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This question is on psychopharmacology: In your opinion,

which of the decision tree is best to choose on the 53year old maria Puerto Rican female. HX of alcohol addiction,
Therapies for patients with Impulsivity, compulsivity, and Addiction
There are 3 decision trees, which are the best.
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 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 weighs 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 has 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 the content of the 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 currently denies 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 tim
RESULTS OF DECISION POINT ONE

- The client returns to the clinic in four weeks.
- Mrs. Perez says she feels "wonderful" as she has not "touched a drop" of alcohol since receiving the injection.
- The 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
Select what you should do next:




Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety.
Refer to a counselor to address gambling issues
Add on Chantix (varenicline) 1 mg orally BID.


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 concernedDecision 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 frequencyDecision Point Three
Select what you should do next:






Comorbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female
 
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 concernedDecision 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 frequencyDecision 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

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Student reviews
83% (6 ratings)

"I really thank you for the thorough explanation and rationale for the choice made. It was easy and concise. The beneficent factor for a Nurse practitioner is to cause no harm to the patient. Rather nurture and heal. However, it becomes for me the most integral part of my ethical reasoning. Thanks again. Elizabeth"