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.
BACKGROUND
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
PLEASE WRITE DECISIONS IN FORMAT OF AN ESSAY TO INCLUDE A PURPOSE STATEMENT, TITLE PAGE, INTRO, BODY, CONCLUSION AND REFERENCES. I HAVE ATTCAHED A SAMPLE FORMAT ESSAY FOR THE SAME TOPIC. PLEASE FOLLOW FORMAT OF ATTACHED FILE AND MAKE PAPER ORIGINAL.
Medication Choices
For this decision tree, three medications are offered:
1) Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
2) Antabuse (Disulfiram) 250 mg orally daily
3) Campral (Acamprosate) 666 mg orally three times/day
Each decision statement should answer all of the following questions. MY DECISIONS ARE DIFFERENT FROM THE SAMPLE PAPER FILE, BUT PAPER NEEDS TO BE IN THE SAME FORMAT WITH THE SAME SUBHEADINGS IN THE SAMPLE PAPER.
Decision #1
Which decision did you select? I selected to start Antabuse (Disulfiram) 250mg orally daily.
Why did you select this decision? All three of these medications are used to treat alcohol dependence but the reason why I choose Antabuse is because the client only has to be sober for 24 hours before initiating treatment (Stahl, 2017). Secondly, Antabuse has been successful in treating alcohol abuse because of the intense side effect individuals get if they consume alcohol while taking Antabuse (Skinner, Lahmek, Pham, & Aubin, 2014). Antabuse as earlier stated intercepts the second stage of alcohol metabolism causing acetaldehyde a highly toxin carcinogen to build up causing an unpleasant feeling for the client like tachycardia, flushing, nausea, and vomiting (Skinner et al., 2014). Hence; due to the unpleasant feeling individuals get for consuming alcohol while on the medication make them stop consuming alcohol.
Why did you not select the other two decisions? I did not select Campral and Naltrexone because the client must be in complete abstinence to commence treatment with these medications (Stahl, 2018).
What were you hoping to achieve by making this decision? I was hoping for the client to stop drinking and reduce gambling.
What was the outcome of your decision? Client returned to clinic in four weeks, and report feeling sedated, fatigue, and has a metallic taste in her month but seems to be going away. Client also report that she has a drink five days after starting the medication and felt like she was going to die, client has reaction like red face, and tachycardia. Client report she continue to visit the casino but spends less than before but her cigarette smoking has reduced.
Was that your expectation? Yes, client has stopped drinking because of unpleasant side effect with Antabuse, also her gambling has reduced. So now let work towards getting total abstinence from alcohol and gambling.
Decision #2
Which decision did you select? I selected to Continue current dose of Antabuse and begin Wellbutrin (bupropion) XL 150 mg orally daily.
Why did you select this decision? I selected this decision because Antabuse is doing what it is supposed to do, and the side effects reported are typical side effects associated with Antabuse and as for the metallic taste, it will eventually go away as evidenced by client statement “seems to be going away” so this is no cause for alarm. I also decided to add Wellbutrin(bupropion) XL to aid in smoking cessation, reduce cravings, and treat depression if there is any. Wellbutrin is exhibited as a successful anti-addiction medication for nicotine (AAC.org, 2018). I also selected to add Wellbutrin because of the effect studies have shown it has on gambling (Black, Arndt, Coryell, Argo, Forbush, Shaw, & Allen, 2007).
Why were the other decisions not selected? I did not select the other two decisions because for one Antabuse is working so there is no needing in adding another alcohol dependence treatment medication like Campral. Also, we are getting some positive result regarding her gambling and is too early to refer her for counseling, we will refer her for counselling if all options fail to correct her gambling habit.
What were you hoping to achieve by making this decision? I was hoping for a decrease in cigarette smoking, alcohol abstinence, and reduction in gambling.
What was the outcome of your decision? The client returned to clinic in four weeks, report she is feeling much better and all reported side effects gone. Client also report a decreased in cigarette smoking, client smokes only a couple of cigarettes a day. Client continue to visit casino, but spending continues to decrease.
Was that your expectation? Yes, I wanted a decrease in cigarette smoking, alcohol abstinence, and decrease spending. All of these was achieved as evidenced by client statement. It will be right to assume that since the client did not report an symptom, it means she is sober. Proceed to decision point three.
Decision #3
Which decision did you select? I selected to maintain current doses of each medication and refer to counselling for her gambling.
Why did you select this decision? I selected to maintain current medications because client is responding to treatment as evidenced by a decrease in cigarette smoking and gambling coupled with alcohol abstinence, hence no change is recommended. Overall, there has being tremendous improve toward cigarette smoking and alcohol consumption, we need counselling to address and attain gambling abstinence. One of the recommended gambling therapies include cognitive behavioral therapy (CBT) (Mayoclinic.org, 2016). CBT focuses on challenging the client regarding her gambling behavior and has evidenced based data proving success with gambling issues (Mayoclinic.org, 2016).
Why were the other decisions not selected? I did not select the other two decisions because, there is no need in increasing Wellbutrin XL because current dose is working just fine, and increase dose may lead to risk for side effects. Client is responding to Antabuse so therefore there is no need to discontinue it.
What were you hoping to achieve by making this decision? I was hoping for a total abstinence from alcohol, gambling and smoking cessation. Am pleased to say therapy was successful.