Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction
The presented case demonstrates a 53-year-old Puerto Rican female with a history of alcohol use disorder ever since her 20s. She however presented to the clinic because of “embarrassing problems” of both alcohol addiction and gambling. She claims that a casino was opened next to her home 2 years ago, which has even made it harder for her to remain sober. She reports enjoying taking alcohol when gambling. She has also increased her cigarette smoking over this period. The patient has also gained weight by about 7 lbs. The patient claims that her gambling made her borrow over $50,000 from her retirement account which she is afraid will bring problems when her husband finds out. Upon conducting the mental status examination, it was noticed that the patient displayed a sad mood with impaired impulse control. She was diagnosed with gambling disorder, and alcohol use disorder as she displayed no other psychiatric symptoms.
Deciding on which medication to prescribe for this patient will depend on several factors affecting her pharmacokinetic and pharmacodynamic processes. For instance, her elderly age, Puerto Rican race, and female gender, in addition to her diagnosis of gambling disorder, and alcohol use disorder will determine the choice of drug to prescribe and the dosage. Her weight gain over the past five years will also help in selecting a drug whose side effects will not worsen the patient’s weight. Several ethical considerations will also be taken into account upon making every decision concerning the most appropriate intervention for the management of the patient’s gambling, cigarette smoking, and alcohol addiction. The purpose of this discussion is to illustrate the decisions made in developing the treatment plan for this patient, with the expected outcome and ethical considerations at each decision point.
Decision #1
Selected Decision and Rationale
The initial intervention was to give naltrexone 380mg intramuscularly injected into the gluteal region every month. Naltrexone is recommended by most national guidelines and professional bodies such as the National Institute for Health and Care Excellence (NICE) as the first line in the management of opioid and alcohol use disorder (Cunningham et al., 2020; Renner & Ward, 2016). It is also approved by the US Food and Drug Administration (FDA) for the same indications given its effectiveness and safety profile displayed by clinical trials (Grant & Chamberlain, 2020; Kelly & Renner, 2016). It acts by purely antagonizing the opioid receptors hence blocking the binding of endogenous opioids. Since the patient has been struggling with the addiction for a long time, it was necessary to consider the long-acting preparation which is only administered once monthly convenient in promoting a high compliance level (Ward et al., 2018). Previous evidence also reports that naltrexone when used with a patient with comorbid alcohol use disorder and gambling, it reduces the urge to gamble by up to 20% (Brière et al., 2019). Consequently, studies show that individuals of Puerto Rican ancestry possess predominantly the genetic polymorphism of the Asp40 allele which is the primary target of naltrexone, hence promoting its effectiveness in managing alcohol addiction (Huggett et al., 2019).
Disulfiram was not appropriate for this patient given that it is short-acting which requires daily administration, in addition to increased incidences of unpleasant side effects such as palpitations and vertigo (Ward et al., 2018). Acamprosate on the other hand is also administered three times a day which is inconvenient for the patient (Brière et al., 2019).
Expected Outcome
Over the following four weeks, the patient will experience a significantly reduced urge to drink alcohol or gamble (Grant & Chamberlain, 2020). She should be able to reduce her smoking habit consequently during this time. No serious adverse effect is expected (Cunningham et al., 2020).
Ethical Considerations
Caring for patients with substance use disorder is always associated with ethical concerns associated with the patient’s judgment, values, and beliefs (Ward et al., 2018). The PMHNP had to consider and respect the patient’s ethnic and social beliefs and values, in addition to displaying great concern for the wellbeing of the patient in a nonjudgmental way (Brière et al., 2019).
Decision #2
Selected Decision and Rationale
The second decision was to refer the patient to a counselor to help with her Gambling. The decision was made based on the reported great effectiveness of the medication in helping the patient stay sober. The patient also reported being anxious, which is a common self-limiting side effect of naltrexone that normally disappears with time (Huggett et al., 2019). However, since the patient’s gambling was still bad, studies show that incorporating psychotherapeutic approaches such as counseling among patients with comorbid substance use and gambling help promote the treatment outcome of both conditions (Grant & Chamberlain, 2020; Kelly & Renner, 2016). The patient also reported that she still smokes, which will be addressed by the specialist who is the counselor (Cunningham et al., 2020). The patient also reported that she still smokes, which is however associated with her gambling habit, hence the need to address gambling as the primary health concern at the moment (Brière et al., 2019; Renner & Ward, 2016).
Valium is addictive and hence discouraged among patients with a history of chronic substance use disorder just like the patient in the provided case study (Ward et al., 2018). Varenicline is also associated with adverse effects when administered as an adjunct to naltrexone such as agitation and nightmares (Huggett et al., 2019).
Expected Outcome
With counseling for the next four weeks, the patient’s urge to gamble will reduce significantly (Brière et al., 2019). She is also expected not to smoke anymore as it was initially brought about by gambling (Grant & Chamberlain, 2020). The anxiety should also resolve within this time. The patient is also expected to continue staying sober.
Ethical Considerations
Nurses are obliged to promote patient-centered care by focusing on their needs. At this point, the patient was concerned with her anxiety and gambling which promoted the need for a counselor (Ward et al., 2018). The PMHNP had to observe ethical principles such as justice, beneficence, and nonmaleficence (Huggett et al., 2019).
Decision #3
Selected Decision and Rationale
The final decision was to explore the issues that the patient was having with her counselor and encourage her to continue taking part in gamblers’ anonymous meetings. The decision was mainly made based on the outcome of the previous intervention as the patient reported that the anxiety had disappeared and she has been active in gamblers anonymous with her main problem being her dislike for the counselor (Brière et al., 2019). Studies show that having a healthy therapeutic relationship between the patient and the counselor is key in promoting the optimal outcomes of psychotherapy (Grant & Chamberlain, 2020; Kelly & Renner, 2016). Challenges with the therapeutic alliance between the patient and the counselor can make her stop therapy (Cunningham et al., 2020; Renner & Ward, 2016). Given that the patient also reported positive outcomes with the Gamblers Anonymous meetings, continuing to participate actively will help manage her gambling even further (Huggett et al., 2019).
Ignoring the patient’s dislike for her counselor was not an appropriate decision as this would have made her stop therapy (Ward et al., 2018). Consequently, discontinuing the use of naltrexone at this point was also not appropriate as the evidence demonstrates the drugs take at least 12 weeks, to completely manage chronic alcoholism (Brière et al., 2019).
Expected Outcome
With appropriate conflict resolution, the patient is expected to enjoy therapy with improved gambling addiction (Huggett et al., 2019). Taking an active role in the Gamblers Anonymous meetings, is also expected to shorten the recovery period (Grant & Chamberlain, 2020). she should be able to stop smoking within this time.
Ethical Considerations
Maintaining a healthy therapeutic alliance between the counselor and the patient is key to promoting positive outcomes. The PMHNP must not discriminate against the patient in any way when addressing the issue, they have with her counselor (Ward et al., 2018). Consequently, respecting the patient’s autonomy is key hence the need to convince her of the importance of continuing with therapy for an optimal outcome (Brière et al., 2019).
Conclusion
The 53-year-old patient in the assigned case study presented with a history of alcohol use disorder and gambling. The patient also reported cigarette smoking which was associated with her gambling. With consideration of this diagnosis in addition to other factors such as her age and race, it was decided that the patient should take naltrexone 380mg intramuscularly injected into the gluteal region every month. Naltrexone is recommended by most clinical practice guidelines for the management of opioid and alcohol addiction due to its great effectiveness and desirable safety profile (Grant & Chamberlain, 2020). Disulfiram and Acamprosate were disregarded due to their increased risks of adverse effects (Ward et al., 2018). After four weeks, the patient reported a positive outcome with alcohol addiction but was concerned about anxiety and gambling (Renner & Ward, 2016). This led to the second decision where the patient was referred to a counselor (Kelly & Renner, 2016). Adding diazepam to the treatment regimen or varenicline was disregarded as it would only complicate the patient’s compliance with an increased incidence of adverse effects (Brière et al., 2019).
After four weeks, the patient reported that her anxiety had disappeared with great progress in Gamblers Anonymous. She, however, disliked her counselor which led to the final decision to examine and address the issues they had and encourages her to continue taking part in Gamblers Anonymous meetings (Huggett et al., 2019). Ignoring the issue, the patient had with her counselor or discontinuing naltrexone was not appropriate at this point. At every decision point, the PMHNP encountered several ethical considerations including respect for patient autonomy and not discriminating against the patient based on her gender, race, or age (Cunningham et al., 2020). Ethical principles such as justice, nonmaleficence, and beneficence were also observed.
References
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