Assignment 1: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction
Maryann Ebom
Doctor of Nursing Philosophy, Walden University
NURS 6630: Psychopharmalogical Approaches to Treat Psychopathology
Dr. Reome
Aug 8th, 2022
Assignment 1: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction
Alcohol use disorder contributes a significant proportion of the mental disorder substance use disorder which often occurs as a consequence of maladaptation to pressures in life. Alcohol use disorder co-occurrence with gambling disorder is increasing in prevalence over the years. Each disorder is a known predisposing factor for the other. There is a greater predisposition to morbidity and mortality than when the disorders occur separately (Atkinson, 2018). The purpose of this paper is to discuss the management of this patient in line with pharmacotherapy and psychotherapy, the expectations during and after treatment, and the ethical considerations during management.
Introduction to the Case
This week’s case study discusses a 53-year-old Puerto Rican female Mrs. Perez who has had alcohol use disorder for more than 25 years and has been part of Alcoholic Anonymous though intermittently. Her alcohol use has deteriorated over 2 years since a casino was opened close to her home. She also reports spending huge sums of money on gambling and her alcohol consumption also increases during gambling sprees. She also reports an increase in the frequency of smoking cigarettes over the past 2 years. She has gained 7lb. In her mental state exam, she is alert and oriented with clear speech. She cannot maintain appropriate eye contact and is avoidant. Her subjective mood is sad and her impulse control is impaired. She has no hallucinations, no involuntary stereotyped movements, no suicidal ideations, and her insight and judgment are intact. Her diagnosis is gambling disorder co-occurring with alcohol use disorder. In this case, decision-making in treatment is influenced by the goal of therapy, treatment duration, the dosage of the drug, socioeconomic status of the patient, gender, the individual drug pharmacokinetics, side effects, and toxicity profile. The purpose of this paper is to discuss the management of this patient in line with pharmacotherapy and psychotherapy, the expectations during and after treatment, and the ethical considerations during management.
Decision 1
Naltrexone 380mg Intramuscularly every 4 weeks.
Why did you select this decision?
Naltrexone is considered one of the first-line drugs in the management of alcohol use disorder. Naltrexone is highly efficacious in the prevention of relapse and reduction in heavy consumption of alcohol. It has also been found to have an average efficacy in the promotion of total abstinence in alcohol use disorder patients (Kedia et al., 2022). According to the American Psychiatry Association, naltrexone proves to have modest efficacy in the treatment of alcohol use disorder with few side effects. The extended-release intramuscular naltrexone greatly improves the adherence to medication by reducing the pill burden and limiting the dose to one monthly injection (Edelman et al., 2018). Naltrexone has also been shown to extinguish the urge to gamble (Kraus et al., 2020). These reasons make Naltrexone the most appropriate in Mrs. Perez’ management.
Why did you not select the other two options provided in the exercise?
Acamprosate offers an alternative to naltrexone in the case of a contraindication to naltrexone use. The three-times daily dose of 666mg of Acamprosate is high and often associated with severe side effects like suicidal ideations, anxiety, and tipping into major depression, especially for this patient whose subjective mood is already sad. Disulfiram is an FDA-approved second-line pharmacotherapy for alcohol use disorder (Stokes & Abdijadid, 2019). Disulfiram usage is marred with a lot of adverse effects ranging from confusion states, and convulsions, to death (Patel & Balasanova, 2021). Its use is restricted to patients who are highly motivated to cease alcohol use. Because of these serious side effects, disulfiram use is marred with non-adherence to therapy. For this particular patient, it may be used when the first-line therapy fails. There is no approved pharmacotherapy for gambling disorder hence there is a further need for patient counseling and cognitive behavioral therapy.
What were you hoping to achieve by making this decision?
After induction of treatment, it is expected that the patient will abstain completely from alcohol and there will be long periods before relapse. Reduced craving for alcohol and reduce total alcohol consumption during therapy (Fairbanks et al., 2020). Few adverse effects are expected as the long-acting slow release is effective at minimizing side effects. The patient is expected to be adherent to the medication as there is no pill burden and the injection is only once a month (Kedia et al., 2022). It is expected that the patient will continue smoking and gambling as these drugs do not treat gambling disorders.
How ethical considerations may impact the treatment plan and communication
The treatment of this patient is based on the four tenets of ethical considerations which include justice, non-maleficence, beneficence, and autonomy. Informed consent is important in patient care. The condition is explained to the patient and she is provided with the best treatment choices based on her condition. The side effects of each of the drug choices are explained to the patient (Davis, 2020). Continuous monitoring of these side effects and the well-being of the patient is mandatory. Preservation of patient confidentiality is essential.
Decision 2
Refer to a counselor to address gambling issues
Why did you select this decision?
Counseling is the mainstay of the management of gambling disorders. According to Atkinson et al (2018), psychotherapy is the most effective treatment of gambling disorder. The aspects of counseling may include gambling anonymous groups, cognitive behavioral therapy, and group therapy (Jonas et al., 2019). Pharmacotherapy only deals to reduce the co-morbidities associated with gambling disorder which in this case is alcohol use.
Why did you not select the other two options provided in the exercise?
Mrs. Perez’ anxiety is a direct consequence of gambling disorder. Psychotherapy is provides a higher efficiency in the management of anxiety than pharmacotherapy (Jonas et al., 2019). For this reason, diazepam will be ineffective. Diazepam is not an indicated treatment for gambling disorder. Diazepam would potentiate depression of the central nervous system. Varenicline is effective in aiding in quitting smoking as a nicotine replacement therapy when used alongside counseling as an adjunct therapy (Rigotti et al., 2022). However, it is important to maintain a monotherapy to prevent any drug-drug interactions.
What were you hoping to achieve by making this decision?
Following counseling, the patient’s anxiety is expected to be allayed. The gambling disorder and smoking are expected to have regressed and stopped after 12 weeks of counseling and cognitive behavioral therapy. With continuation and adherence to the monthly dose of naltrexone, the alcohol use disorder is expected to be distinguished with no withdrawal effects.
How ethical considerations may impact the treatment plan and communication
Counseling employs patient privacy and confidentiality to help build trust between the patient and the counselor. Competence and empathetic listening are vital values for a counselor (Palmer & Burrows, 2020). Informed consent is pivotal. The counselor must be registered under the professional body of counselors. Other tenets like justice, beneficence, and nonmaleficence still apply.
Decision 3
Explore the issue that the patient has with the counselor and encourage attendance of the Gamblers’ anonymous meetings.
Why did you select this decision?
The counseling sessions, however, the challenges ensued prove to have started working for this patient. The anxiety is resolved and she feels supported in the support group she joined. This is a worthwhile path that is proving efficacious in her management. There is a need to look into the issue that the patient holds against the counselor and resolve it if possible. If it is unresolvable, referral to another counselor would be the best course (Atkinson, 2018). This poor relationship would lead to default in therapy. Default in therapy may lead to reverting to gambling.
Why did you not select the other two options provided in the exercise?
Naltrexone use in the treatment of alcohol use disorder runs for a minimum of 6 months (Kedia et al., 2022). Discontinuation of naltrexone after 8 weeks of therapy is too soon and this may give room for relapsing to alcohol use disorder. If the patient continues visiting the counselor yet has an issue with her, it could prove detrimental to the course of therapy (DeAngelis, 2019). From this, it is key to aim at improving the patient-counselor relationship.
What were you hoping to achieve by making this decision?
Exploration of the issue with the counselor will fuel a positive interaction with the patient which in turn will improve the outcome of therapy (DeAngelis, 2019). The patient is also expected to stay in remission for the whole duration of therapy. There will be no adverse effects of the drugs.
How ethical considerations may impact the treatment plan and communication
The right of a patient to choose their counselor is important. Respecting the autonomy of the patient in decision-making is another important consideration (Davis, 2020). Maintenance of patient privacy and confidentiality of patient information is golden.
Conclusion
Co-occurrence of gambling disorder with alcohol use disorder is rising in prevalence as one is likely to tip a person into the other. This co-occurrence increases morbidity and mortality among these patients. This case study offers a perfect avenue for discussion of alcohol use disorder co-occurring with gambling disorder and cigarette smoking. The management is mainly based on pharmacotherapy and cognitive behavioral therapy. This patient displays binge alcohol drinking, smoking cigarettes, and spending excess money in her gambling endeavors. The first line of treatment for Alcohol use disorder co-occurring with a gambling disorder is naltrexone and acamprosate (Kedia et al., 2022). Combination therapy of naltrexone and cognitive behavioral therapy is highly efficacious in the management of this particular case (Jonas et al., 2019). Naltrexone is indicated to reduce alcohol cravings, minimize relapse, and abstain and it is also proven to greatly reduce the urge and the frequency of gambling sprees. The slow-release naltrexone greatly improves adherence. Acamprosate on the other hand has a limited advantage profile. It only promotes abstinence. Disulfiram is an FDA second line in the treatment of alcohol use disorder with limited use only in patients who aim at the complete cessation of alcohol use. Its adverse effects profile is severe ranging from light autonomic disturbances to commas and death (Stokes & Abdijadid, 2019). The pharmacotherapy of choice is greatly influenced by the goal of therapy, treatment duration, the dosage of the drug, socioeconomic status of the patient, the individual drug pharmacokinetics, side effects, and toxicity profile of the drug. The ethical considerations are based on justice, non-maleficence, beneficence, and autonomy. Informed consent, preservation of patient confidentiality, privacy, and respect for a patient’s decision is pivotal (Davis, 2020). The effective treatment of alcohol use disorder co-occurring with gambling disorder and cigarette smoking requires a wholesome treatment of the patient involving physical therapy and psychotherapy.
References
Atkinson, J. (2018). Commonalities in the Association of Behavioral Activation and Behavioral Inhibition with Problem Gambling and Alcohol Use in Young Adult College Students. Journal of Gambling Studies, 35(1), 125–141. https://doi.org/10.1007/s10899-018-9788-5
Davis, C. N. (2020). Guidelines and recommendations for training ethical alcohol researchers. Training and Education in Professional Psychology, 14(1), 52–59. https://doi.org/10.1037/tep0000257
DeAngelis, T. (2019, November 1). Better relationships with patients lead to better outcomes. Https://Www.apa.org. https://www.apa.org/monitor/2019/11/ce-corner-relationships
Edelman, E. J., Moore, B. A., Holt, S. R., Hansen, N., Kyriakides, T. C., Virata, M., Brown, S. T., Justice, A. C., Bryant, K. J., Fiellin, D. A., & Fiellin, L. E. (2018). Efficacy of Extended-Release Naltrexone on HIV-Related and Drinking Outcomes Among HIV-Positive Patients: A Randomized-Controlled Trial. AIDS and Behavior, 23(1), 211–221. https://doi.org/10.1007/s10461-018-2241-z
Fairbanks, J., Umbreit, A., Kolla, B. P., Karpyak, V. M., Schneekloth, T. D., Loukianova, L. L., & Sinha, S. (2020). Evidenced-Based pharmacotherapies for Alcohol Use Disorder. Mayo Clinic Proceedings, 95(9). https://doi.org/10.1016/j.mayocp.2020.01.030
Jonas, B., Leuschner, F., Eiling, A., Schoelen, C., Soellner, R., & Tossmann, P. (2019). Web-Based Intervention and Email-Counseling for Problem Gamblers: Results of a Randomized Controlled Trial. Journal of Gambling Studies. https://doi.org/10.1007/s10899-019-09883-8
Kedia, S. K., Ahuja, N., Dillon, P. J., Jones, A., Kumar, S., & Satapathy, S. (2022). Efficacy of Extended-Release Injectable Naltrexone on Alcohol Use Disorder Treatment: A Systematic Review. Journal of Psychoactive Drugs, 1–13. https://doi.org/10.1080/02791072.2022.2073300
Kraus, S. W., Etuk, R., & Potenza, M. N. (2020). Current pharmacotherapy for gambling disorder: a systematic review. Expert Opinion on Pharmacotherapy, 21(3), 287–296. https://doi.org/10.1080/14656566.2019.1702969
Palmer, K. M., & Burrows, V. (2020). Ethical and Safety Concerns Regarding the Use of Mental Health–Related Apps in Counseling: Considerations for Counselors. Journal of Technology in Behavioral Science. https://doi.org/10.1007/s41347-020-00160-9
Patel, A. K., & Balasanova, A. A. (2021). Treatment of Alcohol Use Disorder. JAMA, 325(6), 596. https://doi.org/10.1001/jama.2020.2012
Rigotti, N. A., Kruse, G. R., Livingstone-Banks, J., & Hartmann-Boyce, J. (2022). Treatment of Tobacco Smoking. JAMA, 327(6), 566. https://doi.org/10.1001/jama.2022.0395
Stokes, M., & Abdijadid, S. (2019, April 10). Disulfiram. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459340/
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