Assessing and Treating Patients with Impulsivity Compulsivity and Addiction

Healthcare providers are responsible for selecting the best medication or therapy interventions for their patients. They make decisions based on the Patient’s characteristics, considering how the medication would affect their pharmacological and pharmacokinetic processes. They also monitor the Patient’s response to the medication over time and decide on the changes that can be made when required, thus ensuring desirable healthcare outcomes.

Assessing and Treating Patients with Impulsivity Compulsivity and Addiction

Ideally, mental health patients should go for follow-ups/checkups every four weeks after administering a treatment/therapy. This paper analyzes a case of a patient with comorbid impulsivity, compulsivity, and addiction and the different treatment decisions made at different points of interacting with the Patient.

Case Study Analysis

The case study involves Mrs. Perez, a 53-year-old Puerto Rican presenting to the clinic reporting a rather embarrassing problem. She admits to having struggled with alcohol since her twenties, although it has been worse for the last two years, trying to maintain sobriety. She also reports having been on and off Alcohol Anonymous for 25 years. She has also been having a problem with gambling, which often leads to more drinking and reckless gambling.

Further, she states that her smoking habit has worsened in the past two years, and she is worried about its effect on her health. She also reports abstaining from drinking but takes a few bottles to even out from gambling. She notes that she does not smoke so much while she is drinking. However, she reports she has gained weight from drinking and is concerned about the money she borrowed from her retirement plan to pay off her gambling debts.

The mental status exam reveals that she is alert, dressed appropriately, and has coherent, clear, and goal-directed speech. However, she avoids eye contact, and her self-reported mood is sad. Her impulse control is impaired, but she denies suicidal or homicidal ideations. From the assessment results, the diagnosis is gambling disorder and alcohol use disorder.

Decision Point One

The first decision is to begin Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region, administered every four weeks. FDA has approved Vivitrol for opioid and alcohol use disorders (Malone et al., 2019). The medication is the best decision for the Patient since it reduces the intoxication and the euphoric effect of alcohol, thus effectively treating heavy drinking. The Patient in our case study is a heavy drinker and has attempted abstaining from alcohol for the last 25 years in vain. Thus, this medication will help address the problem of heavy drinking.

The other medication option was Campral (acamprosate) 666 mg orally three times/day. Campral is an FDA-approved medication for alcohol dependence, used together with counseling and other psychosocial interventions. The medication was declined since it is not a first-line drug for treating alcohol use disorder but is used as an adjunct to other psychosocial interventions such as counseling.

In addition, it has some adverse side effects, such as nausea, loss of appetite, drowsiness, fatigue, and weight gain/loss, among others. The Patient is already complaining of weight gain; thus, a medication that would increase the weight gain is not the best for her. Despite its effectiveness in alcohol abstinence and reduction in alcohol intake, the medication is known to be ineffective when used alone. However, it can be used together with counseling and psychosocial support.

The other treatment option for the Patient was beginning Antabuse (disulfiram) 250mg orally daily. Antabuse is an FDA-approved drug used to treat alcohol use disorder by having unpleasant symptoms that discourage the Patient from alcohol intake.

According to Bhatia et al. (2022), Antabuse produces a disulfiram-ethanol reaction when the Patient uses alcohol, thus the accumulation of acetaldehyde. However, the drug has been reported to have adverse drug reactions in some patients, thus the reason for declining the option (Bhatia et al., 2022).

Some common side effects of this medication include nausea, diarrhea, altered consciousness, and convulsions. Although the adverse reactions are meant to discourage the Patient from further alcohol intake, some side effects and adverse drug reactions, such as altered consciousness, would affect the Patient significantly.

The ethical considerations for selecting Vivitrol are beneficence- ensuring that this medication will provide the best health outcomes for the Patient and nonmaleficence- ensuring that the drug does not cause harm to the patient and the side effects are minimized. The primary objectives of this decision were to reduce smoking, gambling, and drinking and improve her self-reported mood.

Decision Point Two

The Patient returned to the clinic after four weeks and reported that she felt wonderful, having not touched a drop of alcohol. She also reported that she is still involved in gambling, even though it is once in a while. However, when she does, she spends a lot. She also reported concerns about continued smoking and a feeling of anxiety.

Based on these results, the decision was to refer her to a counselor to address the gambling issue while maintaining Vivitrol medication to avoid symptoms of relapse. The option was selected since the Patient already shows a positive response to abstaining from alcohol, and the sad self-reported mood is addressed. However, the gambling issue is still present and has a considerable negative effect on the Patient.

There is no FDA-approved medication for gambling (Di Nicola et al., 2020). Thus, the best decision was to refer the Patient to the counselor. More so, counseling psychotherapy would help address the issue of anxiety.

The other option was adding Chantix (Varenicline) 1mg orally BID. Chantix is an FDA-approved medication for smoking cessation that reduces withdrawal symptoms following smoking cessation (Singh & Saabadadi, 2022). The primary complaint was alcohol use. Therefore, although Chantix would help with smoking cessation, it was not the primary concern. The Patient returned positively to Vivitrol medication since she reported having not touched alcohol since then. Thus, adding Chantix was not selected.

Adding on Valium (diazepam) 5 mg orally TID/PRN/anxiety was the other option that was declined. Despite the patient’s anxiety, counseling psychotherapy would address it more than Valium. Valium also had adverse side effects that would affect the Patient further, including drowsiness, muscle weakness, dry mouth, and constipation. Additionally, the Patient has shown a positive response to the previous medication, Vivitrol; thus, adding on it would be unnecessary.

The ethical consideration at this point is confidentiality. Counselors maintain client confidentiality at all costs. Since the Patient considers her problem embarrassing, a referral to a counselor who maintains confidentiality is crucial. The patient management objectives at this point are to address gambling and anxiety issues and maintain alcohol abstinence.

Decision Point Three

The Patient returned to the hospital four weeks later, reporting that her anxiety was gone entirely. She also reported that she did not like the counselor. Furthermore, she stated that she had joined a gamblers anonymous group whereby she felt supported.

Based on these results, the decision made at this point is to explore the issues Mrs. Perez is having with her counselor and encourage her to continue attending the gamblers’ anonymous group meetings. The option was selected since the Patient has had a positive response to the current psychosocial therapy on anxiety, and an improvement is seen in the reduction of gambling addiction.

The second option was discontinuing Vivitrol and exploring issues between her and the counselor. The choice was declined since the Patient also needed to deal with the gambling addiction disorder, which was still a concern. More so, there is no reason to discontinue Vivitrol since it still produces positive results.

The other option to continue seeing the current counselor was declined since it did not consider the issues forcing Mrs. Perez not to like the counselor. Exploring her issues with the counselor is essential in ensuring successful psychotherapy. A poor relationship with the counselor can lead to poor health outcomes (Ryu, Banthin & Gu, 2021).

At this point, the objective of patient management is to address the gambling issue entirely and enhance the total remission of symptoms. The ethical consideration in making this decision is beneficence. The psychiatric nurse practitioner has the patient’s best interest at heart and ensures that the decision best benefits the Patient. Furthermore, the nurse encouraged the Patient to join a smoking cessation program to ensure total remission of presenting symptoms and enhance a desirable overall health outcome for the Patient.

Conclusion

The first decision for the Patient was administering Vivitrol. The other medication options, Antabuse and Campral, were not selected due to their self-limiting side effects and adverse drug reactions. The Patient presented with anxiety during the second visit, a primary reason that led to decision point two being referral to a counselor for the gambling issue.

The Patient responded positively to the psychosocial therapy but reported that she did not like the counselor. The third decision was to encourage the Patient to continue attending Gamblers Anonymous and review issues between her and the counselor. It is also worth noting that the Patient was encouraged to look for a smoking cessation program, thus improving her well-being and overall health outcomes.        

References

  • Bhatia, G., Sarkar, S., Adagadda, S. S., & Chadda, R. K. (2022). Disulfiram safety in alcohol use disorders: Experience from an addiction treatment center in India. Indian Journal of Psychiatry64(2), 216. https://doi.org/10.4103%2Findianjpsychiatry.indianjpsychiatry_386_21
  • Di Nicola, M., De Crescenzo, F., D’Alò, G. L., Remondi, C., Panaccione, I., Moccia, L.& Janiri, L. (2020). Pharmacological and psychosocial treatment of adults with gambling disorder: A meta-review. Journal of Addiction Medicine14(4), e15-e23. https://doi.org/10.1097/ADM.0000000000000574
  • Malone, M., McDonald, R., Vittitow, A., Chen, J., Obi, R., Schatz, D., Tofighi, D., Garment, A., Kamard, A., Godfeld, A., Gold, H., Alaska, E., Rotrosen, J. & Lee, J. D. (2019). Extended-release vs. oral naltrexone for alcohol dependence treatment in primary care (XON). Contemporary Clinical Trials81, 102-109. https://doi.org/10.1016/j.cct.2019.04.006
  • Ryu, J., Banthin, D. C., & Gu, X. (2021). Modeling therapeutic alliance in the age of telepsychiatry. Trends in cognitive sciences25(1), 5-8. https://doi.org/10.1016/j.tics.2020.10.001
  • Singh, D. & Saadabadi, A. Varenicline. (2022). In: StatPearls [Internet] Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK534846

Assessing and Treating Patients with Impulsivity Compulsivity and Addiction Case Study Assignment Instructions

CASE STUDY

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing problem.”

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 2 years, she has been having more and more difficulty maintaining her sobriety since the opening of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its 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 2 years and she is concerned about the negative effects of the cigarette smoking on her health.

She states that she attempts to abstain from drinking but 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 she 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 borrowed over $50,000 from her retirement account to pay off her gambling debts, and her husband does not know.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert and 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. When 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 and self-reported mood. She denies visual or auditory hallucinations, and 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.

Diagnosis: Gambling disorder, alcohol use disorder

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) – Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

  • 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) -Refer to counselor to address gambling issues

  • 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) – Explore the issues that Mrs. Perez is having with her counselor, and encourage her to continue attending Gambler’s Anonymous Meetings

  • 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 recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.