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 stop to complete the following:

  • Decision #1 
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. 
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
  • Decision #2 
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. 
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3 
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. 
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

reflect on the decisions that you made and share ethical considerations that relate to the case. I would like to see your reasoning for selecting one medication over the other options.

  // Comorbid Addiction (ETOH and Gambling)

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

Puerto Rican female

 

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office 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 two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their 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 two 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 that 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 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 has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert, 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. As 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 & self-reported mood. She visual or auditory hallucinations, 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, al

  // Comorbid Addiction (ETOH and Gambling)

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

Puerto Rican female

 

Decision Point One

Naltrexone (Vivitrol) 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 said that she felt “wonderful” as she has not “touched a drop” to drink 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 have her concerned

Decision Point Two

Select what the PMHNP should do next:



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
  • Client is asking today for you to increase the valium dose or frequency

Decision Point Three

Select what the PMHNP should do next:



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

  // Comorbid Addiction (ETOH and Gambling)

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

Puerto Rican female

 

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 your 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 when she does go. She has noticed that her cigarette smoking is increasing

Decision Point Two

Select what the PMHNP should do next:



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
  • Client reports that she has managed to avoid alcohol as she is afraid of the side effects of the medications when she does drink
  • Client reports that over the course of the past two weeks, her cigarette consumption is “almost double—I’m up to almost 2 packs a day!”

Decision Point Three

Select what the PMHNP should do next:



Continue current doses of medications and discuss smoking cessation options

Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

T

  // Comorbid Addiction (ETOH and Gambling)

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

Puerto Rican female

 

Decision Point One

Campral (acamprosate) 666 mg orally TID

RESULTS OF DECISION POINT ONE

  • Client returns to clinic in four weeks
  • 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
  • Clientis She is also reporting that she is having “out of control” anxiety

Decision Point Two

Select what the PMHNP should do next:



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 you to increase the valium dose or frequency
  • Although she reports that her anxiety is gone, she still reports suicidal ideation, but states “with that valium stuff, who cares?”

Decision Point Three

Select what the PMHNP should do next:



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

Guidance to Student

Given her weight (less than 60 kg), Acamprosate (Campral) should have been started at 666 mg orally BID. Her side effects were most likely related to the high starting dose- higher than the drug should have been started at considering her body weight.

Although the anxiety is problematic side effect, it is not as serious as her suicidal ideation. The suicidal ideation is a side effect which should have signaled the need to discontinue the drug, and consider a different agent such as disulfiram.

Medication should never be added treat sid