Assessing and treating patient with impulsivity 

Assessing and treating patient with impulsivity: Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing problem…

Assessing and treating patient with impulsivity 

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents 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 2 years, she has been having more and more difficulty maintaining her sobriety since the opening of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its 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 2 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 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 she 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 borrowed over $50,000 from her retirement account to pay off her gambling debts, and her husband does not know.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert and 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. When 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 and self-reported mood. She denies visual or auditory hallucinations, and 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

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

Comorbid Addiction (ETOH and Gambling) Case Study
The incidence of pathological gambling continues to rise and fall over time as its definitions, diagnostic criteria, assessments, and instruments change. According to Tacket et al. (2017), approximations of lifetime pathological gambling range from 3.5% to 4%, while precursor problem gambling ranges between 2.9% to 4.8%. Gambling Disorder (GD) refers to a persistent maladaptive pattern of gambling that leads to clinically significant impairment or distress. GD diagnostic criteria require that individuals present with four or more of the nine symptoms experienced within 12 months (Rash et al., 2016). These researchers further opine that the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) had pathological gambling renamed GD and reclassified from impulse control disorder to an addiction-related disorder, thus capturing the long-held conceptualization that GD is an addiction (Rash et al., 2016).
The connection between GD and Alcohol Use Disorder (AUD) includes analogous diagnostic criteria, shared genetic underpinnings, high rates of comorbidity, similar effects on an individual’s neurobiological processes, and standard treatment approaches. Expanding on analogous diagnostic criteria between GD and AUD, the construct of tolerance has it that in GD, the patient gambles with more money to achieve the desired level of excitement. At the same time, the AUD victim increases more amounts of alcohol to achieve the desired effect or needed level of intoxication (Cowlishaw, 2014). This paper, therefore, purposes to outline a three-point decision-making plan for a patient diagnosed with GD and AUD.
Decision Point #1
At decision point 1(DP#1), the treatment options available are to either initiate a Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every four weeks, initiate Antabuse (disulfiram) 250 mg PO daily, or initiate Campral (acamprosate) 666 mg three times a day. Option 1, which entails prescribing Vivitrol injection, 380 mg IM every four weeks, was selected as my best option. Vivitrol is `the injectable form of Naltrexone ad is preferred to oral naltrexone as the latter can cause hepatocellular injury when given in excess. In patients dependent on opioids, Vivitrol precipitates the withdrawal symptomology by occupying the opioid receptors, thus blocking the effects of endogenous opioid peptides. The injection should not be administered intravenously, subcutaneously, or into fatty tissue. Its side effects include nausea, sleepiness, painful joints, and muscle cramps.
In a study comparing the efficacy of LAI naltrexone compared to oral naltrexone and the time to relapse for AUD, it was determined that LAI naltrexone is linked to an increased time to relapse compared to oral naltrexone at the selected VAMC (Leighty & Ansara, 2019). In this study, where 32 patients took part, 16 were put on oral naltrexone, and the other 16 were put on LAI naltrexone. The findings echo those of Anton (2008), who determined that naltrexone was more efficacious than a placebo since it increased the percentage of days of abstinence (80.6% vs. 75.1%). As such, I opted for this option.
Why the Other Two Options Provided In the Exercise Were Not Selected
Starting Antabuse (disulfiram) at 250 mg PO daily was rejected because this drug has Disulfiram works by irreversibly Inhibiting aldehyde dehydrogenase (ALDH1A1) since it competes with nicotinamide adenine dinucleotide (NAD) located at the cysteine residue in the active site of the enzyme. It effectively converts acetaldehyde to acetate since it is a hepatic enzyme of the main oxidative pathway of alcohol metabolism. FDA approval is a second-line option, unlike naltrexone (Stokes & Abdijadid, 2017). The drug is contraindicated in patients with low thyroid hormone levels, diabetes, and organic mental disorder. Its side effects include eye pain, sudden vision loss, jaundice, and unusual thought behavior.
At the same time, there are limited trials to support the efficacy of disulfiram. Some studies report that it does not reduce the craving for alcohol and, if ingested with alcohol, can trigger unpleasant symptoms as it inhibits aldehyde dehydrogenase and the metabolism of alcohol (Winslow et al., 2016). Furthermore, compliance is a significant issue as effectiveness increases if administered under supervision. Acamprosate got its FDA approval for AUD treatment in 2004 and is recommended as a first-line agenda for AUD. Carpenter et al. (2018) also report that it is approved to maintain absence from alcohol use. Acamprosate is also known to have adverse events like diarrhea. The drug also can increase suicidal ideations implying that HCPs have to closely monitor mood changes in the patient (Campral, 2012).
Treatment Goals, Ethical Consideration, and Communication to the Patient
The primary goal for the GD and AUD patient is detoxification after identifying the drug use and problem behavior of gambling. One of the core ethical principles of biomedical ethics is always not to harm, and therefore the patient is not prescribed Campral due to its potential for suicidality.
Results of Decision Point 1
. The patient returns to the clinic in four weeks and reports she feels wonderful and reports not taking any alcohol since receiving the injection. The patient also admits to smoking and occasionally visits the Casino, but she spends quite some money gambling during these visits.
Decision Point #2
At the second decision point (DP#2), the treatment options are to add on valium(diazepam) 5 mg PO TID /PRN anxiety, refer the patient to a counselor to address gambling issues, or add on Chantix (varenicline) 1mg PO BID where the option for referral to a counselor is selected. In a study using a randomized control design with 38 subjects conducted by Wong et al. (2015), it was found that the participants in the experimental group significantly decreased gambling severity and frequencies.
Why the Other Two Options Provided In the Exercise Were Rejected
Dhaliwal et al. (2021) aver that valium (diazepam) is a benzodiazepine drug with FDA approval for short-term anxiety disorders. Like other benzodiazepines, valium exerts its effects by facilitating GABA activity at various sites. In particles, valium binds at the allosteric site within the interface between the alpha and gamma units on GABA- A receptor chloride. Some of the valium’s adverse effects are increased suicidality, high dependency and abuse, respiratory depression, and cardiovascular collapse.
On the other hand, Chantix, whose active component is varenicline, works by blocking the effects of nicotine in the body. It attaches to the nicotine receptors within the brain so that nicotine does not. Chantix ensures dopamine release but in significantly reduced amounts (O’Malley et al., 2018). This action, therefore, helps the patient to quit smoking. Chantix is indicated in smoking but has adverse effects like nausea, insomnia, abnormal vivid dreams, and headaches. Since varenicline excretion occurs through the renal route, the provider should closely monitor the patient’s renal function. The provider should also look for signs of depression, agitation, behavior changes, suicidal ideation, and skin reactions. Compared to non-medication interventions with no side effects, these two options were rejected.
In summary, these two options involved the introduction of a new medication to help address the problem of GD, yet to date, no drug has been approved (Yau et al., 2015). It is instructive to note that the patient reports positive results with LAI Naltrexone on this visit in controlling her AUD since she has touched a drop of alcohol in the last four weeks. Choi et al. (2017) further note that pharmacotherapy can have a positive impact but only if it is used to resolve underlying comorbidities. Opioid receptor antagonists, SSRIs, and mood stabilizers have been used in GD patients. Rickles et al. (1993) conducted a study on multiple TCAs, including diazepam or placebo, over eight weeks, and diazepam was found to be superior to trazodone and imipramine within 14 days, Non – pharmacological interventions are considered first-line treatment in the treatment of anxiety and the medication was therefore rejected.
Treatment Goals and Ethical Considerations
Treatment goals at DP#2 are to correct the cognitive distortion and decision/reward processing associated with gambling. Petry et al. (2006) aver that CBT has shown efficacy in a randomized trial comprising ten weekly 60-minute psychotherapy sessions. At this stage, prescribing medications for gambling disorder would violate the principle of non-maleficence since medications have side effects and the other comorbidity appears to be well controlled with the LAI naltrexone injection (Bipeta, 2019). Other ethical considerations are that the provider should maintain ethical standards expected of compulsive gamblers’ counselors.
Results of DP#2
The patient returns to the clinic in 4 weeks and reports that the anxiety she has been experiencing is gone. She reports she met with the counselor whom she did not like and has joined a support group Gamblers Synonymous (GA), where she even spoke for the first time. She is also very positive and reports feeling supported in this group
Decision Point #3
At Decision Point ( DP#3), the treatment options are to either explore the issue that the patient has with her counselor and simultaneously encourage her to continue attending the Gamblers Anonymous meetings or to encourage Mrs. Perez to continue seeing her current counselor and continue with the Gamblers Anonymous(GA) Group or discontinue Vivitrol, or encourage Mrs. Perez to continue seeing her counselor besides taking part in the support group (GA). I opted for option 1, which is first to explore the patient’s issue with her counselor even as I encourage her to continue participating in the GA meetings. From the outset, compulsive gambling counselors must adhere to ethical standards if their endeavor to cultivate a belief in the dignity and worth of human beings is to be realized. In practicing their craft, the ethical principles of autonomy, beneficence, and justice must guide professional and societal expectations. The counselor needs to try couple therapy instead of individual therapy (Tremblay et al., 2015). In this study, the researchers established five themes, starting with the gambler’s anxiety about having to reveal their gambling problems in couple therapy. Acting non-judgmental way toward the patient would help make her feel accepted.
Why the Other Two Options Provided In the Exercise Were Not Selected
Option 2 was rejected because it implicitly ignores the power of counseling relationships. O’Connor (2019) contends that power differentials between the counselor and their patient can significantly impact the therapeutic relationship. Additionally, two months is considered a very short time to discontinue Vivitrol. According to Zur (2018), providers should decide what they want to share about themselves and the patients during therapy. Likewise, discontinuation of Vivitrol and encouraging the patient to continue taking part in GA meetings was rejected because discontinuing naltrexone at8 weeks is deemed too early. Once discontinued, relapse rates are as high as 39% (Leighty & Ansara, 2019).
Treatment Goals
At DP#3, the main goal of treatment for GD and AUD treatment is to achieve complete abstinence or significant reduction of the two disorders. Once abstinence is achieved, there is a need to prevent relapse. It is important to note that these goals are developed with the patient on a personalized basis. Kim et al. (2018) emphasize the need for motivational interviewing combined with flexibility and willingness to collaborate with the patient to help them achieve the set goals. Successful treatment of these two comorbid disorders requires both to be adequately addressed at every stage of the treatment process.
Conclusion
This essay has determined that GD and AUD are two of the most prevalent comorbid addiction disorders with striking similarities and tend to take similar treatment approaches. Although rare, it has also been established that medication interventions have demonstrated their effectiveness in addressing AUD (Grant et al., 2002). At DP#1, the administration of LAI Vivitrol was selected because of its efficacy in resolving patient adherence to medication by administering a 30-day dose in one injection. Studies on LAI naltrexone in the treatment of AUD indicate it significantly reduces drinking days while increasing abstinence rates and length of continuous abstinence (Garbutt et al., 2005).

Likewise, at DP# 2, a nonpharmacological approach was adopted to address GD and the patient’s anxiety. As Choi et al. (2017) note, no medication has received FDA approval for GD treatment, yet psychotherapy approaches have demonstrated comparative success. Okuda et al. (2017) note that cultural factors like beliefs and values of an individual’s group comprise normative patterns of help-seeking behaviors. Within the context of immigrants, the acculturation process plays a crucial role in initiating and maintaining GD. During therapy, the counselor and the patient can track gambling and no gambling days, and then patients can regard themselves for the non-gambling days (Petry et al., 2005). It is noteworthy to acknowledge that the use of counseling registered success as the patient stopped being anxious and reduced the frequency of gambling visits while constructively taking part in the GA support group.
Lastly, the counselor should cultivate a good therapeutic relationship and always adhere to the set ethical standards, so the patients feel supported. Successful abstinence from alcohol and gambling and becoming constructively engaged would also help the patient stop smoking as time progresses.

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