Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction Essay

Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction Essay

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. 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.        

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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 Psychiatry, 64(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 Medicine, 14(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 Trials, 81, 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 sciences, 25(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

Comorbid Ad Assignment 1: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction
Impulsivity, compulsivity, and addiction are challenging disorders for patients across the life span. Impulsivity is the inclination to act upon sudden urges or desires without considering potential consequences; patients often describe impulsivity as living in the present moment without regard to the future (MentalHelp.net, n.d.). Thus, these disorders often manifest as negative behaviors, resulting in adverse outcomes for patients. For example, compulsivity represents a behavior that an individual feels driven to perform to relieve anxiety (MentalHelp.net, n.d.). The presence of these behaviors often results in addiction, which represents the process of the transition from impulsive to compulsive behavior.
In your role as the psychiatric nurse practitioner (PNP), you have the opportunity to help patients address underlying causes of the disorders and overcome these behaviors. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with impulsivity, compulsivity, and addiction.
Reference: MentalHelp.net. (n.d.). Impaired decision-making, impulsivity, and compulsivity: Addictions’ effect on the cerebral cortex. https://www.mentalhelp.net/addiction/impulsivity-and-compulsivity-addictions-effect-on-the-cerebral-cortex/
To prepare for this Assignment:
• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring therapy for impulsivity, compulsivity, and addiction.
The Assignment: 5 pages
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, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that 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.

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• 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)
• 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.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
diction (ETOH and Gambling)

Comorbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female

Decision Point One

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
RESULTS OF DECISION POINT ONE
• Client returns to clinic in four weeks
• Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since receiving the injection
• Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)
• Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also has her concerned
Decision Point Two

 

Refer to a counselor to address gambling issues

RESULTS OF DECISION POINT TWO
• Mrs. Perez returns in 4 weeks and reports that the anxiety that she had been experiencing is gone.
• She reports that she has met with the counselor, but she did not really like her.
• She also started going to a local meeting of Gamblers Anonymous. She states that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group.
Decision Point Three

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Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetings

Guidance to Student

Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, 8 weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As will be covered in more depth in future courses, ruptures in the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA-approved treatments for gambling addiction. The mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the Gamblers Anonymous meetings, she should be encouraged to continue her participation with this group.
You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.