smoking problem and is concerned about its effects on her health.

She has attempted to quit drinking; however, gambling stresses her out, and she takes a few drinks to calm down. She smokes less while drinking but smokes more when playing at the machines. She has also gained extra weight from the drinking. She has also borrowed over $50,000 from her retirement account to pay off her gambling debts without the knowledge of her husband.

Are you looking to get your assignment done ? Get in touch with us.

Her mental examination shows she is alert and oriented to person, place, time, and event. She is well dressed as per the weather. She has clear, coherent, goal-directed speech and transparent thought processes. She avoids eye contact and has no noteworthy mannerisms, gestures, or tics. She reports she is sad. Her affect reflects the interview content and self-reported mood. She has no visual or auditory hallucinations and no delusions. She has good insight and judgment but impaired impulse control and has no suicidal or homicidal ideation. The patient is diagnosed with comorbid gambling disorder and alcohol use disorder.

Decision #1

The first decision is to give the patient a Vivitrol (naltrexone) injection, 380 mg intramuscularly, in the gluteal region every four weeks as first-line medication. The patient has shown to have increased alcohol dependence due to her gambling problem. The first decision point is to select a medication plan that will combat the patient’s need to use alcohol. Vivitrol is an opioid antagonist. Opioid antagonists block opioid receptors in the brain and induce anti-depressant and anti-addictive activities with a significant reduction in stress responses (Chavkin, 2018). Vivitrol, as an extended-release drug, influences the hypothalamus, pituitary, and adrenal axis action, suppressing the need to drink alcohol.

Antabuse (disulfiram) 250 mg orally every morning and Campral (acamprosate) 666 mg orally TID were not selected due to efficacy and side effects concerns. The patient has a consistent drinking pattern, and therapy may take time to be effective. Both options are less effective if treatment has not been fully initiated and the patient keeps drinking. Adherence and compliance with medication plans have also been noted to be low in patients using disulfiram therapy due to experienced side effects and mode of delivery (de Sousa, 2019). Although animal tests show Campral to be efficacious in alcohol dependence management (Christopher Johnson et al., 2019), it is less effective in humans if the patient continues using it.

The decision to use Vivitrol (naltrexone) injection, 380 mg, was to help achieve progressively reduced alcohol use as the gambling therapy progresses with minimum side effects and risk of relapses. Vivitrol (naltrexone) has also proved to be efficacious in medication-assisted treatment (MAT) in patients with opioid dependency disorders (Rodighiero, 2019). Two examples of ethical considerations impacting the treatment plan are the medication-related safety of the patient and the need to provide the most beneficial treatment plan.

Decision #2

The second decision during the patient’s second visit to the clinic will be to refer her to a counselor to address gambling issues. The patient has noted that she has been feeling wonderful and has abstained from alcohol since the Vivitrol (naltrexone) 380 mg injection. She has reduced her gambling; however, she seems to spend a lot of money when she gambles and still smokes. She also has anxiety. Therefore, a counselor is required to combat the patient’s gambling and anxiety issues. Psychological therapy reinforced with pharmacotherapy is an effective strategy in the management of gambling addiction in patients with or without comorbid psychiatric disorders (Echeburúa & Amor, 2021).

The other available options of adding Valium (diazepam) 5 mg orally TID/PRN for anxiety and adding on Chantix (varenicline) 1 mg orally BID were not selected. Although Valium is a first-line medication for anxiety, it is linked to adverse side effects, including dependence, cognitive impairment, and reduced tolerability during use (Cheng et al., 2018). Chantix (varenicline) 1 mg has adverse effects in smoking patients, such as nightmares, nausea, suicidal ideation (DeVoss, 2019), and the risk of varenicline-induced seizures (Chopra et al., 2019).

The choice to refer the patient to a counselor was to combine therapy with the Vivitrol injection to improve both gambling and alcohol addiction outcomes and avoid other side effects due to the augmentation of the current treatment with other medications. Research evidence proved that combined pharmacotherapy and psychotherapeutic interventions for gambling addicts with comorbid alcohol addiction is a more effective strategy than using pharmacotherapy alone (Bodor et al., 2021). The ethical considerations at this point influencing the treatment choice include concerns over patient safety and providing the most beneficial care.

Decision #3

After the third visit, the decision is to explore the patient’s issue with her counselor and encourage her to continue attending the Gamblers Anonymous meetings. During the second visit, the patient reported that her anxiety was gone; however, she does not like her counselor. She has also been attending Gamblers Anonymous meetings and spoken at the meetings, and she feels supported in this group. The counselor-patient relationship is a determining factor for the patient’s engagement in therapy. Patient-counselor conflicts or misunderstandings can lead patients to discontinue their treatment therapy prematurely (Mitchell et al., 2018).

The other options of encouraging Mrs. Perez to continue seeing her current counselor and continuing with the Gamblers Anonymous group, discontinuing Vivitrol, and enabling Mrs. Perez to continue seeing her counselor and participating in the Gamblers Anonymous group were not selected. Both options ignore the issues between the patient and the counselor and continue with the therapy. Evidence has also linked poor patient-therapist relationships to poor health outcomes (Cano-Ibáñez et al., 2021). Although research has somewhat noted that Vivitrol reduces effectiveness progressively beyond three weeks of the therapy (Knopf, 2019), it is essential to maintain the Vivitrol dosage combined with gambling psychotherapy. The decision to sort out the patient’s issue with their counselor is to improve their relationship and take advantage of the benefits of an excellent counselor-patient relationship during therapy. At this point, it is essential to talk to Mrs. Maria Perez about her smoking, solve issues with her counselor, and encourage her to continue attending her group meetings. The ethical considerations include her autonomy to make such decisions and educating her on what benefits her.

Conclusion

Mrs. Maria Perez was diagnosed with comorbid gambling disorder and alcohol use disorder. This is a common comorbidity. Gambling disorder is a maladaptive behavior that influences the development of other addiction disorders and vice versa. Research evidence has argued that a majority of the people who develop gambling addiction disorders are more likely to develop alcohol, drug, and substance addictions (Leino et al., 2021). The disorders can be diagnosed based on the presented symptoms, observations of the patient, and the medical and related behavioral history review. However, it is essential to establish the diagnosis based on the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) provisions.

These comorbid disorders can be challenging to manage even if professional help is available, as they depend mainly on the commitment of the patient. Comorbid EtOH and gambling disorders negatively impact the individual patient’s life, their relationships with their family and friends, and their financial and economic well-being (Paterson et al., 2019). The decision on the first-line treatment plan should focus on the more beneficial and productive therapies for the patient with less harm. Vivitrol (naltrexone) 380 mg injection is more advantageous to the patient with comorbid EtOH and gambling disorders as a first-line medication as compared to Antabuse (disulfiram) 250 mg orally every morning and Campral (acamprosate) 666 mg orally TID. Vivitrol, as an extended-release opioid antagonist, has a higher efficacy in reducing alcohol dependence in patients with gambling disorders, irrespective of the effectiveness of psychotherapy. Antabuse (disulfiram) and Campral (acamprosate) require the patient to first abstain from alcohol to be effective and have significant side effect concerns.

References

Bodor, D., Ricijaš, N., & Filipčić, I. (2021). Treatment of gambling disorder: review of evidence-based aspects for best practice. Current Opinion in Psychiatry, 34(5), 508–513. https://doi.org/10.1097/YCO.0000000000000728

Cano-Ibáñez, N., Zolfaghari, Y., Amezcua-Prieto, C., & Khan, K. S. (2021). Physician–Patient Language Discordance and Poor Health Outcomes: A Systematic Scoping Review. Frontiers in Public Health, 9, 158. https://doi.org/10.3389/FPUBH.2021.629041/BIBTEX

Chavkin, C. (2018). Kappa-opioid antagonists as stress resilience medications for the treatment of alcohol use disorders. Neuropsychopharmacology 2018 43:9, 43(9), 1803–1804. https://doi.org/10.1038/s41386-018-0046-4

Cheng, T., Wallace, D. M., Ponteri, B., & Tuli, M. (2018). Valium without dependence? Individual GABAA receptor subtype contribution toward benzodiazepine addiction, tolerance, and therapeutic effects. Neuropsychiatric Disease and Treatment, 14, 1351. https://doi.org/10.2147/NDT.S164307

Chopra, D. A., Shah, A. B., Vadhariya, A. H., & Painter, J. T. (2019). The risk of varenicline-induced seizure among those who have attempted to quit smoking using pharmacotherapy. Epilepsy & Behavior, 97, 169–173. https://doi.org/10.1016/J.YEBEH.2019.05.031

Christopher Johnson, B. A., Carolina, N., Hampson, R. E., Joost Maier, A. X., James Daunais, C. B., Nader, M. A., & Stanford, T. R. (2019). EFFECTS OF ALCOHOL AND ACAMPROSATE, AN ALCOHOL USE DISORDER TREATMENT, ON NONHUMAN PRIMATE BEHAVIOR AND MEMORY.

De Sousa, A. (2019). Disulfiram in the Management of Alcohol Dependence. Disulfiram, 21–30. https://doi.org/10.1007/978-981-32-9876-7_3

DeVoss, M. (2019). Smoking Cessation Treatments include Varenicline (Chantix®️), NRTs, and Nicotine Dependence. Biology: Student Scholarship & Creative Works. https://digitalcommons.augustana.edu/biolstudent/19

Echeburúa, E., & Amor, P. J. (2021). Psychological Management of Gambling Disorder With or Without Other Psychiatric Comorbidities. Textbook of Addiction Treatment, 929–942. https://doi.org/10.1007/978-3-030-36391-8_65

Knopf, A. (2019). Patients report Vivitrol decreasing in effectiveness by week 3. Alcoholism & Drug Abuse Weekly, 31(23), 4–5. https://doi.org/10.1002/ADAW.32390

Leino, T., Torsheim, T., Griffiths, M. D., & Pallesen, S. (2021). The relationship between substance use disorder and gambling disorder: A nationwide longitudinal health registry study. https://doi.org/10.1177/14034948211042249

Mitchell, S. G., Monico, L. B., Leitch, E., Kelly, S. M., Gryczynski, J., Jaffe, J. H., O’Grady, K. E., & Schwartz, R. P. (2018). Counseling Staff’s Views of Patient-Centered Methadone Treatment: Changing Program Rules and Staff Roles. The Journal of Behavioral Health Services & Research 2018 45:3, 45(3), 506–515. https://doi.org/10.1007/S11414-018-9603-1

Paterson, M., Taylor, M., & Gray, M. (2019). Trajectories of Social and Economic Outcomes and Problem Gambling Risk in Australia. Social Indicators Research 2019 148:1, 148(1), 297–321. https://doi.org/10.1007/S11205-019-02194-W

Rodighiero, R. (2019). Comparing the Efficacy of Medication-Assisted Treatment with Buprenorphine/Naloxone Vs. Naltrexone in Opioid Dependent Patients. Lynchburg Journal of Medical Science, 1(2). https://digitalshowcase.lynchburg.edu/dmscjournal/vol1/iss2/27

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

Question

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.

Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction

You should evaluate all options at each decision point before deciding and moving throughout the exercise. Before deciding, ensure that you have researched each option 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)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your suggestions and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your reasoning, it will not count toward the resource requirement. It would be best if you were utilizing the primary and secondary literature.