case study

Case Study: A 54-Year- Old Puerto Rican Woman with Co-morbid Addiction Disorder (ETOH and Gambling).

Linda Simo

Walden University

NURS 6630, Psychopharmacologic Approach to Treatment of Psychopathology

Dr. Earle Reome

07/24/2020

Globally, mental, neurological and substance use (MNS) disorders are among the leading causes of disability, contributing to 10.4% of global disability-adjusted life years, where depression and alcohol use disorder (AUD) are reported to be the second and third leading causes of years lived with disability (Luitel et.al., 2019). Evidence has shown over half of the people that are depressed, and 87% of people with alcohol abuse and dependence do not receive any treatment; hence, a reason why complications following the abuse of these substances occur. As a psychiatric nurse practitioner, the first important step that is needed in the treatment of a 53-year-old Puerto Rican female who presents to my office today for gambling and alcohol use disorder will be a detailed evaluation of the chief complaint and associated symptoms. The goal of writing the paper will be to have a good evaluation and analysis of symptoms and review the three choices of medication I will prescribe for this patient. Factors that might affect the pharmacokinetics and pharmacodynamics of choice of drug and the ethical consideration that might affect the impact of the medication to be used will also be discussed in the paper.

Decision One

In this situation, the medication I will prescribe will be Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every four weeks. Naltrexone is an opioid receptor antagonist that is FDA approved for alcohol dependence, blockade of effects of exogenously administered opioids (oral), and prevention of relapse to opioid dependence (Stahl, 2013). The onset of action is within 2 to 15 minutes, with duration of action of 1 to 4 hours; moreover, metabolism is in the liver while excretion is through the kidney (Woo & Robinson, 2016). The pharmacodynamics is the reduction of alcohol consumption through modulation of opioid systems, thereby reducing the reinforcing effects of alcohol. Naltrexone is contraindicated in those currently using opioids due to the possibility of serious adverse events (SAEs) of either over-rapid opioid withdrawal or overdose of opioids, which can be life-threatening (Bolton et. al., 2019). 

I did not choose Antabuse (Disulfiram) because there is also limited trials to support the effectiveness of the medication. Furthermore, Antabuse does not reduce the craving of alcohol, but it causes unpleasant symptoms when alcohol is ingested such as sedation, fatigue, and other serious adverse effects (Winslow, Onysko & Herbert, 2015). The reason I did not choose Campral (Acamprosate) was because this drug is most effective at maintaining abstinence in patients who are not currently drinking alcohol (Winslow, Onysko & Herbert, 2015). For my patient this is not the case. The other reason I did not choose this medication is because it has the tendency to causes serious adverse effects such as suicidal ideation and anxiety disorders (Woo & Robinson, 2016).

After four weeks, I expect this patient to come back with some positive results of consuming less alcohol than before or has stopped drinking alcohol. Also, since she usually attends social gatherings, I will expect her to find less interest in drinking when she goes to the casino. Furthermore, I expect her to come back with some form of anxiety symptoms which will be as a result of the side effect from Naltrexone (Vivitrol) but will go away with time. Usually the anxiety associated with this medication may be transient. These are the expected result that was achieved in the first four weeks, hence, setting a balance between the achieved and the expected results.

Decision Two

After returning to the clinic in four weeks, the patient reported positive improved and excellent comments about her condition where she stated that she did not “touch a drop” of alcohol and her frequency going to the casino has reduced since the injection but admits that when she goes she ends up spending a lot of money gambling. Since Naltrexone is working to address her excessive alcohol consumption, I would now address her present concerns which is a complaint of still smoking, some anxiety and continuous gambling. My first choice will be therapy. According to Spithoff and Kahan (2015) it is recommended to offer all patient with Alcohol User Disorder (AUD) counseling sessions and ongoing follow-up. I will recommend a counselor who can address her gambling issues because there is no medication to treat this condition and to encourage her to join a local chapter of gamblers anonymous. If her gambling is controlled, it will reduce some of her anxiety which might have been caused by the fact that she borrowed and spent a lot of the money gambling without her husband’s knowledge. The fact that the patient complained of some anxiety means that it is a new symptom which might have been caused by Naltrexone (Vivitrol); or it might have been triggered by her going back to the casino and spending a lot of money gambling. If the patient’s anxiety is due to drug induced side effect, it is usually not recommended as a first choice to prescribe a benzodiazepine in a client who is already having issues with alcohol or other substance dependencies (Stahl, 2013). Referring her to counselor and waiting another couple of weeks to see if her anxiety goes away will be a better option than prescribing another addictive medication or adding another anti-alcohol medication. If she does not get better the next time she comes then I will further evaluate.

I did not choose Chantix because of its dependency, agitation, nausea, and vomiting side effects (Woo & Robinson, 2016). Moreover, the issue of excessive alcohol consumption is already being resolved by the first medication. Chantix is also one of the FDA approved medication for Alcohol User Disorder (AUD). The greatest concern is the gambling issue which seem to be affecting the patient’s personal finances. I expect her to come back in 4 weeks and reports reduced gambling and a total absence of anxiety problems. After four weeks, the anxiety went away but not the gambling problem because she did not like the counselor. However, she was able to join an anonymous group which has supported her thus far. Since the achieved and the expected outcome is not fully balanced, the next decision must be taken.

Decision Three

The third decision will be to explore the issue between Ms. Perez and her counselor and encourage her to continue with the gambler's anonymous group. It would be good to know why the patient did not get along with her counselor. Although controversy exists in the literature regarding how long to maintain a patient on Naltrexone (Vivitrol), however, discontinuation of this medication will be too soon even though she has stopped drinking alcohol I will explore the issue between her and the counselor and then see if a resolution could be found because it is known that “ruptures and the therapeutic alliance can result in client’s stopping therapy (Stahl, 2013). I will still encourage her to attend the meetings of the support group for gambling activities. Although there is increasing acknowledgement that gambling is an important public health concern, one issue that is not yet adequately examined is what a public health advocacy approach to gambling harm prevention and reduction should look like (David et al., 2020). The importance of seeing a counselor will be reinforced by clearing informing the patient that the chances of reducing or stopping gambling is low if she discontinues the service of the counselor. I will also discuss the importance of smoking cessation in other to address the issue of addictions and the impacts on her overall health. I would expect her to stop gambling as soon as she resumes her therapy with the counselor and to schedule another follow up visit with her.

Ethical Considerations

Ethical consideration is significant when managing any patient. Moreover, effective communication will serve as the basis for ethical considerations. Naltrexone (Vivitrol) is an FDA approved medication in the United States for those that have an addiction to alcohol. Therefore, there is a brilliant potency with little/no adverse effects for all races. In conclusion, the first important step that is needed in the treatment of a 53-year-old Puerto Rican female who presents to my office today for gambling and alcohol use disorder will be a detailed evaluation of the chief complaint and associated symptoms. This is followed by the administration of Naltrexone while monitoring the progress and adverse effects of the medication with therapy from the counselor in conjunction with joining the gambling anonymous support group to fight the gambling habit.

References

Bolton, M., Hodkinson, A., Boda, S., Mould, A., Panagioti, M., Rhodes, S., … van Marwijk, H. (2019). Serious adverse events reported in placebo randomized controlled trials of oral naltrexone: a systematic review and meta-analysis. BMC Medicine, 17(1), 10. https://doi-org.ezp.waldenulibrary.org/10.1186/s12916-018-1242-0

David, J. L., Thomas, S. L., Randle, M., & Daube, M. (2020). A public health advocacy approach for preventing and reducing gambling related harm. Australian and New Zealand Journal of Public Health, 44(1), 14–19. https://doi-org.ezp.waldenulibrary.org/10.1111/1753-6405.12949

Luitel, N. P., Garman, E. C., Jordans, M. J. D., & Lund, C. (2019). Change in treatment coverage and barriers to mental health care among adults with depression and alcohol use disorder: a repeat cross-sectional community survey in Nepal. BMC Public Health, 19(1), 1350. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-019-7663-7

Spithoff, S., & Kahan, M. (2015). Primary care management of alcohol use disorder and at-risk drinking. Can Fam Physician, 61(6), 515-521. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463892/

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Winslow, B. T., Onysko, M., & Herbert, M. (2016). Medication for alcohol use disorder. Am Fam Physician. 15;93(6), 457-465. Retrieved from www.aafp.org/afp/2016/0315/p457-s1.html

Woo, T.; Robinson M.V. (2016). Pharmacotherapeutics for Advance Practice Nurse Prescribers (4th ed.). Philadelphia, PA.