Treating Impulsivity, Compulsivity, and Addiction

The Assignment
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. Treating Impulsivity, Compulsivity, and Addiction
ACTUAL ASSIGNMENT
PLEASE Addressed each of the following bullets with a subtopic, include references; in-text citation in each paragraph. Please use my articles and any additional one should come from USA and must be within last five years only that is from 2014 to 2018. Please do not begin a paragraph with author name(s) (PLEASE USE parenthetical/in-text citations) Thanks
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At each decision point stop to complete the following:
• Decision #1
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
 Include how ethical considerations might impact your treatment plan and communication with clients.

CASE STUDY: 53-year-old Puerto Rican Female
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/08/mm/co-morbid_addiction_etoh_and_gambling/index.html

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. Treating Impulsivity, Compulsivity, and Addiction
Diagnosis: Gambling disorder, alcohol use disorder

Decisions Made and Outcomes (Needed to formulate the paper)
Decision Point One: Select what the PMHNP should do:
Naltrexone (Vivitrol) 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
My Decision: Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region 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
Select what the PMHNP 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
My Decision: Refer to a counselor to 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
Select what the PMHNP 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
My Decision: Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers 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.

REFERENCES/RESOURCES
Required Media
Laureate Education (2016c). Case study: A Puerto Rican woman with comorbid addiction [Interactive media file]. Baltimore, MD: Author
Note: This case study will serve as the foundation for this week’s Assignment.

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
• Chapter 14, “Impulsivity, Compulsivity, and Addiction”
Stahl, S. M., & Grady, M. (2012). Stahl’s illustrated substance use and impulsive disorder New York, NY: Cambridge University Press.
To access the following chapter, click on the Illustrated Guides tab and then the Substance Use and Impulsive Disorders tab.
• Chapter 10, “Disorders of Impulsivity and Compulsivity”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press. Treating Impulsivity, Compulsivity, and Addiction
To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
Book Excerpt: Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders. Treatment Improvement Protocol Series, No. 32. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64350/
• Chapter 1, “Substance Use Among Adolescents”
• Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”
• Chapter 7, “Youths with Distinctive Treatment Needs”
University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control in adulthood, study finds. Retrieved from https://www.sciencedaily.com/releases/2016/01/160120201324.htm
Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375–381. doi:10.1111/j.1365-2125.2012.04457.x
Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing, 42(4), 10–15. doi:10.3928/00989134-20160314-04
Salmon, J. M., & Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in older adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis, 8(1), 74–84. doi:10.1080/15504263.2012.648439
Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., & … Soares, J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry, 55(6), 1337–1341. doi:10.1016/j.comppsych.2014.04.018
Treating Impulsivity, Compulsivity, and Addiction

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