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 two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their 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 two 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 that 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 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 has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not ... - Get Instant Homework

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office 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 two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their 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 two 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 that 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 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 has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.

MENTAL STATUS EXAM

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

Decision Point One

Antabuse (Disulfiram) 250 mg orally every morning ON

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

Antabuse (Disulfiram) 250 mg orally daily

Campral (Acamprosate) 666 mg orally three times/day

· Client returns to clinic in four weeks

· Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

· Clientis She is also reporting that she is having “out of control” anxiety..

Decision Point Two

Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms

RESULTS OF DECISION POINT TWO Decision Point Two

Select what the PMHNP should do next:

Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety

Refer to a counselor to address gambling issues

Add on Chantix (varenicline) 1 mg orally BID

Client returns to clinic in four weeks
Mrs. Perez reports that when she first received the valium, it helped her tremendously. She states “I was like a new person- this is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her valium early. She is asking today for you to increase the valium dose or frequency
Although she reports that her anxiety is gone, she still reports suicidal ideation, but states “with that valium stuff, who cares?”;;;;;;;;
Decision Point Three
Add on Wellbutrin (bupropion) XL 150 mg orally daily
Guidance to Student
Given her weight (less than 60 kg), Campral should have been started at 666 mg orally BID. It is possible that the higher dose may be responsible for the severity of the symptoms that Mrs. Perez is experiencing.
Technically, the drug should have been stopped (not simply decreased) once Mrs. Perez reported suicidal ideation. Even with the decrease in dose, she is still having suicidal ideation, which indicates the need to discontinue the drug. Although controversy exists regarding how long to use pharmacologic approaches to treatment of alcohol dependence, 8 weeks is probably insufficient, therefore, the drug should not simply be discontinued without using a different agent in its place.
Mrs. Perez should be started on Antabuse at 250 mg orally daily and referred to psychotherapy to address her gambling issue.
In all cases, the PMHNP needs to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions and to enhance her overall health. The decision to begin Wellbutrin XL 150 mg orally daily may help achieve this goal, but this choice does not address her abstinence from alcohol.
Additionally, it should be noted that although Mrs. Perez reports that she has been avoiding the casino secondary to her fear that she will drink, this “fear” has not actually treated her gambling addiction. This particular addiction has resulted in considerable personal financial cost to Ms. Perez. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and she should also be encouraged to establish herself with a local chapter of Gamblers Anonymous.
Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

edit this or redo other assignment.

Assessing and Treating Clients with Impulsivity, Compulsivity and Addiction

Pharmacotherapy practice to treating substance use disorders is often referred to as medication assisted treatment (MAT) (Sharp et al., 2018). In this practice, specific medications approved by Federal Drug Administration (FDA) are used in combination with counseling and behavioral therapies in treatment of a substance use disorder (Sharp et al, 2018) Medications can reduce the cravings and other symptoms associated with withdrawal from a substance by occupying receptors in the brain associated with using that drug (agonists or partial agonists), block the rewarding sensation that comes with using a substance (antagonists), or induce negative feelings when a substance is taken ( SAMHSA, 2016). MAT has been primarily used for the treatment of opioid use disorder but is also used for alcohol use disorder and the treatment of some other substance use disorders. This paper focuses on pharmacotherapy approaches to treatment of alcohol use disorder, gambling disorder and smoking addiction in a 53 year- old female of Puerto origin.

Case Scenario

Decision Number One

Naltraxone (Vivitrol) injection, 380 mg intramuscularly in gluteal region every four weeks.

Rationale: Pharmacotherapy should be used in patients with alcohol use disorder who have current, heavy use and ongoing risk for consequences from use, motivated to reduce alcohol intake and do not have medical contraindications to the individual drug choice (SAMHSA, 2016). As the 53 year-old female has acknowledged that she has a drinking problem and has tried psychosocial approach with alcoholic anonymous(AA) without success, adding medication such as naltrexone would be warranted as next step. In random clinical trials (RCTs) naltrexone medication has been shown to reduce heavy drinking and enhance the likelihood of abstinence ( Garbutt et al., 2014)

Naltraxone is mu opioid receptor antagonist, can be in form of oral ( Revia) and injection( Vivitrol) ( Stahl, 2017)….