NURS 6630 Assignment 1: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction
Impulsivity disorders are characterized by the inability to resist the sudden, powerful desire to do something and difficulties controlling emotions or behaviors. On the other hand, addiction is a complex mental condition characterized by compulsive substance use regardless of detrimental consequences. The purpose of this paper is to describe a patient with an addiction disorder and the treatment interventions.
Introduction to the Case
The case scenario depicts Mrs. Perez, a 53-year-old Puerto Rican woman with alcohol drinking problems since her late teenage years. Perez has been a part of Alcoholics Anonymous from time to time for the last 25 years. The
patient also reports that she has been finding it more difficult to remain sober in the past two years since a casino was opened in her neighborhood. Perez mentions that she gets high when gambling since she takes some drinks when playing high-stake gambling games. However, this leads to increased alcohol consumption and irresponsible gambling. In addition, the client states she has increasingly been smoking in the past two years and is worried about the adverse health impacts.
Mrs. Perez reports that she has tried refraining from alcohol consumption, but gambling makes her high, making her take a few drinks to even up. She has also realized that when she consumes alcohol, she smokes minimally, but she enjoys smoking when gambling. The patient has experienced weight gain from excessive drinking, and her current weight is 122 lbs, having gained 7 lbs. The patient is worried since she borrowed more than $50,000 from her retirement account to pay gambling debts. Noteworthy MSE findings include avoiding eye contact, sad mood, and impaired impulse control. Mrs. Perez is diagnosed with Gambling disorder and alcohol use disorder. The patient factors that may affect decision-making with regard to treatment include age, overall health status, comorbid mental health illnesses, the patient’s previous experience with medication, the patient’s beliefs and opinions on useful therapies, history of treatment compliance, and the patient’s motivation for abstinence.
Decision #1
Vivitrol (naltrexone) injection, 380 mg IM in the gluteal region four-weekly.
Reason for this Decision
Naltrexone was the ideal treatment because it is an FDA-indicated drug for treating alcohol use disorder (AUD). Joshi et al. (2021) explain that naltrexone alleviates alcohol cravings, decreases alcohol consumption, and the monthly injectable formulation helps in compliance. Kranzler and Soyka (2018) explain that naltrexone decreases mesolimbic opioidergic activity, thus controlling the dopamine-mediated rewarding effects of alcohol, resulting in decreased alcohol consumption.
Why Other Decisions Were Not Selected
Disulfiram was not ideal because the physical reaction of alcohol and disulfiram causes dizziness, tachycardia, nausea, flushing, chest pain, and BP changes, which can harm patients, making it less recommended (Joshi et al., 2021). Acamprosate was not selected because it is approved by the FDA to promote abstinence in patients who are abstinent when starting treatment (Kranzler & Soyka, 2018). Mrs. Perez was not abstinent and thus not a suitable candidate for acamprosate therapy.
What I Was Hoping To Achieve By Making This Decision
The PMHNP hoped that naltrexone would reduce the patient’s alcohol cravings and excessive consumption (Witkiewitz et al., 2019). Kranzler and Soyka (2018) found that naltrexone effectively reduces the risk of relapse into alcohol and relapse to binge drinking.
Ethical Considerations, Impact on Treatment Plan and Communication
Nonmaleficence impacted the treatment plan since the PMHNP had to select the intervention with the best outcomes and the least side effects. Consequently, naltrexone was chosen for its strong safety profile, and disulfiram was rejected. Respect for autonomy impacted communication with the clinician seeking patient consent to initiate treatment.
Decision #2
Refer the patient to a counselor to address gambling issues.
Reason for this Decision
The patient was referred to a counselor because she had persistent gambling issues that got her into financial problems. Menchon et al. (2018) explain that psychological therapies are the most effective approach for gambling disorders and are connected with marked improvements in the short and the long term. Counseling focuses on the patient, enabling them to search and solve uncertainties, and improving their willingness to change behavior (Ribeiro et al., 2021).
Why Other Decisions Were Not Selected
Adding diazepam to treat anxiety was not ideal because the patient’s anxiety is a likely side effect of naltrexone therapy and thus does not justify medication (Joshi et al., 2021). Chantix was also not added to promote smoking cessation because the smoking problem was linked to gambling, and thus it is important first to solve the gambling issue. Menchon et al. (2018) explain that cognitive behavioral therapy (CBT) facilitates an individual’s understanding of cognitive distortions connected to gambling behavior.
What I Was Hoping To Achieve By Making This Decision
The PMHNP hoped that psychological therapy would help the patient identify cognitive distortions connected with her gambling behavior. Counseling weakens the irrational beliefs, perseveration patterns, and magical thinking associated with the gambling disorder (Menchon et al., 2018). Ribeiro et al. (2021) explain that counseling primarily focuses on the patient’s behavior, cognition, and motivation, thus solving the psychological determinants of gambling.
Ethical Considerations Impact on Treatment Plan and Communication
Beneficence influenced the patient’s treatment since the PMHNP had to refer the patient for counseling to address the gambling issue and promote better health outcomes. Confidentiality impacted communication since the PMHNP had to ensure the patient’s health information was kept confidential and only shared after obtaining the patient’s consent.
Decision #3
Identify the patient’s problems with her counselor, and encourage her to continue attending GA meetings.
Reason for this Decision,
The PMHNP selected this decision because the client reported not liking her counselor, which could affect her adherence to counseling sessions and treatment outcomes. Bolsinger et al. (2020) explain that creating a good therapeutic relationship (TR) in counseling is crucial to improving clinical outcomes, quality of patient care, and patient satisfaction. Kleiven et al. (2020) explain that it is essential for the patient to open up to and connect with personal issues internally, despite this being highly uncomfortable.
Why Other Decisions Were Not Selected
It was not ideal to encourage the patient to continue counseling without addressing the concerns with the counselor because it would have further worsened the therapeutic relationship between Mrs. Perez and the counselor. Kleiven et al. (2020) explain that the TR in psychotherapy is crucial since it facilitates the clients’ ability to approach, acknowledge, and reflect upon challenging issues with sincerity and authenticity. Discontinuing naltrexone was not also ideal because it exhibited efficacy in alleviating alcohol consumption and cravings (Joshi et al., 2021).
What I Was Hoping To Achieve By Making This Decision
The PMHNP hoped that exploring Mrs. Perez’s issues with her counselor would enable her to open up and have an effective relationship with the counselor (Kleiven et al., 2020). Bolsinger et al. (2020) found that a positive TR is connected with better therapy outcomes with regard to clinical improvement, re-hospitalization, and patient satisfaction.
Ethical Considerations Impact on Treatment Plan and Communication
Beneficence affected the treatment plan since the PMHNP had to help the patient identify her issues with the counselor to create a positive TR, promoting better outcomes. Besides, the respect for autonomy affected communication with the client since the PMHNP had to engage the patient to identify the issues with the counselor and address them.
Conclusion
Mrs. Perez was diagnosed with alcohol use disorder and gambling disorder based on her history of excessive alcohol consumption and gambling, which got her in financial trouble. The patient was prescribed Naltrexone injection, 380 mg four weekly, since it reduces alcohol consumption and alcohol cravings (Joshi et al., 2021). Besides, naltrexone is well-tolerated and is not associated with dependence. Disulfiram was not selected because of its disulfiram-alcohol interaction, which causes BP changes, nausea, chest pain, flushing, dizziness, and tachycardia. Acamprosate was not also ideal because it is indicated for patients who have already achieved abstinence (Kranzler & Soyka, 2018).
The patient’s gambling disorder persisted, and the PMHNP referred her for counseling. A psychotherapy approach was the most ideal since it is considered the most treatment for gambling disorders and associated with marked improvements in the short and the long term (Menchon et al., 2018). However, she reported having issues with the counselor, although she participated in gambler anonymous groups. Consequently, the PMHNP sought to examine the client’s issues with her counselor and encouraged her to continue attending GA meetings. This was crucial to maintain a positive TR and ensure the client received the maximum from psychotherapy.
References
Bolsinger, J., Jaeger, M., Hoff, P., & Theodoridou, A. (2020). Challenges and Opportunities in Building and Maintaining a Good Therapeutic Relationship in Acute Psychiatric Settings: A Narrative Review. Frontiers in psychiatry, 10, 965. https://doi.org/10.3389/fpsyt.2019.00965
Joshi, P., Duong, K. T., Trevisan, L. A., & Wilkins, K. M. (2021). Evaluation and Management of Alcohol Use Disorder among Older Adults. Current geriatrics reports, 10(3), 82–90. https://doi.org/10.1007/s13670-021-00359-5
Kleiven, G. S., Hjeltnes, A., Råbu, M., & Moltu, C. (2020). Opening Up: Clients’ Inner Struggles in the Initial Phase of Therapy. Frontiers in Psychology, 11, 591146. https://doi.org/10.3389/fpsyg.2020.591146
Kranzler, H. R., & Soyka, M. (2018). Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review. JAMA, 320(8), 815–824. https://doi.org/10.1001/jama.2018.11406
Menchon, J. M., Mestre-Bach, G., Steward, T., Fernández-Aranda, F., & Jiménez-Murcia, S. (2018). An overview of gambling disorder: from treatment approaches to risk factors. F1000Research, 7, 434. https://doi.org/10.12688/f1000research.12784.1
Ribeiro, E. O., Afonso, N. H., & Morgado, P. (2021). Non-pharmacological treatment of gambling disorder: a systematic review of randomized controlled trials. BMC Psychiatry, 21(1), 105. https://doi.org/10.1186/s12888-021-03097-2
Witkiewitz, K., Litten, R. Z., & Leggio, L. (2019). Advances in the science and treatment of alcohol use disorder. Science advances, 5(9), eaax4043. https://doi.org/10.1126/sciadv.aax4043
There is a close connection between impulsivity, compulsivity, and addiction. While addiction is defined as a process coordinating the change from an impulsive to compulsive behavior, impulsivity occurs in the early stages of addiction. A person acting impulsively experiences the pleasure of their addiction, and the compulsive aspect would take control when there is a shift causing a person to stay away from their addictions. However, the compulsive behavior would compel a person to participate in their addictions to relieve themselves from the withdrawal effects. The purpose of this paper is to show how to assess and develop a personalized treatment plan for clients with impulsivity, compulsivity, and addiction based on the decision on medications to prescribe to a client, including ethical and legal implications related to the described treatment for clients with impulsivity, compulsivity and addiction.
Introduction to the Case Study
The case in this assignment involves a 53-year-old Puerto Rican female who was administered to the clinic because of an “embarrassing problem” with alcohol addiction in her early 20s when her father passed. The client’s report on being involved in alcoholism is anonymously defined as “on and off” for the past 25 years. The patient also has difficulty in maintaining sobriety which has worsened in the last two years due to her battling with gambling addiction after a casino was opened near her home. This increased the rate of her cigarette smoking, and she is concerned about the negative effect of cigarette smoking on her health.
Decision #1
Initiate the treatment with Naltrexone (Vivitrol) 380mg injection intramuscularly through the gluteal region after every four weeks.
Reason for this Decision
Naltrexone (Vivitrol) is a common description for alcohol addiction, and it works by reducing the amount of alcohol intake by modulating opioid systems. Solli et al. (2018) ascertains that this aids in reinforcing the side effects of alcohol. FDA approved Naltrexone injection in 2006 to address the problem of compliance with oral Naltrexone. The drug is taken monthly instead of taking the daily oral dosage of Naltrexone, that is used to reduce the opportunity of patients discontinuing their medications impulsively.
Why Other Decisions Were Not Selected
Antabuse (Disulfiram) 250 mg orally daily and Campral (Acamprosate) 666 mg orally three times a day are not ideal for this client. These medications are always prescribed for clients who would want to continue abstaining from alcohol. A client taking Antabuse and drinking alcohol may experience adverse side effects such as alcohol toxicity (Mason & Heyser, 2021). This makes this drug not ideal for the client at this time. On the other hand, Campral is not fit for the client because of her weight. She weighs 122lbs which is less than 132lbs. Such patients should take four tablets a day instead of six.
What I Was Hoping to Achieve by Making This Decision
By administering this medication, I hope to decrease the alcohol craving in the patient without letting her go through severe side effects and any future relapses. Naltrexone injection can start working within a few days, but its optimal effect would not be seen until the end of one or two weeks. After four weeks, the client reported to the clinic that she felt wonderful and had not craved alcohol or been in the casino as often since she received her first Naltrexone injection. However, she is concerned that her smoking habit is still persistent and also fights the problem of anxiety and goes to the casino.
Ethical Considerations Impact on Treatment Plan and Communication
Beneficence and patient right to autonomy influence the treatment plan for the patient. I had to select a medication associated with the best outcomes and consequently prescribed Naltrexone injection because there is evidence supporting its efficacy in treating addiction. Besides, I had to seek consent from the patient to initiate treatment.
Decision #2
Refer the client to a counselor to address the gambling issue.
Reason for this Decision
Despite the client responding positively to the given treatment, her gambling addiction is still persistent and needs to be addressed. Therefore, referring her to a counselor is the correct stage to take for the client. Fighting gambling addiction is not easy, but it can be achieved with the help of support groups and treatment programs. The counselor helps the client to identify the underlying cause of pathogenic gambling (Pettorruso et al., 2020). One cause of gambling is living in an environment where gambling is widely practiced and accepted. Such environments increase the chances of a person becoming a compulsive gambler. In this case, the client got hooked on gambling when her friend went to see the new casino that had just been launched. Support groups will allow gamblers to share their feelings and, experiences, strengths, and hope that they may solve their problems collectively. On the other hand, the client reported feeling anxiety as a side effect of the Naltrexone injection. To solve this, the client should be educated on the side effect and allow her body to adjust to the medication.
Why Other Decisions Were Not Selected
Other treatment choices for anxiety, such as Valium (diazepam) 5 mg orally TID/PRN and Chantix (Varenicline) 1 mg orally BID, are not correct now. The client already has addiction treatment, and it would not be wise to add Valium, a long-acting benzodiazepine and highly addictive (Zahid et al., 2018). On the other hand, Chantix could be significant to stop smoking, but the main priority, in this case, is to stop or bring the gambling habit under control.
What I Was Hoping to Achieve by Making This Decision
I am hoping that the client will report positive effects from counseling and support programs. I expect that the client will continue with the current medication of Naltrexone injection with no side effects (Solli et al., 2018). The client returned to the clinic after four weeks reporting that the anxiety was gone, and she met with the counselor. However, she complained that she never liked her counselor but also admitted that she felt supported by the support groups she had joined.
Ethical Considerations Impact on Treatment Plan and Communication
Beneficence and nonmaleficence impacted treatment since I had to select a therapy that would improve the patient’s outcomes without compromising safety. For example, I switched to counseling to enhance the patient’s outcomes and alleviate the side effects of anxiety brought by Naltrexone injection (Pettorruso et al., 2020). Confidentiality impacted communication since I had to assure the patient that the information would be kept confidential and only shared after their consent.
Decision #3
Address the issue that the patient is facing with the counselor and encourage to attend the support group.
Reason for this Decision
At this point, the client is making better progress with the given treatment. However, the issue that the client is facing with the counselor needs to be addressed as it could trigger relapse in the current treatment.
Why Other Decisions Were Not Selected
The other option of discontinuing the Naltrexone injection and encouraging the patient to continue seeing her counselor, and going to the support group program is not appropriate at this time (Pettorruso et al., 2020). The naltrexone injection effect may be invisible for four weeks. Therefore, it is not advisable to discontinue the medication as early as now. It is also imperative that the client be encouraged to attend the support groups while solving the issue between her and the counselor.
What I Was Hoping to Achieve by Making This Decision
I am hoping that the client will continue with her treatment of Naltrexone injection, support group program, and counseling to increase the progress on the treatment plan. Although gambling addiction might be serious, it could be approached by combining various therapeutic modalities to meet a better patient outcome.
Ethical Considerations Impact on Treatment Plan
Beneficence affected treatment since I had to maintain Naltrexone injection, support programs, and counseling since they are associated with better outcomes, and studies support their efficacy in alleviating addiction symptoms. I had to involve the patient in making treatment decisions, which shows respect for autonomy and affects communication.
Conclusion
The 53-year-old Puerto Rican female reports that she had been admitted to the clinic with an embarrassing problem related to her alcohol, gambling, and smoking addiction. In my treatment plan, I initiated the medication by offering Naltrexone (Vivitrol) 380mg injection intramuscularly through the gluteal region after every four weeks. The client responded positively to the treatment and reported her alcohol addiction. However, she was still struggling with gambling, so I decided to refer her to counseling and support groups to solve her issues related to gambling. Her following assessment showed positive results because she was refraining from gambling. My third decision was to continue her on Naltrexone (Vivitrol) 380mg injection intramuscularly through the gluteal region after every four weeks and solve issues she was facing with her counselor. These measures gave a positive outcome to the patient despite them triggering beneficence and nonmaleficence ethical principles.
References
Bifarin, O., & Stonehouse, D. (2022). Beneficence and nonmaleficence: collaborative practice and harm mitigation. British Journal of Healthcare Assistants, 16(2), 70-74. https://doi.org/10.12968/bjha.2022.16.2.70
Mason, B. J., & Heyser, C. J. (2021). Alcohol use disorder: The role of medication in recovery. Alcohol Research: Current Reviews, 41(1). https://doi.org/10.35946%2Farcr.v41.1.07
Pettorruso, M., Zoratto, F., Miuli, A., De Risio, L., Santorelli, M., Pierotti, A., … & di Giannantonio, M. (2020). Exploring dopaminergic transmission in gambling addiction: A systematic translational review. Neuroscience & Biobehavioral Reviews, 119, 481-511. https://doi.org/10.1016/j.neubiorev.2020.09.034
Solli, K. K., Latif, Z. E. H., Opheim, A., Krajci, P., Sharma‐Haase, K., Benth, J. Š., … & Kunoe, N. (2018). Effectiveness, safety and feasibility of extended‐release Naltrexone for opioid dependence: a 9‐month follow‐up to a 3‐month randomized trial. Addiction, 113(10), 1840-1849. https://doi.org/10.1111/add.14278
Zahid, H., Tsang, B., Ahmed, H., Lee, R. C. Y., Tran, S., & Gerlai, R. (2018). Diazepam fails to alter anxiety-like responses but affects motor function in a white-black test paradigm in larval zebrafish (Danio rerio). Progress in Neuro-Psychopharmacology and Biological Psychiatry, 83, 127-136. https://doi.org/10.1016/j.pnpbp.2018.01.012
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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.
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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.
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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.
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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.
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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.
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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.
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Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
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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.
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Total Points: 100
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