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

Co-morbid Addiction (ETOH and Gambling) 53-year-old Puerto Rican Female

Puerto Rican female

Decision Point One

Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the Naltrexone (Vivitrol) Injection, 380mg intramuscularly in gluteal region every 4 weeks

n every 4 weeks

RESULTS OF DECISION POINT ONE

· Client returns to clinic in four weeks

· Mrs. Perez said that she felt “wonderful” as she has not “touched a drop” to drink 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 have her concerned

Decision Point Two

Refer to a counselor to address gambling issues address gambling issues

RESULTS OF DECISION POINT TWO

· Client returns to clinic in four weeks

· Client reports that the anxiety that she had been experiencing is gone

· Client reports that she has met with the counselor, but did not really like her. She did start going to a local meeting gamblers anonymous. She stated that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group

Decision Point Three

Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gambler’s Anonymous meetings

Guidance to Student Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, four 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 you will learn in future courses, ruptures and 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, and 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.

The PMHNP needs to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.

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 stop to complete the following:

·  Decision #1

·  Which decision did you select?

·  Why did you select this decision? Support your response with evidence and references to the Learning Resources.

·  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

·  Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

·  Decision #2

·  Why did you select this decision? Support your response with evidence and references to the Learning Resources.

·  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

·  Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

·  Decision #3

·  Why did you select this decision? Support your response with evidence and references to the Learning Resources.

·  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

·  Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

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

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 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