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.

· 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

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 Three

Continue current dose of Vivitrol, increase Valium to 10 mg orally TID/PRN/anxiety. Refer to counseling for her ongoing gambling issue

Guidance to Student

Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication, and like other side effects, the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol, or other substance dependencies. Additionally, benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perez’s case.

The most appropriate course of action in this case would be to continue the current dose of Vivitrol, while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At that point, you would need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists.

Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current dose of Valium. Additionally, the client should be referred for counseling to help with her gambling addiction, as there are no FDA approved medications gambling disorder.

Medication should never be added treat side effect of another medication, unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a client with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures).

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.

You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.