Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction A 53-year-old Puerto Rican female, MWe’llaria Perez, presented herself today to the clinic with what she termed an “embarrassing problem.”
Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction
A 53-year-old Puerto Rican female, MWe’llaria Perez, presented herself today to the clinic with what she termed an “embarrassing problem.” She had alcohol problems in her late teenage years after her father died and has struggled with alcohol since her 20s. For the past 2client, she has been inconsistently involved with Alcoholics Anonymous. In the last two years, she has worked to keep sober after a new casino opened near her home. She got hooked when she visited the casino with a friend during its opening. She enjoys gambling and drinks one or two bottles to calm her in high-stake bets. This leads to more drinking and uncontrolled gambling. In the past two years, she has also developed a cigarette smoking problem and is concerned about its effects on her health.
She has attempted to quit drinking; however, gambling stresses her out, and she takes a few drinks to calm down. She smokes less while drinking but smokes more when playing at the machines. She has also gained extra weight from the drinking. She has also borrowed over $50,000 from her retirement account to pay off her gambling debts without the knowledge of her husband.
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Her mental examination shows she is alert and oriented to person, place, time, and event. She is well dressed as per the weather. She has clear, coherent, goal-directed speech and transparent thought processes. She avoids eye contact and has no noteworthy mannerisms, gestures, or tics. She reports she is sad. Her affect reflects the interview content and self-reported mood. She has no visual or auditory hallucinations and no delusions. She has good insight and judgment but impaired impulse control and has no suicidal or homicidal ideation. The patient is diagnosed with comorbid gambling disorder and alcohol use disorder.
Decision #1
The first decision is to give the patient a Vivitrol (naltrexone) injection, 380 mg intramuscularly, in the gluteal region every four weeks as first-line medication. The patient has shown to have increased alcohol dependence due to her gambling problem. The first decision point is to select a medication plan that will combat the patient’s need to use alcohol. Vivitrol is an opioid antagonist. Opioid antagonists block opioid receptors in the brain and induce anti-depressant and anti-addictive activities with a significant reduction in stress responses (Chavkin, 2018). Vivitrol, as an extended-release drug, influences the hypothalamus, pituitary, and adrenal axis action, suppressing the need to drink alcohol.
Antabuse (disulfiram) 250 mg orally every morning and Campral (acamprosate) 666 mg orally TID were not selected due to efficacy and side effects concerns. The patient has a consistent drinking pattern, and therapy may take time to be effective. Both options are less effective if treatment has not been fully initiated and the patient keeps drinking. Adherence and compliance with medication plans have also been noted to be low in patients using disulfiram therapy due to experienced side effects and mode of delivery (de Sousa, 2019). Although animal tests show Campral to be efficacious in alcohol dependence management (Christopher Johnson et al., 2019), it is less effective in humans if the patient continues using it.
The decision to use Vivitrol (naltrexone) injection, 380 mg, was to help achieve progressively reduced alcohol use as the gambling therapy progresses with minimum side effects and risk of relapses. Vivitrol (naltrexone) has also proved to be efficacious in medication-assisted treatment (MAT) in patients with opioid dependency disorders (Rodighiero, 2019). Two examples of ethical considerations impacting the treatment plan are the medication-related safety of the patient and the need to provide the most beneficial treatment plan.
Decision #2
The second decision during the patient’s second visit to the clinic will be to refer her to a counselor to address gambling issues. The patient has noted that she has been feeling wonderful and has abstained from alcohol since the Vivitrol (naltrexone) 380 mg injection. She has reduced her gambling; however, she seems to spend a lot of money when she gambles and still smokes. She also has anxiety. Therefore, a counselor is required to combat the patient’s gambling and anxiety issues. Psychological therapy reinforced with pharmacotherapy is an effective strategy in the management of gambling addiction in patients with or without comorbid psychiatric disorders (Echeburúa & Amor, 2021).
The other available options of adding Valium (diazepam) 5 mg orally TID/PRN for anxiety