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[ANSWERED!] Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.” 

The Assignment:

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

o Which decision did you select?

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

· Decision #2

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

· Decision #3

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Note: Support your rationale with a minimum of three academic resources no more than five years old. 

Co-morbid Addiction (ETOH and Gambling)

53-year-old 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, alcohol use disorder

Decision Point One:

Select what the PMHNP should do:

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 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 this point, we 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.

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

Expert Answer and Explanation

Assessing and Treating Clients with Impulsivity, Compulsivity, and Addiction

Introduction

Alcohol addiction is one of the compulsive behaviors that can lead to the occurrence of anxiety attacks among patients (Currow et al., 2020). Mrs. Perez, a 53 y.o. woman presents to the facility with difficulty in maintaining sobriety, which she confesses to have affected her for the past two years. She also says that she has had alcohol problems since the death of her father when she was a teenager, and has also been a victim of smoking and reckless gambling (Laureate Education, 2016). In addition, she explains that she is anxious because she has borrowed a total of $50,000 from her retirement account to settle gambling debts without the awareness of her husband (Laureate Education, 2016). The mental status exam shows that she is alert and oriented to person, event, place, and event. She, however, does not maintain eye contact during the interview, and her self-reported mood is sad (Laureate Education, 2016). Though she has impaired impulse control, she denies suicidal ideation. To help control these symptoms, the PMHNP needs to perform a close analysis of some of the suitable medications as presented in the three decision points.

Decision #1

In the first decision point, the PMHNP should give the patient Naltrexone injection 280mg intramuscularly via the gluteal region every four weeks. I would select this option because naltrexone is a common drug for patients with alcohol dependence, and physicians can use it to solve anxiety attacks associated with drug dependence (Parma et al., 2016). By selecting this decision, I would hope to reduce the habit of gambling by the patient as well as smoking. After returning to the clinic in four weeks, the client explains that she has reduced going to the casino, but spends a lot of money when she goes (Laureate Education, 2016). She also explains that she has not stopped smoking has anxiety and is concerned about that. The results of the decision match the expectations partially as the client reduced the gambling habit but was still smoking and had problems in anxiety.

Decision #2

At this level, I would add valium 5mg orally TID/PRN/anxiety. The main reason I would select this option is because the naltrexone given to the patient was ineffective in treating anxiety, and a suitable alternative for the same would be appropriate. Valium would be a suitable alternative because it is also widely used in the treatment of anxiety. By giving this drug, I was hoping to reduce the anxiety experienced by the patient as well as her smoking habits (Shively et al., 2017). The results of the decision is that the patient says that the drug helped her greatly, but later on she had problems waiting before taking one dosage and the next, and could even take it earlier than the recommended time. Also, the patient mentions that she would wish the frequency of the drug increased (Laureate Education, 2016). This shows that the patient could be getting some form of addiction to the drug. The results differ from the expectations because despite reducing the anxiety, the drug has created a new problem of addiction in the patient.

Decision #3

In the last decision point, I would continue the current dose of naltrexone and also the current valium dose, and also refer the client to a counsellor to help solve the gambling problem. By making this decision, I was hoping to control the addiction problem of valium as well as reduce the ongoing problem of gambling. The results of the decision indicate the client is going on with the medication, and that anxiety is a common side effect of naltrexone, which can be efficiently corrected by the valium. Also, the health care giver should not initiate benzodiazepines in a client when she already has problems of drug dependency. It is also not right to use benzodiazepines for long periods as they often increase resistance with usage (Givens, 2016).

The best option at this point would be maintaining the naltrexone dosage while decreasing the dosage of valium with the aim of discontinuing the valium in a period of two weeks. This would allow a close review of whether or not the side effect of anxiety that naltrexone has still persists. Also, there are no FDA approved drugs for gambling, and hence referral of the client to a counsellor would be a suitable course of action (George & Reddy, 2019). Increasing valium dosage or maintaining the current dosage is inappropriate as the client would have greater addiction problems. Medication cannot be used to treat the side effects of another medication unless the side effects are transient. Lastly, the client needs to be encourage d to partner with a local support group of gamblers in which she would slowly quit the gambling habit (Laureate Education, 2016). The smoking cessation options should also be presented to the patient. The results of the decision differ from my expectations in that continuation of valium dosage would bring about more damage of the client, and enhancing the overall health of the patient would need more strategic approaches.

References

Currow, D. C., Chang, S., Reddel, H. K., Kochovska, S., Ferreira, D., Kinchin, I., & Ekström, M. (2020). Breathlessness, Anxiety, Depression, and Function–The BAD-F Study: A Cross-Sectional and Population Prevalence Study in Adults. Journal of pain and symptom management, 59(2), 197-205.

George, E. K., & Reddy, P. H. (2019). Can Healthy Diets, Regular Exercise, and Better Lifestyle Delay the Progression of Dementia in Elderly Individuals? Journal of Alzheimer’s disease, 72(s1), S37-S58.

Givens, C. J. (2016). Adverse drug reactions associated with antipsychotics, antidepressants, mood stabilizers, and stimulants. Nursing Clinics, 51(2), 309-321.

Laureate Education (2016c). Case study: A Puerto Rican woman with comorbid addiction [Interactive media file]. Baltimore, MD: Author

Parma, V., Cellini, N., Guy, L., McVey, A., Rump, K., Worley, J., & Miller, J. (2019). Profiles of Autonomic Activity in Autism Spectrum Disorder with and without Anxiety.

Shively, C. A., Silverstein-Metzler, M., Justice, J., & Willard, S. L. (2017). The impact of treatment with selective serotonin reuptake inhibitors on primate cardiovascular disease, behavior, and neuroanatomy. Neuroscience & Biobehavioral Reviews, 74, 433-443.

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