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

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

Advanced practice nurses assess, diagnose, and treat patients in their respective specializations. Psychiatric mental health nurse practitioners rely on clinical presentations to diagnose, classify, and manage patients. A keen analysis of their presenting illness and symptomatic treatment remains the mainstay management of most mental health disorders. The FDA, Mental Health Act, and the national institute of mental health recommend that patients receive a clinical assessment every four weeks after initiating therapy. During the visits, nurses assess patient presentation and review treatment objectives to inform their decisions. Remission and medication side effects are the primary basis for care decisions. Obsessive-compulsive and related disorders (OCRDs) are personality disorders characterized by irrational fear and repetitive behaviors. OCRDs cause significant brain impairment and have similar risks, risk factors, and responses to medications. Impulsivity, compulsivity, and addiction are symptoms accompanying many psychiatric disorders and are the focus of this assessment.

Case Study Analysis

Mrs. Maria Perez, a 53-year-old Puerto Rican female, presents to the clinic with an “embarrassing problem.” She admits having problems with alcohol and has been in AA on and off for 25 years. Over the last two years, she has been struggling with gambling, to which she feels hooked. She takes alcohol to cool her as she awaits the high-stake games. Drinking leads to more reckless gambling and drinking, and her cigarette smoking has become a bigger problem, and she is concerned about her health. She reports getting “high” from gambling and either drinks or smokes to “even out.” She has tried to stop gambling without avail: she is addicted. She has gained much weight from drinking and has been forced to borrow from her retirement to pay off her debts. Her mental status exam revealed eye avoidance with no other significant presenting symptom. The assessment results lead to a gambling disorder and alcohol use disorder diagnosis.

Decision One Decision#1

The overall goals/ objectives of this patient’s management are reduced gambling, drinking, and smoking and an improved mood (she reports her mood as sad) (Stahl, 2021). The first chosen decision is to put the patient on Antabuse (disulfiram) 250 mg orally every morning. Antabuse (Disulfiram) is an FDA-approved medication used to encourage ethanol intake. The medication irreversibly inhibits acetaldehyde dehydrogenase that oxidizes alcohol and leads to a disulfiram-acetaldehyde complex, leading to unpleasant symptoms that gradually discourage alcohol intake. Akbar et al. (2018) note that undesirable symptoms include a flushing headache, difficulty breathing, blurred vision, hypotension, nausea, vomiting, sweating, thirst, and tachycardia. The experience is undesirable and discourages patients from making the decision. The medication is best used by intentional patients who verbalize the desire to stop alcohol. With this decision, alcohol intake in this patient worsens the gambling disorder due to irrational decision-making. An ethical and legal implication of this choice is the desire to ensure the patient is willing to stop the drug. Another crucial ethical implication is confidentiality for this patient who confides in the nurse.

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every four weeks, is declined choice. Vivitrol is an FDA-approved long-acting naltrexone medication used for alcohol and opioid use disorders. The drug blocks the euphoria and intoxication caused by alcohol, discouraging drug intake. However, the medication is associated with a risk of overdose as individuals try to get the euphoria and intoxication caused by alcohol (Akbar et al., 2018). Unlike other medications, the drug’s efficacy alone is low and is thus used as an adjunctive therapy to other medications. Unlike disulfiram, this medication reduces the intoxication and euphoria effect and is effective in heavy drinking but may not lead to total remission (Akbar et al., 2018).

Campral (acamprosate) 666 mg orally three times/day was another medication option. Campral is an FDA-approved medication for alcohol use disorder used to stabilize the normal brain signaling pathways and subsequent brain changes associated with alcohol withdrawal (Stern et al., 2016). The medication is used alongside counseling. When used alone, the medication is ineffective, but individuals can reduce alcohol intake or abstain with psychosocial support. Akbar et al. (2018) note that acamprosate is not used as a first-line medication but as an adjunct to psychosocial interventions.

Decision Point #2

After initiating Antabuse (disulfiram) 250mg every morning, the patient comes to the clinic after four weeks complaining of sedation, fatigue, and a self-limiting metallic taste. The patient had a disulfiram-alcohol reaction after a single drink. The objectives of the second decision are to eliminate fatigue and sedation and prevent the recurrence of the disulfiram-alcohol reaction. The ethical consideration is to ensure patients receive the best intervention and the least harm from dosages and drug side effects. The choice is to continue the current dose of Antabuse and refer to counseling for ongoing gambling issues. Ginley et al. (2019) note that there are no FDA-approved medications for gambling disorders; hence counseling is the mainstay treatment. The medication’s minor side effects are sedation, fatigue, and a self-limiting metallic taste. Frequency change in the medication administration to when most inactive, such as when going to bed, is the ideal decision. The reaction to taking alcohol when on disulfiram is expected, and counseling to abstain from alcohol is vital.

The other options are to continue the current dose of Antabuse and begin Campral (acamprosate) 666 mg orally BID or continue the current dose of Antabuse and begin Wellbutrin (bupropion) XL 150 mg orally daily. The desired outcome of the medication was reduced alcohol intake/ abstinence. The patient had only one drinking episode in four weeks, meaning she is achieving remission, and there is no need for therapy change (Abkar et al., 2018). The side effects are minor and self-limiting hence the need to continue the drug and not add another drug for alcohol use disorder management. Polypharmacy in alcohol use disorder is linked to drug interactions leading to severe side effects such as fatigue, sedation, vision changes, nausea, and vomiting, which can negatively affect the patient’s quality of life (Guerzoni et al., 2018). Minimizing the therapeutic interventions is thus necessary, especially when a primary intervention is effective, eliminating the two interventions.

Decision Point #3

After the second decision, the patient saw a counselor but did not like her. She also started attending a gambling anonymous group to help with her gambling problem. She reports feeling supported but raises concerns about her smoking problem, which has not ceased yet. This decision aims to understand the reason for the strained relationship between her and her counselor and remedy the situation. Another objective is to ensure that alcohol abstinence/reduced intake is maintained and that no side effects arise. The most important ethical and legal consideration is beneficence and non-maleficence. While encouraging counseling and other interventions, it is essential to ensure they do not cause harm (such as emotional stress after being forced to see a counselor) and enhance adherence and patient collaboration. The chosen intervention is to explore Mrs. Perez’s issue with her counselor, encourage her to continue attending the Gamblers Anonymous meetings, and discuss smoking cessation options. The patient reports feeling supported and able to speak up; hence the intervention is effective, and there is a need to encourage it.

Discussing smoking cessation options with the client increase their participation in the intervention and the overall success of smoking management (Lowenstein et al., 2018). The patient needs support, and understanding the causes and nature of the estranged relationship with the counselor will help understand the problem and devise a way to handle the gambling issues. Discussing the smoking cessation options will help determine the most appropriate method to ease this client’s smoking burden. Discontinuing a therapeutically effective drug is not a good option due to the higher chances of alcohol use disorder relapse. Failure to explore the relationship with the counselor could have a debilitating effect. Conflicts can arise due to personal issues or when the client perceives the low efficacy of the counselor’s interventions.

Conclusion

The first decision for this patient was to understand the possibility of compliance and implement an FDA-approved intervention to manage the alcohol use disorder that worsens the gambling “embarrassing problem.” Disulfiram causes severe side effects when one ingests alcohol. The drug also causes fatigue and sedation, and a metallic taste that goes away. These symptoms are self-limiting. Avoiding polypharmacy in alcohol use disorder is essential due to drug interactions that cause severe side effects. Most patients conflict with healthcare providers, especially when they feel the interventions are not effective. It is crucial to understand the causes of a strained relationship between the patient and the counselor and advice on the way forward. In addition, discussing smoking cessation options will help select an effective intervention in which the patient will likely cooperate to produce better outcomes.

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References

Akbar, M., Egli, M., Cho, Y. E., Song, B. J., & Noronha, A. (2018). Medications for alcohol use disorders: An overview. Pharmacology & Therapeutics, 185, 64-85. https://doi.org/10.1016/j.pharmthera.2017.11.007

Ginley, M. K., Rash, C. J., & Petry, N. M. (2019). Psychological interventions in gambling disorder. In Gambling disorder (pp. 181-194). Springer, Cham. https://doi.org/10.1007/978-3-030-03060-5_9

Guerzoni, S., Pellesi, L., Pini, L. A., & Caputo, F. (2018). Drug-drug interactions in the treatment for alcohol use disorders: A comprehensive review. Pharmacological Research, 133, 65-76. https://doi.org/10.1016/j.phrs.2018.04.024

Lowenstein, L. M., Deyter, G. M., Nishi, S., Wang, T., & Volk, R. J. (2018). Shared decision-making conversations and smoking cessation interventions: critical components of low-dose CT lung cancer screening programs. Translational Lung Cancer Research, 7(3), 254. https://doi.org/10.21037/tlcr.2018.05.10

Stahl, S. M. (2021). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge university press. https://doi.org/10.1017/9781108975292

Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier

 

Please be mindful of plagiarism and APA format, I have included the rubric. Please use my course resources as one of my references as instructed. Please include Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier

Learning Resources
Required Readings (click to expand/reduce)

Kelly, J. E., & Renner, J. A. (2016). Alcohol-Related disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.

Renner, J. A., & Ward, N. (2016). Drug addiction. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.

Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders: Treatment improvement protocol series, no. 32. http://www.ncbi.nlm.nih.gov/books/NBK64350/

Chapter 1, “Substance Use Among Adolescents”
Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”
Chapter 7, “Youths with Distinctive Treatment Needs”
University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control. Journal of Psychosocial Nursing & Mental Health Services, 54(4), 15.

Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375–381. https://doi.org/10.1111/j.1365-2125.2012.04457.x

Hulvershorn, L. A., Schroeder, K. M., Wink, L. K., Erickson, C. A., & McDougle, C. J. (2015). Psychopharmacologic treatment of children prenatally exposed to drugs of abuse. Human Psychopharmacology, 30(3), 164–172. https://doi.org/10.1002/hup.2467

Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing, 42(4), 10–15. https://doi.org/10.3928/00989134-20160314-04

Salmon, J. M., & Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in older adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis, 8(1), 74–84. https://doi.org/10.1080/15504263.2012.648439

Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., Olvera, R., Swann, A. C., & Soares, J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry, 55(6), 1337–1341. https://doi.org/10.1016/j.comppsych.2014.04.018

Medication Resources (click to expand/reduce)

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

naltrexone (revia/vivitrol)
naloxone
acamprosate
disulfiram
Required Media (click to expand/reduce)

Case Study: A Puerto Rican Woman with Comorbid Addiction

Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources (click to expand/reduce)

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)

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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)

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.

I have uploaded the decisions