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. 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. 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.
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 Decision Point One Select what you should do: Vivitrol (naltrexone) 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 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 Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety RESULTS OF DECISION POINT TWO 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 an increase the Valium dose or frequency Decision Point One Antabuse (disulfiram) 250 mg orally every morning RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Mrs. Perez reports to the office complaining of sedation, fatigue, and a “metallic taste” in her mouth, which “seems to be going away.” She also reports that she had just one drink about 5 days after starting the drug and thought that she would “die.” She reports that her face was red, and she felt that her heart would “pound right out of my chest.”
Mrs. Perez also reports that she continues to visit the casino but has not been spending as much money there. She has noticed that her cigarette smoking is increasing Decision Point Two Continue current dose of Antabuse and begin Campral (acamprosate) 666 mg orally BID RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Mrs. Perez reports that the metallic taste is “still there” but that it doesn’t bother her anymore She reports that she has managed to avoid alcohol as she is afraid of the side effects of the medications when she does drink She reports that over the course of the past 2 weeks, her cigarette consumption is “almost double—I’m up to almost 2 packs a day!” Decision Point One Campral (acamprosate) 666 mg orally TID RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Upon return 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 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 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 an increase in the Valium dose or frequency Although she reports that her anxiety is gone. She still reports suicidal ideation, but she states, “With that Valium stuff, who cares?”
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