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 migh

CORMORNID ADDICTION (ETOH AND GAMBLING)

53-YEAR-OLD PUERTO RICAN FEMALE

BACKGROUND

MRS. MARIA PEREZ IS A 53-YEAR-OLD PUERTO RICAN FEMALE WHO PRESENTS TODAY DUE TO A RATHER “EMBARRASSING PROBLE”.

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 20s AND HAS BEEN INVOLVED WITH ALCOHOL ANONYMOUS “ON AND OFF” FOR THE PAST 25 YEARS. SHE STATES THAT FOR THE PAST 2 YEARS, SHE HAS BEEN HAVING MORE AND MORE DIFFICULTIES MAINTAING HER SOBRIETY SINCE THE OPENING OF THE NEW “RISEN 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 REPORT THAT HER CIGARRETTE 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 HAS ATTEMPTED TO SUBSTAIN FROM DRINKING BUT SHE GETS SUCH A “HIGH” FROM THE ACT OF GAMBLING THAT SHE NEEDS A FEW DRINKS TO “EVEN OUT.” SHE ALSO NOTICED THAT WHEN SHE DRINKS, SHE DOSEN’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 122LBS, WHICH REPRESENTS A 7LB WEIGHT GAIN FROM HER USUAL 115 LBS WEIGHT.

MRS. PEREZ IS QUIET 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 EVENTS. SHE IS DRESSED APPROPRIATE 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 DEMONSTATES NO NOTEWORTHY MANNERISMS, GESTURES OR TICS. SHE SELF-REPORTED MOOD IS “SAD.” AFFECT IS APPROPRIATE TO CONTENT OF CONVERSATION AND SELF-REPORTED MOOD. SHE DENIES AUDITORY OR VISUAL HALLUCINATIONS, AND NO DELUSIONAL OR PARANOID THOUGHT PROCESSES ARE READILY APPRECIATED. INSIGHT AND JUDGEMENT ARE GROSSLY INTACT;HOWEVER, IMPULSE CONTROL IS IMPAIRED. SHE IS CURRENTLY DENYING SUICIADAL OR HOMICIDAL IDEATIONS.

DIAGNOSIS: GAMBLING DISORDER, ALCOHOL USE DISORDER

DECISION POINT ONE

SELECT WHAT YOU SHOULD DO

• VIVTROL (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

RESULTS TO DECISION POINT ONE

1. CLIENT RETURNS TO THE CLINIC IN FOUR WEEKS

2. UPON RETURN MRS PEREZ HAS STATES THAT SHE NOTICED THAT SHE HAS BEEN HAVING SUICIDAL IDEATIONS OVER THE PAST WEEK, AND IT SEEMS TO BE GETTING WORST.

3. SHE IS ALSO REPORTING THAT SHE IS HAVING “OUT OF CONTROL” ANXIETY

DECISION POINT TWO

SELECT WHAT YOU SHOULD DO

• EDUCATE MRS. PEREZ ON THE SIDE EFFECTS OF CAPRAL AND ADD VALIUM (DIAZEPAM) 5 MG ORALLY TID TO ADDRESS ANXIETY SYMPTOMS

• DISCONTINUE CAPRAL AND BEGIN ANATABUSE (DISULIFRAM) 250 MG ORALLY DAILY

• DECREASE CAPRAL TO 666 MG ORALLY BID

RESULTS OF DECISION POINT TWO

1. CLIENT RETURNS TO THE CLINIC IN FOUR WEEKS

2. MRS. PEREZ STATES THAT THE SUICIDAL THOUGHTS HAVE ABATED BUT REPORTS THAT SHE HAS BEEN FEELING TIRED FOR SEVERAL HOURS AFTER TAKING THE DRUG

3. SHE REPORTS THAT SHE HAS NOT BEEN GOING TO THE CASINO BECAUSE SHE IS AFRAID THAT SHE MIGHT BE TEMPTED TO DRINK, AND SHE NOTICED THAT THE LAST TIME SHE DRANK, SHE FELT NAUSEOUS AND BEGAN TO VOMIT. SHE ALSO REPORTED THAT IT FELT LIKE HER HEART WOULD “POUND RIGHT OUT” OF HER CHEST.” SHE DOES REPORT THAT SHE IS SMOKING MORE HOWEVER.

DECISION POINT THREE

SELECT WHAT YOU SHOULD DO

• DISCONTINUE ANTABUSE AND DISCUSS SMOKING CESSATION OPTIONS

• CONTINUE ANTABUSE IN THE MORNING AND DISCUSS SMOKING CESSATION OPTIONS

• CHANGE ANTABUSE DOSE TO BEDTIME AND DISCUSS SMOKING CESSATION OPTIONS

GUIDANCE TO STUDENT

SEDATION OCCURS IN MANY PEOPLE TAKING ANATABUSE. MRS. PEREZ IS EXPERIENCING SIDE EFFECTS WHEN SHE CONSUMES ALCOHOL WITH THIS DRUG, WHICH IS THE EXPECTED/INTENDED THERAPUETIC EFFECT. AS A “SIDE EFFECT” SHE IS AVODING THE CASINO, WHICH IS ALSO HELPING. AT THIS POINT IT IS NOT APPROPRIATE TO DISCONTINUE ANTABUSE. DESPITE THE FACT THAT CONTROVERSY EXISTS REGARDING HOW LONG SOMEONE SHOULD REMAIN ON THIS MEDICATION, THE CLIENT HAS ONLY BEEN ON THIS DRUG FOR FOUR WEEKS. ADDITIONAL TIME ON THIS MEDICATION WOULD BE PRUDENT.

TO MINIMIZE THE SIDE EFFECT OF SEDTION, THE ADMINISTRATION OF THE DRUG SHOULD BE CHANGED TO BEDTIME. IN ALL CASES, YOU NEED TO DISCUSS SMOKING CESSATION OPTIONS WITH MRS. PEREZ IN ORDER TO ADDRESS THE TOTALITY OF ADDICTIONS AND TO ENHANCE HER OVERALL HEALTH.

ADDITIONALY, IT SHOULD BE NOTED THAT ALTHOUGH MRS. PEREZ HAS REPORTED THAT SHE HAS BEEN AVOIDING THE CASINO SECONDARY TO HER FEAR THAT SHE WILL DRINK , THIS “FEAR” HAS NOT ACTUALLY TREATED HER GAMBLING ADDICTION. THIS PARTICULAR ADDICTION HAS RESULTED IN CONSIDERABLE PERSONAL FINANCIAL COST. TO MRS. PEREZ. MRS. PEREZ NEEDS TO BE REFERRED TO A COUNSELOR WHO SPECIALIZES IN THE TREATMENT OF GAMBLING DISORDER, AND SHE SHOULD ALSO BE ENCOURGAED TO ESTABLISH HERSELF WITH A LOCAL CHAPTER OF GAMBLING ANONYMOUS