Puerto Rican Woman with Comorbid 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.
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.
Mrs. Maria Perez is a 53 year old Puerto Rican
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 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
· 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
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
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
Decision Point Three
Select what you should do next:
Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetings
Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group
Discontinue Vivitrol. Encourage Mrs. Perez to continue seeing her counselor and to continue participating in the Gamblers Anonymous group
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
Refer to a counselor to address gambling issues
RESULTS OF DECISION POINT TWO
• Mrs. Perez returns in 4 weeks and reports that the anxiety that she had been experiencing is gone.
• She reports that she has met with the counselor, but she did not really like her.
• She also started going to a local meeting of Gamblers Anonymous. She states that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group.
Decision Point Three
Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group
Guidance to Student
Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, 8 weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As will be covered in more depth in future courses, ruptures in the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA-approved treatments for gambling addiction. The mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the Gamblers Anonymous meetings, she should be encouraged to continue her participation with this group.
You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.