Week 10: Therapy for Patients With Impulsive/Substance Use Disorders (SUD)

The case study is about a 53-year-old female who presented with complaints about alcoholism and addiction to gambling. She reported that the alcoholism problem began during her teenage-hood when the father died. Her alcoholism has deteriorated within the last two years.  She is also addicted to gambling since there is a casino near her home; the gambling worsens her gambling. Her smoking has also worsened over the last 2 years. She is very concerned about the gambling debts and has not revealed the debts to the husband. The MSE shows that the client is alert and well-oriented. Her speech is coherent and clear. However, her eye contact is avoidant and her self-reported mood is sad. Her affect is appropriate and the insight and judgment grossly intact. Her impulse control is however impaired.  The client was thus diagnosed with gambling disorder, alcohol use disorder.

Decision Point One

The available treatment decisions are Vivitrol (naltrexone) injection, 380 mg; Antabuse (disulfiram) 250 mg; and Campral (acamprosate) 666 mg. Antabuse is an FDA-approved medication to treat alcoholism and works by producing a very unpleasant response when an individual takes alcohol (Pederson et al., 2018) while under the medication. Campral is combined with counseling and support to assist individuals with alcoholism to hinder them from drinking alcohol. The medication is recommended for individuals who are no longer taking alcohol (Spoorthy et al., 2019). Naltrexone is an FDA-approved medication to treat alcoholism and works by preventing the binding of alcohol to receptors and hence reduces the craving to drink alcohol (Lopez et al., 2017). The decision to have the patient start a Naltrexone injection every 4 weeks was selected. This decision was chosen because of the efficacy of naltrexone in treating alcoholism for people who are still taking alcohol like the client has been shown. Moreover, the medication will be administered through injection after four weeks which will improve her adherence to treatment (Aletraris et al, 2015).

By selecting naltrexone, it is expected that the client craves to drink alcohol will reduce due to the efficacy of the medication in reducing alcohol craving (Lopez et al., 2017). It is also expected that she will tolerate the medication.

As expected, after four weeks the client reported that her alcoholism cravings had reduced. Moreover, the frequency of going to the casino decreased, but she reported she was still using a lot of money to gamble. The client also reported that she was having anxiety, a common side effect with naltrexone (Candidate et al., 2017). She also reported increased smoking.

Informed consent was sought from the client before naltrexone was prescribed to the client. This ensured that she understood everything about the medications before agreeing to start treatment.

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Decision Point Two

The available treatment options include adding valium; referring the client to a counselor to address gambling; or adding Chantix. Valium is a benzodiazepine used to treat anxiety while Varenicline is a medication used to treat smoking. The decision to refer the client to a counselor to have the gambling issue addressed was selected because gambling seems to be a major problem for the client and psychotherapy is the mainstay treatment for treating gambling (Torres-Rodríguez et al., 2018).

Referral of the client to a counselor expected that the gambling would stop and thus she would stop spending so much money to gamble. This is due to the efficacy of psychotherapy in treating gambling addiction. The counseling was also meant to address the client’s anxiety.

However, even though the client reported that the anxiety had refused which would, in turn, reduce the gambling, she reported that she did not like her counselor which indicated a poor therapeutic relationship. A poor therapeutic relation is likely to adversely affect the treatment outcomes.

Before the client was referred to a counselor, her informed consent was sought. Additionally, the ethical principle of beneficence was chosen where the referral to the counselor was perceived as the decision likely to have the best care outcomes for the client.

Decision Point Three

The available treatment decisions include exploring the issue the client has with the counselor and encourage her to attend the gamblers anonymous meetings; encourage the client to continue seeing the current counselor and continue attending gamblers anonymous group; or have the client discontinue vivitrol and encourage the client to continue seeing the current counselor and continue attending gamblers, anonymous group. The decision that was selected is to have the issue the client has with the client explored and encourage her to continue going to the gamblers anonymous meetings. This is because a good therapeutic relationship improves health outcomes (Kornhaber et al., 2016). Therefore, the issue needs to be explored to encourage the client to adhere to the treatment in order to treat the gambling addiction. Moreover, the client’s attendance at anonymous meetings with providing her with the necessary peer support so that she can stop the addictions (Tracy & Wallance, 2016). Discontinuing Vivitrol was not considered as this would interfere with the client’s treatment for alcoholism while the option of having the client continue with counseling and attending gambling anonymous meetings was not considered because a poor therapeutic relationship is likely to affect the treatment outcomes and hence there is a need to explore the issue (Kornhaber et al, 2016).

The selection of exploring the issue the client has with the counselor and encourage her to attend the gamblers anonymous meetings expected that the therapeutic relationship would improve to encourage the client’s adherence to treatment.

When selecting this decision, beneficence was applied in order to ensure the best care outcomes for the client. Autonomy was also applied where the client was not forced or influenced in any way to continue her counseling with a counselor she did not like.

Conclusion

The first decision was for the client to start a Naltrexone injection, 380 mg in order to treat alcoholism and promote treatment adherence. With this decision, the client stopped taking alcohol, but she reported serious gambling and increased smoking. The second decision was thus to refer her to a counselor to have the gambling issue addressed since psychotherapy is very effective in treating gambling addiction. However, the client reported that she did not like the counselor, which could interfere with treatment outcomes, due to poor therapeutic relationships. Therefore, the last decision was to explore the issue she could be having with the counselor and encourage her to continue with the gambling anonymous meetings. Before starting treatment, informed consent was obtained from the client. Moreover, her autonomy was respected as she was not forced to have any treatment. Finally, beneficence was applied as all treatment decisions aimed to achieve the best care outcomes for the client.

References

Aletraris L, Edmond M & Roman P. (2015). Adoption of Injectable Naltrexone in U.S. Substance Use Disorder Treatment Programs. J Stud Alcohol Drugs. 76(1): 143–151.

Candidate S, Carnaby G, Cook C & Cook R. (2017). A Systematic Review of Naltrexone for Attenuating Alcohol Consumption in Women with Alcohol Use Disorders (AUD). Alcohol Clin Exp Res. 41(3): 466–472.

Kornhaber R, Walsh K, Duff J & Kim W. (2016). Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review. J Multidiscip Health. 1(9), 537–546.

Lopez C, Barr S & Michael A. (2017). Efficacy of Naltrexone for the Treatment of Alcohol Dependence in Latino Populations. J Stud Alcohol Drugs. 78(4), 629–634.

Pedersen, B., Askgaard, G., Jørgensen, C., Oppedal, K., & Tønnesen, H. (2018). Disulfiram for alcohol use disorder. The Cochrane Database of Systematic Reviews, 2018(9), CD010487. https://doi.org/10.1002/14651858.CD010487.pub2

Spoorthy, M. S., Godi, S., & Singh, L. K. (2019). Deterrent Action of Acamprosate: A Case Report. Addiction & Health, 11(4), 276–280. https://doi.org/10.22122/ahj.v11i4.248

Tracy K & Wallance S. (2016). Benefits of peer support groups in the treatment of addiction.       Subst Abuse Rehabil. 1(1), pp: 143–154.

Torres-Rodríguez A, Mark G & Xavier C. (2018). The Treatment of Internet Gaming Disorder: a Brief Overview of the PIPATIC Program. Int J Ment Health Addict. 16(4), 1000–1015.

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Impulsivity and compulsivity have a wide range of clinical presentations and often overlap with many other psychiatric disorders. Some individuals act without forethought and have difficulty saying “no” to certain things, such as using illicit drugs or spending money, whereas other individuals engage in compulsive behaviors with undesirable consequences. In some cases, these impulsive and compulsive behaviors also fuel issues with addiction. To effectively assess and treat patients, you must understand how these disorders differ as well as how their symptoms impact patients and their families.

This week, as you examine therapies for individuals with impulsivity, compulsivity, and addiction, you explore the assessment and treatment of patients with these disorders. You also consider ethical and legal implications of these therapies.

Learning Objectives

Students will:

Assess patient factors and history to develop personalized therapy plans for patients with impulsivity, compulsivity, and addiction

Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for impulsivity, compulsivity, and addiction

Synthesize knowledge of providing care to patients presenting for impulsivity, compulsivity, and addiction

Analyze ethical and legal implications related to prescribing therapy for patients with impulsivity, compulsivity, and addiction

Learning Resources

Required Readings (click to expand/reduce)

Kelly, J. E., & Renner, J. A. (2016). Alcohol-Related disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.

Renner, J. A., & Ward, N. (2016). Drug addiction. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.

Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders: Treatment improvement protocol series, no. 32. http://www.ncbi.nlm.nih.gov/books/NBK64350/

Chapter 1, “Substance Use Among Adolescents”

Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”

Chapter 7, “Youths with Distinctive Treatment Needs”

University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control. Journal of Psychosocial Nursing & Mental Health Services, 54(4), 15.

Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375–381. https://doi.org/10.1111/j.1365-2125.2012.04457.x

Hulvershorn, L. A., Schroeder, K. M., Wink, L. K., Erickson, C. A., & McDougle, C. J. (2015). Psychopharmacologic treatment of children prenatally exposed to drugs of abuse. Human Psychopharmacology, 30(3), 164–172. https://doi.org/10.1002/hup.2467

Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing, 42(4), 10–15. https://doi.org/10.3928/00989134-20160314-04

Salmon, J. M., & Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in older adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis, 8(1), 74–84. https://doi.org/10.1080/15504263.2012.648439

Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., Olvera, R., Swann, A. C., & Soares, J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry, 55(6), 1337–1341. https://doi.org/10.1016/j.comppsych.2014.04.018

Medication Resources (click to expand/reduce)

IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.

naltrexone (revia/vivitrol)

naloxone

acamprosate

disulfiram

Required Media (click to expand/reduce)

Case Study: A Puerto Rican Woman with Comorbid Addiction

Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources (click to expand/reduce)

Lupi, M., Martinotti, G., Acciavatti, T., Pettorruso, M., Brunetti, M., Santacroce, R., Cinose, E., Di Iorio, G., Di Nicola, M., & Di Giannantonio, M. (2014). Pharmacological treatments in gambling disorder: A qualitative review. Biomed Research International, 2014. https://doi.org/10.1155/2014/537306

Assignment: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction

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.

In your role as the psychiatric nurse practitioner (PNP), you have the opportunity to help patients address underlying causes of the disorders and overcome these behaviors. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with impulsivity, compulsivity, and addiction.

Reference: MentalHelp.net. (n.d.). Impaired decision-making, impulsivity, and compulsivity: Addictions’ effect on the cerebral cortex. https://www.mentalhelp.net/addiction/impulsivity-and-compulsivity-addictions-effect-on-the-cerebral-cortex/

To prepare for this Assignment:

Review this week’s Learning Resources, including the Medication Resources indicated for this week.

Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring therapy for impulsivity, compulsivity, and addiction.

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.

CASE STUDY

omorbid 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 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 #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.

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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.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

 

Rubric

1.)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.

9 (9%) – 10 (10%)

The response accurately, clearly, and fully summarizes in detail the case for the Assignment.

The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.

2.) Decision #1 (1–2 pages)

 

  • 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.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

3.) Decision #2 (1–2 pages)

 

  • 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.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

4.) Decision #3 (1–2 pages)

 

  • 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.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

5.) 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.

14 (14%) – 15 (15%)

The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient.

The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided.

6.) Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 (5%) – 5 (5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

7.) Written Expression and Formatting – English writing standards:

Correct grammar, mechanics, and proper punctuation

5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors.

8.) Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.

5 (5%) – 5 (5%)

Uses correct APA format with no errors.

APA form please, and all references must be within 5yrs.

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