ASSESSING AND TREATING PATIENTS WITH IMPLUSIVITY, COMPLUSIVITY, AND ADDICTION NURS 6630

ASSESSING AND TREATING PATIENTS WITH IMPLUSIVITY, COMPLUSIVITY, AND ADDICTION NURS 6630

Impulsivity disorders are characterized by the inability to resist the sudden, powerful desire to do something and difficulties controlling emotions or behaviors. On the other hand, addiction is a complex mental condition characterized by compulsive substance use regardless of detrimental consequences. The purpose of this paper is to describe a patient with an addiction disorder and the treatment interventions.

Introduction to the Case

The case scenario depicts Mrs. Perez, a 53-year-old Puerto Rican woman with alcohol drinking problems since her late teenage years. Perez has been a part of Alcoholics Anonymous from time to time for the last 25 years. The patient also reports that she has been finding it more difficult to remain sober in the past two years since a casino was opened in her neighborhood. Perez mentions that she gets high when gambling since she takes some drinks when playing high-stake gambling games. However, this leads to increased alcohol consumption and irresponsible gambling. In addition, the client states she has increasingly been smoking in the past two years and is worried about the adverse health impacts.

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Mrs. Perez reports that she has tried refraining from alcohol consumption, but gambling makes her high, making her take a few drinks to even up. She has also realized that when she consumes alcohol, she smokes minimally, but she enjoys smoking when gambling. The patient has experienced weight gain from excessive drinking, and her current weight is 122 lbs, having gained 7 lbs. The patient is worried since she borrowed more than $50,000 from her retirement account to pay gambling debts. Noteworthy MSE findings include avoiding eye contact, sad mood, and impaired impulse control. Mrs. Perez is diagnosed with Gambling disorder and alcohol use disorder. The patient factors that may affect decision-making with regard to treatment include age, overall health status, comorbid mental health illnesses, the patient’s previous experience with medication, the patient’s beliefs and opinions on useful therapies, history of treatment compliance, and the patient’s motivation for abstinence.

Decision #1

Vivitrol (naltrexone) injection, 380 mg IM in the gluteal region four-weekly.

Reason for this Decision

Naltrexone was the ideal treatment because it is an FDA-indicated drug for treating alcohol use disorder (AUD). Joshi et al. (2021) explain that naltrexone alleviates alcohol cravings, decreases alcohol consumption, and the monthly injectable formulation helps in compliance. Kranzler and Soyka (2018) explain that naltrexone decreases mesolimbic opioidergic activity, thus controlling the dopamine-mediated rewarding effects of alcohol, resulting in decreased alcohol consumption.

Why Other Decisions Were Not Selected

Disulfiram was not ideal because the physical reaction of alcohol and disulfiram causes dizziness, tachycardia, nausea, flushing, chest pain, and BP changes, which can harm patients, making it less recommended (Joshi et al., 2021). Acamprosate was not selected because it is approved by the FDA to promote abstinence in patients who are abstinent when starting treatment (Kranzler & Soyka, 2018). Mrs. Perez was not abstinent and thus not a suitable candidate for acamprosate therapy.

What I Was Hoping To Achieve By Making This Decision

The PMHNP hoped that naltrexone would reduce the patient’s alcohol cravings and excessive consumption (Witkiewitz et al., 2019). Kranzler and Soyka (2018) found that naltrexone effectively reduces the risk of relapse into alcohol and relapse to binge drinking.

Ethical Considerations, Impact on Treatment Plan and Communication

Nonmaleficence impacted the treatment plan since the PMHNP had to select the intervention with the best outcomes and the least side effects. Consequently, naltrexone was chosen for its strong safety profile, and disulfiram was rejected. Respect for autonomy impacted communication with the clinician seeking patient consent to initiate treatment.

Decision #2

Refer the patient to a counselor to address gambling issues.

Reason for this Decision

The patient was referred to a counselor because she had persistent gambling issues that got her into financial problems. Menchon et al. (2018) explain that psychological therapies are the most effective approach for gambling disorders and are connected with marked improvements in the short and the long term. Counseling focuses on the patient, enabling them to search and solve uncertainties, and improving their willingness to change behavior (Ribeiro et al., 2021).

Why Other Decisions Were Not Selected

Adding diazepam to treat anxiety was not ideal because the patient’s anxiety is a likely side effect of naltrexone therapy and thus does not justify medication (Joshi et al., 2021). Chantix was also not added to promote smoking cessation because the smoking problem was linked to gambling, and thus it is important first to solve the gambling issue. Menchon et al. (2018) explain that cognitive behavioral therapy (CBT) facilitates an individual’s understanding of cognitive distortions connected to gambling behavior.

What I Was Hoping To Achieve By Making This Decision

The PMHNP hoped that psychological therapy would help the patient identify cognitive distortions connected with her gambling behavior. Counseling weakens the irrational beliefs, perseveration patterns, and magical thinking associated with the gambling disorder (Menchon et al., 2018). Ribeiro et al. (2021) explain that counseling primarily focuses on the patient’s behavior, cognition, and motivation, thus solving the psychological determinants of gambling.

Ethical Considerations Impact on Treatment Plan and Communication

Beneficence influenced the patient’s treatment since the PMHNP had to refer the patient for counseling to address the gambling issue and promote better health outcomes. Confidentiality impacted communication since the PMHNP had to ensure the patient’s health information was kept confidential and only shared after obtaining the patient’s consent.

Decision #3

Identify the patient’s problems with her counselor, and encourage her to continue attending GA meetings.

Reason for this Decision,

The PMHNP selected this decision because the client reported not liking her counselor, which could affect her adherence to counseling sessions and treatment outcomes. Bolsinger et al. (2020) explain that creating a good therapeutic relationship (TR) in counseling is crucial to improving clinical outcomes, quality of patient care, and patient satisfaction. Kleiven et al. (2020) explain that it is essential for the patient to open up to and connect with personal issues internally, despite this being highly uncomfortable.

Why Other Decisions Were Not Selected

It was not ideal to encourage the patient to continue counseling without addressing the concerns with the counselor because it would have further worsened the therapeutic relationship between Mrs. Perez and the counselor. Kleiven et al. (2020) explain that the TR in psychotherapy is crucial since it facilitates the clients’ ability to approach, acknowledge, and reflect upon challenging issues with sincerity and authenticity. Discontinuing naltrexone was not also ideal because it exhibited efficacy in alleviating alcohol consumption and cravings (Joshi et al., 2021).

What I Was Hoping To Achieve By Making This Decision

The PMHNP hoped that exploring Mrs. Perez’s issues with her counselor would enable her to open up and have an effective relationship with the counselor (Kleiven et al., 2020). Bolsinger et al. (2020) found that a positive TR is connected with better therapy outcomes with regard to clinical improvement, re-hospitalization, and patient satisfaction.

Ethical Considerations Impact on Treatment Plan and Communication

            Beneficence affected the treatment plan since the PMHNP had to help the patient identify her issues with the counselor to create a positive TR, promoting better outcomes. Besides, the respect for autonomy affected communication with the client since the PMHNP had to engage the patient to identify the issues with the counselor and address them.

Conclusion

Mrs. Perez was diagnosed with alcohol use disorder and gambling disorder based on her history of excessive alcohol consumption and gambling, which got her in financial trouble. The patient was prescribed Naltrexone injection, 380 mg four weekly, since it reduces alcohol consumption and alcohol cravings (Joshi et al., 2021). Besides, naltrexone is well-tolerated and is not associated with dependence. Disulfiram was not selected because of its disulfiram-alcohol interaction, which causes BP changes, nausea, chest pain, flushing, dizziness, and tachycardia. Acamprosate was not also ideal because it is indicated for patients who have already achieved abstinence (Kranzler & Soyka, 2018).

 The patient’s gambling disorder persisted, and the PMHNP referred her for counseling. A psychotherapy approach was the most ideal since it is considered the most treatment for gambling disorders and associated with marked improvements in the short and the long term (Menchon et al., 2018). However, she reported having issues with the counselor, although she participated in gambler anonymous groups. Consequently, the PMHNP sought to examine the client’s issues with her counselor and encouraged her to continue attending GA meetings. This was crucial to maintain a positive TR and ensure the client received the maximum from psychotherapy.

References

Bolsinger, J., Jaeger, M., Hoff, P., & Theodoridou, A. (2020). Challenges and Opportunities in Building and Maintaining a Good Therapeutic Relationship in Acute Psychiatric Settings: A Narrative Review. Frontiers in psychiatry, 10, 965. https://doi.org/10.3389/fpsyt.2019.00965

Joshi, P., Duong, K. T., Trevisan, L. A., & Wilkins, K. M. (2021). Evaluation and Management of Alcohol Use Disorder among Older Adults. Current geriatrics reports, 10(3), 82–90. https://doi.org/10.1007/s13670-021-00359-5

Kleiven, G. S., Hjeltnes, A., Råbu, M., & Moltu, C. (2020). Opening Up: Clients’ Inner Struggles in the Initial Phase of Therapy. Frontiers in Psychology, 11, 591146. https://doi.org/10.3389/fpsyg.2020.591146

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review. JAMA, 320(8), 815–824. https://doi.org/10.1001/jama.2018.11406

Menchon, J. M., Mestre-Bach, G., Steward, T., Fernández-Aranda, F., & Jiménez-Murcia, S. (2018). An overview of gambling disorder: from treatment approaches to risk factors. F1000Research, 7, 434. https://doi.org/10.12688/f1000research.12784.1

Ribeiro, E. O., Afonso, N. H., & Morgado, P. (2021). Non-pharmacological treatment of gambling disorder: a systematic review of randomized controlled trials. BMC Psychiatry, 21(1), 105. https://doi.org/10.1186/s12888-021-03097-2

Witkiewitz, K., Litten, R. Z., & Leggio, L. (2019). Advances in the science and treatment of alcohol use disorder. Science advances, 5(9), eaax4043. https://doi.org/10.1126/sciadv.aax4043