Walden University
NURS 6630N
Therapy for Clients with Impulsivity, Compulsivity, and Addiction
Introduction
Impulsivity, compulsivity, and addiction are common cases that clinicians encounter in their daily operations. PMHNP should assess the conditions of a patient and make a series of decisions to promote recovery. The case study involves Mrs. Perez who is addicted to alcohol, gambling, and smoking. One of the best medications is Naltrexone (Vivitrol) injection 380mg. Naltrexone is approved by the FDA and has a track record of efficacy in both children and adults (Brünen et al., 2019). The patient should also be referred to a counselor for further assistance. Treatment should also observe ethical issues such as the patient’s autonomy, consent, and patient-centered care. Impulsivity, compulsivity, and addiction require clinicians to make a series of appropriate decisions and monitor their patients to enhance recovery.
Decision #1
Prescribe Naltrexone (Vivitrol) injection 380mg in the gluteal region. The patient should get an injection every four weeks.
Rationale
The purpose of selecting the Naltrexone (Vivitrol) injection 380mg is due to its long history in addressing compulsive disorders associated with alcohol dependence and gambling. Clinicians also indicate that the medication is effective since it has fewer side effects. Stahl (2013) also indicate that Naltrexone injection is one of the best medications that clinicians can use for better results. The injection is also strong enough to generate the necessary results after several weeks (Brünen et al., 2019). For example, the medication works in the brain by reducing the urge to engage in compulsive behavior. Notably, it suppresses the cravings by binding the receptors in the brain that trigger specific behaviors (López et al., 2017). When they bind on the receptor, they inhibit the brain from triggering an urge.
Naltrexone injection is also an effective medication compared to the other two options. One of the reasons is that it is less toxic and thus healthy to the liver. Metabolism and distribution of the drug in the body are effective for both adults and teenagers (López et al., 2017). Metabolism also controls the negative effects of the drug on patients. It also triggers fewer side effects such as nausea. It was also necessary to select an injection to promote compliance levels (Edgerton et al., 2019). For example, it is risky to prescribe oral tablets to a client who has a history of on-and-off engagement in Alcohol Anonymous groups. The information shows that there is a risk the patient can take the medication inconsistently. Non-compliance with medication can undermine the process of recovery and trigger a relapse (Edgerton et al., 2019). A relapse can undermine treatment since it can lead to another period of years of enslavement by the compulsive behavior.
Selecting Naltrexone injection was the best decision compared to the other available medication. One of the reasons is that the medications did not meet the required threshold of providing safety and efficacy in treatment. Antabuse (Disulfiram) 250 mg orally is not a favorable choice for the treatment of the compulsive disorder (Kovács et al., 2017). Antabuse causes significant side effects such as flushing, neck pain, nausea, sweating, and rapid weight gain. The negative effects can lead to non-compliance especially for a client who is already overweight. Side effects of Antabuse can also be complex when the mixed effects of alcohol (Kovács et al., 2017). It is thus not a frontline medication for the treatment of compulsive disorders such as alcohol dependence, gambling, and smoking.
Another option was Campral (acamprosate) 666 mg orally TID, which also did meet the required threshold. Research shows that it can cause severe side effects such as diarrhea, vomiting, loss of appetite, fatigue, dizziness, and weight (Dowling et al., 2016). Some of the side effects can also undermine the health of the 53-year-old woman. It can also lead to non-compliance issues and other health conditions. It can also cause suicidal thoughts, which can be complex when a patient is drunk. It is thus not a preferable option when other available medications such as Naltrexone injection are available (Dowling et al., 2016). Clinicians are required to always prescribe medication that does not expose a patient o harm.
Expected Outcomes
One of the first expected outcomes is that the patient will take the injection and report to the clinic after four weeks. It is expected that she will report a significant reduction in the urge to drink alcohol. For example, the patient can report complete cessation or a reduction in the amount. She is also expected to report a decrease in the urge to gamble at the casino. The two expectations should also be accompanied by the decreased urge to visit the casino. A reduction in compulsive behavior should also involve the cessation of smoking (Dowling et al., 2016). The various conditions are interrelated and thus suppressing one is a great step in overcoming other urges. Stahl (2013) indicates that clinicians can prescribe Naltrexone to address compulsive behaviors such as smoking, alcohol dependence and gambling.
The expected outcomes are based also on the FDA guidelines. The approval guidelines indicate that Naltrexone is safe and efficient to treat addiction to drugs such as alcohol. Research also shows that the medication decreases the pleasurable sensations related to alcohol (Dowling et al., 2016). Taking the injection thus decreases the motivation to take alcohol. The drug is effective and the only side effect is anxiety according to Stahl (2013). However, the anxiety will abate with time.
Actual vs. Projected Outcomes
The first clinic after four weeks, the client reports a major improvement in her condition. For example, she indicates that her urge to drink alcohol has reduced significantly over the last four weeks. According to Mrs. Perez, she has not ‘taken a bottle’ for a month. She reports that the experience is great since she has never failed to take alcohol every week since her 20s. Another positive report is that she is less interested in visiting the casino. However, she only went there twice. As a result, her expenditure on gambling has reduced significantly. However, she indicated that she was still smoking, but with decreasing interest in cigarettes. She also complains about anxiety, which was expected.
The results are similar to the projected outcomes, although with only minor differences. The similarities between the expected results and outcomes show that Naltrexone is a safe and efficient medication for patients with alcohol compulsive behavior (Dowling et al., 2016). One of the outcomes that had not been projected was that she will reduce her expenditure on gambling. The outcome is positive and it shows that the medication should not be changed since it has generated positive results.
Decision #2
Continue with Naltrexone 380mg injection every four weeks.
Rationale
The purpose of continuing with the medication is because it is already generating positive results. Although the patient has not fully recovered, changing the drug is not effective. Treatment of mental disorders requires consistency in the prescription of drugs since abrupt changes in medication can trigger negative outcomes (Luczak & Wall, 2016). For example, the patient reported she has not taken alcohol for the last one month and rarely goes to the casino. She also reports that although she is still smoking, the urge to smoke is decreasing. It is also not effective to introduce a new drug such as Chantix (varenicline) 1 mg orally BID to address an issue such as smoking. Treatment compulsive behaviors do not require polypharmacy since it can lead to negative effects on a patient (Brünen et al., 2019). Drugs such as Chantix can also undermine the treatment of mental disorders by causing suicidal thoughts or depression. Depression can trigger a relapse leading to more alcohol abuse cases (Brünen et al., 2019). In addition, it is not safe to increase the dose since the current one is already generating the expected outcomes. For example, increasing the dose can lead to anxiety.
The decision will also involve assessing the patient for any weight changes. The patient should also honestly indicate if they have reduced appetite. It is essential to educate the patient on the issue to avoid negative outcomes.
During the treatment, it is paramount to refer the patient to a counselor. Compulsive disorders such as gambling and anxiety require counseling therapy (López et al., 2017). One of the approaches that a counselor will apply is cognitive behavior therapy. The approach is crucial in helping an addicted person to replace negative behavior with healthy habits. Research on the treatment of mental disorders shows that pharmacological and non-pharmacological strategies are effective in addressing complex health issues (López et al., 2017).
Projected Outcomes
The patient is expected to report to the clinic after four weeks for further assessment. One of the projected outcomes is that the patient will report a substantial reduction in drinking urges. Research shows that Naltrexone is a reliable medication for the reduction of compulsive disorders such as alcohol addiction (Edgerton et al., 2019). It is also expected that the patient should not be going to the casino, which can trigger her drinking and smoking urges. Another projected outcome is that the patient is no longer interested in gambling or the interesting is dwindling (Edgerton et al., 2019). It is also expected that the sessions with a counselor will lead to positive outcomes.
Actual vs. Projected Outcomes
The patient reports after four weeks with a positive result that the negative behaviors such as alcohol addiction and smoking had reduced significantly. For example, she reported visiting the casino once and did not take any bottle of alcohol. Another positive outcome is that the patient reported the anxiety had abated. Additionally, she indicated that the counselor was awesome in helping her to change her thoughts on gambling. However, she preferred going to the Gambler’s anonymous meetings the counselor referred her to. One of the reasons why the meetings were better is that they had real and practical problems and solutions (Kovács et al., 2017). It is also important to note that the projected outcomes had various similarities with the outcomes. One of the major differences is that the patient preferred the gambler’s anonymous meeting to counseling sessions. However, they indicate that a positive response to treatment is being achieved.
Decision #3
The third decision is to continue with the current medication and encourage the patient to continue attending the gambler’s anonymous meeting. It is also essential to resolve the issue with the counselor.
Rationale
The justification for continuing with the current medication is due to the positive results evident in the patient. For example, the patient has stopped taking alcohol, going to the casino and reduced the rate of smoking. The positive results are part of the expectations of the treatment plan. Additionally, the medication has not generated any significant negative side effects that can warrant a change of medication (Kovács et al., 2017). She is also liking the gambler’s anonymous meetings, which is essential in developing positive behavior. Despite the positive outcomes is, however, not advisable to withdraw the medication. Withdrawing the medication can cause a relapse which is detrimental in treatment (Dowling et al., 2016). A relapse can trigger the patient to resume drinking and gambling.
Projected Outcomes
One of the major expectations is that the patient will continue responding positively to treatment. It is expected that her urge to drink alcohol, smoke or gamble will decline exponentially. PMHNP also expects that the client will no longer visit the casino since the environment or friends can pull her back into negative behavior. The patient should also continue attending the gambler’s anonymous meeting (Dowling et al., 2016). The meetings are essential since they provide the patient with the necessary social support in the endeavor to quit negative behaviors.
Ethical Considerations
One of the ethical issues affecting treatment is promoting open communication with the patient. Stahl (2013) indicates it is essential to inform the patient about the condition, medication, effects, and side effects. The information will help the patient to make an informed choice about the treatment. For example, it is essential to explain to clients issues such as anxiety or weight gain (Luczak & Wall, 2016). Informing the patients will ensure they consent to treatment without coercion. A healthcare provider should also provide medication that does not harm the patient (Brünen et al., 2019). In the current case study, there were other drugs with more negative side effects. Clinicians should always abide by the ethical code ‘do no harm’ (López et al., 2017). The code helps them to always seek the best in every treatment plan. Selecting the best treatment plan will also gain the trust of the patient.
Treatment of patients with mental disorders and negative behaviors should be patient-centered. The focus is to ensure the person can comply with the medication to ensure complete recovery. It is thus crucial to avoid forcing the patient back to the counselor’s office, whereas they already prefer the anonymous meetings. Ethical issues determine the communication between a patient and care provider and improve the efficiency of the treatment plan.
Conclusion
Patients with diverse conditions always report to a clinician’s office seeking treatment. One of the common conditions is co-morbidity such as alcohol addiction and gambling. It is crucial to examine the medical history of a patient to determine the best medication. The case study of Mrs. Perez involves addiction to alcohol, gambling, and smoking. One of the best decisions is to prescribe Naltrexone (Vivitrol) injection 380mg. The drug is effective in the treatment of addiction conditions by suppressing the urge to partake in an activity such as drinking alcohol or smoking. The patient demonstrated positive results and thus it was not essential to change the drug. It was also critical to refer the patient to a counselor for further assistance to resolve the gambling issue. Treatment of clients with impulsivity requires close monitoring of the progress and prudent decision-making to prevent relapse and promote full recovery.
References
Brünen, S., Bekier, N. K., Hiemke, C., Korf, F., Wiedemann, K., Jahn, H., & Kiefer, F. (2019). Therapeutic drug monitoring of naltrexone and 6β-naltrexone during anti-craving treatment in alcohol dependence: reference ranges. Alcohol and Alcoholism, 54(1), 51-55. https://doi.org/10.1093/alcalc/agy067
Dowling, N. A., Merkouris, S. S., & Lorains, F. K. (2016). Interventions for comorbid problem gambling and psychiatric disorders: Advancing a developing field of research. Addictive Behaviors, 58, 21-30. https://doi.org/10.1016/j.addbeh.2016.02.012
Edgerton, J. D., Keough, M. T., & Roberts, L. W. (2019). An exploratory study of alcohol dependence and problem gambling co-development trajectories in young adults. International Gambling Studies, 19(1), 1-21. https://doi.org/10.1080/14459795.2018.1497070
Kovács, I., Richman, M. J., Janka, Z., Maraz, A., & Andó, B. (2017). Decision making measured by the Iowa Gambling Task in alcohol use disorder and gambling disorder: a systematic review and meta-analysis. Drug and Alcohol Dependence, 181, 152-161. https://doi.org/10.1016/j.drugalcdep.2017.09.023
López, C. M., Barr, S. C., Reid-Quiñones, K., & de Arellano, M. A. (2017). Efficacy of Naltrexone for the Treatment of Alcohol Dependence in Latino Populations. Journal of Studies on Alcohol and Drugs, 78(4), 629-634. https://doi.org/10.15288/jsad.2017.78.629
Luczak, S. E., & Wall, T. L. (2016). Gambling problems and comorbidity with alcohol use disorders in Chinese‐, Korean‐, and White‐American college students. The American Journal on Addictions, 25(3), 195-202. https://doi.org/10.1111/ajad.12350
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
