I want this assignment asap -PLAGIARISM MUST BE LESS THAN 10% 

sychosis and schizophrenia greatly impact the brain’s normal processes, which interferes with the ability to think clearly. When symptoms of these disorders are uncontrolled, clients may struggle to function in daily life. However, clients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with psychosis and schizophrenia.

Learning Objectives

Students will:

• Assess client factors and history to develop personalized plans of antipsychotic therapy for clients
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring antipsychotic therapy
• Evaluate efficacy of treatment plans
• Analyze ethical and legal implications related to prescribing antipsychotic therapy to clients across the lifespan

   

To prepare for this Assignment:

• Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.

The Assignment

Examine Case Study: Pakistani Woman with Delusional Thought Processes. 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.

At each decision point stop to complete the following:

• Decision #1
  • Which decision did you select?
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
• SAMPLE  ONLY 

  

NURS 6630 

WEEK SEVEN

Case 2: Volume 2, Case #11: The figment of a man who looked upon the lady

Introduction

Briefly, this is a scenario of a 42 year- old woman with a complex psychiatric history extending from depression, posttraumatic stress disorder, insomnia, visual hallucinations (little man)and impaired behavior with aggression. In the course of more than 36 months, the client was treated with Paroxetine (SSRI), Bupropion ( NDRI), Tiagabine, Ramelteon and , but finally a combination of Lexapro, Bupropion and quetiapine was able to decrease her symptoms . The client’s medical history includes diabetes, hypertension, CAD, hyperlipidemia, COPD, OSA, GERD, Glaucoma, overweight and a remote history of substance abuse. 

  Related Professional Questions

  Certain medications or supplements can cause symptoms of mental illness and also due to her extensive medical history and usage of multiple medications I would ask the following questions:  

1. Do you take any over -the – counter, herbal supplements or remedies and I would check for interactions with current medication regimen?

2. When and how often do you use your albuterol inhaler ? Some of the side effects of albuterol include anxiety, nervousness, and insomnia ( Cunha, 2016)

Sleep Hygiene: Do you keep regular sleep schedule ? Do you drink caffeine beverages close to bedtime? 

Patient History

The patient may not be a reliable source of information, particularly that she has a significant mental illness that affects her functioning, hence verifying her responses with her direct family members, and mental social workers to get clues to the underlying or precipitating causes of mental crisis. Also checking facility records from previous encounters, or any psychiatric hospitalizations would be useful. 

Diagnostics Testing

1. Thyroid Stimulating Hormone (TSH). Based on recent evidence, the prevalence of depressive symptoms in hypothyroidism was nearly 50%, and clinical depression occurs in more than 40% of people suffering from hypothyroidism ( Bhagwat, 2017)

2. Electrocardiogram (ECG) The client has cardiovascular diseases ( HTN, CAD), with risks of cardio complications. In the setting of taking antidepressants and antipsychotics, baseline ECG and possibly every three to six months would be appropriate.  Several atypical antipsychotics including quetiapine (Seroquel) are known to cause prolongation of the QT interval, hypothesized to occur via direct inhibition of the cardiac delayed potassium rectifier channel, which extends the ventricular repolarization process (Zhai et al., 2017)

Differential Diagnoses

1. Posttraumatic Stress Disorder ( PTSD)_

2. Major Depressive Disorder  (MDD)

3. Insomnia Disorder.

  Pharmacotherapy Options for Sleep/ Wake cycle

1. Zolpidem (Ambien) 5mg oral at bedtime for Seven days. 

Zolpidem is nonbenzodiazepine hypnotic, it works by enhancing GABA inhibitory actions that provide sedative hypnotic effects more selectively than other actions of GABA (Stahl, 2017). With its side effects of sedation,  low dose prescribed as the client has respiratory problems (sleep apnea OSA)).  Studies have shown that Zolpidem did not significantly worsen OSA as measured by the numbers and duration of pauses in breathing during sleep, but in one trial, it significantly lowered minimum oxygen levels during the night when compared with placebo ( Mason & Smith, 2015). 

2. Trazadone 25 mg oral at bedtime for Thirty days. 

Trazadone is a serotonin 2 antagonist/reuptake inhibitor, used in management of depression and insomnia. It is absorbed well, metabolized by CYP 450 3A4 with average half life of 6hrs. It has less side sedative effects compared to zolpidem (Stahl, 2017)

The best choice for the client would be Trazadone as there is no reliable evidence of dependence or withdraws and it can also work for the client’s depression. 

Conclusion

 The case was a perfect example how it is sometimes difficult to find effective pharmacological treatments of psychiatric illnesses. In the course of four years, the client was prescribed 5-6 medications targeting different neurotransmitters to improve the symptoms. Client’s polypharmacy increased risks of drug-drug interactions, and her medical comorbidities increased risks of adverse reactions. Lesson learned from this study was  that treatment  should be optimally initiated after diagnosis, and augment or switching to a new agent must be carefully  done in consideration of possible  side effects and better outcomes. 

References

Bhagwat, N., Tayde, P., Sharma, P., Sharma, B., Dalwadi, P., Sonawane, A., … Varthakavi, P. (2017). Hypothyroidism and depression: Are cytokines the link? Indian Journal of Endocrinology and Metabolism, 21(6), 886. Retrieved from https://web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=7&sid=aeb79c1d-68dc-40a4-bd10-f956796bc9e8%40sessionmgr101

Cunha, J. (2016). Common Side Effects of Ventolin HFA (Albuterol Sulfate Inhalation Aerosol) Drug Center – RxList. Retrieved from https://www.rxlist.com/ventolin-hfa-side-effects-drug-center.htm

Mason, M., & Smith, I. (2015). Effects of opioid, hypnotic and sedating medications on obstructive sleep apnoea (OSA) in adults with known OSA | Cochrane. Retrieved from http://www.cochrane.org/CD011090/AIRWAYS_effects-opioid-hypnotic-and-sedating-medications-obstructive-sleep-apnoea-osa-adults-known-osa

Zhai, D., Lang, Y., Dong, G., Liu, Y., Wang, X., Zhou, D., … Zhang, R. (2017). QTc interval lengthening in first-episode schizophrenia (FES) patients in the earliest stages of antipsychotic treatment. Schizophrenia Research, 179, 70-74. Retrieved from https://resolver-ebscohost-com.ezp.waldenulibrary.org/openurl?ID=pmid%3a27727006&genre=article&atitle=QTc+interval+lengthening+in+first-episode+schizophrenia+(FES)+patien

 

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 Note;; this must be done in 10 hours.

      

Advances in genetics and epigenetics have changed the traditional understanding of mood disorders, resulting in new evidence-based practices. In your role as a psychiatric mental health nurse practitioner, it is essential for you to continually educate yourself on new findings and best practices in the field. For this Assignment, you consider best practices for assessing and treating adult and geriatric clients presenting with mood disorders.

Learning Objectives

Students will:

• Assess client factors and history to develop personalized plans of antidepressant therapy for adult and geriatric clients
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in adult and geriatric clients requiring antidepressant therapy
• Evaluate efficacy of treatment plans
• Analyze ethical and legal implications related to prescribing antidepressant therapy to adult and geriatric clients

Examine Case Study: An Elderly Hispanic Man With Major Depressive Disorder. 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.

• At each decision point stop to complete the following:
  • Decision #1
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
  • Decision #2
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
• Also include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

 

Review the following medications:

• amitriptyline
• bupropion
• citalopram
• clomipramine
• desipramine
• desvenlafaxine
• doxepin
• duloxetine
• escitalopram
• fluoxetine
• fluvoxamine
• imipramine
• ketamine
• mirtazapine
• nortriptyline
• paroxetine
• selegiline
• sertraline
• trazodone
• venlafaxine
• vilazodone
• vortioxetine

 you can edit my work bellow, add more information  , and use same medication therapy. Plagiarism must be less than 15 %

      Introduction

Improving depression care for depressed older men is a public health priority because older men are less likely than older women to receive depression treatment and are also more likely to commit suicide .Depressive disorder causes a continuous feeling of worthlessness , hopelessness and unhappiness to the victim and loss of interest in what they used to enjoy doing, also call major depressive disorder (MDD) or clinical depression (Unützer & Park, 2012). 3 Depression is one of the most common mental health problem leading to disabling in older men (Unützer & Park, 2012). A Late-life depression (LLD), is referring to depression that recurs in old age (having begun earlier in life) and again late in life; this negatively affect patients cognitive impairment, functional impairment, and development of Alzheimer’s disease and vascular dementia (Diniz & Reynolds, 2014).

3 Late-life depression (LLD is associated with burden of medical illnesses (especially cardiovascular and cerebrovascular) and risk of death. Patients assessment for depression should be using a standard rating scale, and initiate effective treatment such as antidepressant medications or evidence-based psychotherapies and psychiatric follow up. Electroconvulsive therapy (ECT) (Unützer & Park, 2012) can be an alternative for patients who are not improving. Antidepressants reduce the consequences of depression. 3 It is important to note that depressed adults may be at increased risk for antidepressant adverse effects. (Diniz & Reynolds, C. F. (2014). 3 This week paper focuses the identifying and treatment of late-life depression of an Elderly Hispanic Man with history of Major Depressive Disorder (MDD)

Decision #1

1 Will start with Zoloft 25 mg orally daily

Reason for the Selection:

3 Assessment tool used is Montgomery–Åsberg Depression Rating Scale (MADRS), patient score 52, which is an indication of severe depression. When choosing an antidepressant my treatment option is based on the best side effect profile and lowest risk of drug-drug interactions Wiese, (2011). Wellbutrin is an antidepressant, but can cause seizures and Effexor may increase blood pressure Wiese, (2011). Zoloft is one of the most effective and safest medication for the treatment of severe depression in adults (Flint & Rifat, 2013. My best option is Zoloft 25mg which is best choice because of harmless to the elder (Flint & Rifat, 2013). Antidepressant use in the elderly are thought to be due to changes in hepatic metabolism with aging, concurrent medical conditions, and drug-drug interactions (Wiese, B. 2011). 3 (Flint & Rifat, 2013).

Expected Results

The patient should be able to improve within two weeks. Some signs should might be am improve in his work, exercise, hobbies, intellectual pursuits, as well improve sleep. 3When using Zoloft, the level of awareness should improve. It must be noted that the patient is back on track with motivation to follow his normal activities and relate well with associates (Flint & Rifat, 2013).

1 Differences between Expected Results and Actual Results

3 Expected outcome after the use of Zoloft 25mg is the patient will see improvement in his mental capability and importantly that there was no side effect of the medication.The patient revisited after four weeks on his follow up appointment and reported of a decrease in the symptoms, but with a complain of sexual dysfunction and insomnia. The difference in the expected result and the outcome may be reason out that the body of the patient is trying to adjust to the medication while solving the problem of MDD (National Alliance on Mental Illness, 2017).

1 Decision Point Two

Selected Decision: 1 Augmenting agent such as Wellbutrin XL 100 mg in morning

Reason for Selection

3 The added augmenting agent such as Wellbutrin XL150mg in morning was because the patient has some complain of having decrease sex drive, impotence, or difficulty in having an orgasm and sleep problem (insomnia). Bupropion is an antidepressant with excellent tolerability in elderly person improve depression, insomnia, somatic symptoms, work functioning, and certain quality-of-life measures in elderly depressed subjects with medical disorders (American Psychiatric Association, 2013). Though, patient verbalized decrease in the depression symptoms because of using Zoloft, but because of decrease sex drive and insomnia, Zoloft will be decrease to 12.5mg orally every day and continue to watch for side effects, like suicidal tendency in the elderly, and complain about ejaculatory and sexual dysfunction (American Psychiatric Association, 2013).

Expected Results

3 With the combination of using Wellbutrin and Zoloft, it is still expected to see the patient to continue to experience reduction in depression symptom. The therapeutic effect should be observable which will motivate and encourage the patient.

1 Differences between Expected Results and Actual Results

3 The expected outcome after four weeks visitation is that the therapeutic effect of the medication will be clear and no more report of adverse reaction, that shows patient is tolerating the medications as agree. The actual result was that the patient report that there was more reduction in the MDD symptom and improved in the side effect which is insomnia and sexual dysfunction.

Decision Selected

1 Decision Point Three

3 Selected Decision I will discontinue Zoloft 12.5mg orally daily and increase the dosage of Wellbutrin to 150mg XL every morning.

1 Reason for Selection

3 The desire result was not obtained in the second stage though the patient observe reduction in the symptom of MDD, but the resulting side effect is not reducing or eliminated. Wellbutrin XL can help to reduce depression and remove most of the side effect of Zoloft (Mangoni, & Jackson, 2004), also this will help attain therapeutic effect with his symptoms until his next appointment to evaluate response to therapy (Mangoni, & Jackson, 2004). The patient will have to be monitor closely because of the medication adjustment side effect, the suicidal tendency (Mangoni, & Jackson, 2004).

Expected Results

3 At this point the patient is anticipated to experience close to zero symptom of major depressive disorder without any side effect, the sleeping problem or insomnia, sexual dysfunction. He is also expected to have good interaction with neighbor and friends.

1 Differences between Expected Results and Actual Results

Wellbutrin 150mg XL, there is a solution in the treatment of the patient with MDD, (Laureate Education, 2016). 3 When the medication is working well with no side effect, patient will continue with Wellbutrin XL 150mg orally daily dose and will be re-evaluated during the next appointment, medication can be increase if there is a reduction in symptoms to achieved desired maximum therapeutic effect. The actual result from the patient is that the medication is achieving the therapeutic effect that is needed by the patient (Mangoni, & Jackson, 2004).

1 Impact of Ethical Considerations on Treatment Plan

3 Ethical Considerations on treatment plan of a psychiatry patients can be complicated which can arise from plan therapy. Addressing the side effects of medications should be the most important in the plan of this therapy which include suicidal tendencies, dosage adjustment and close monitoring for effects (Flint & Rifat, 2013. Some drugs can cause patients to have suicidal tendencies (Flint & Rifat, 2013. Ethically there are sometimes practitioner are being influence by the health insurance of the patient, that is it easier to have a claim for drug treatment than physical therapy, therefore the health professional will choose to go the route of drug treatment. In all consideration the beneficence and no maleficence principles must be observe, the best treatment and best drug that sooth the patient must be administered.

Conclusion

When treating patients, we must understand that some drugs are good for a patient but the side effect on the patient might be grave. A careful treatment and monitoring of patients is important for total healing (NAMI National Alliance on Mental Illness, 2017).

References

4 American Psychiatric Association. (2013). 3 Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC: Author. Note: 3 Retrieved from Walden Library databases.

Diniz, B. 3 S., & Reynolds, C. F. (2014). 3 Major Depressive Disorder in Older Adults:

Benefits and Hazards of Prolonged Treatment. Drugs & Aging, 31(9), 661–669.http://doi.org/10.1007/s40266-014-0196-y

Flint, A. 3 J., & Rifat, S. L. (2013). 5 The effect of sequential antidepressant treatment on

geriatric depression. 3 Journal of affective disorders, 36(3), 95-105.

Laureate Education. (2016g). Case study: 1 An elderly Hispanic man with major depressive

disorder [Interactive media file]. Baltimore, MD: Author.

Mangoni, A. 3 A., & Jackson, S. H. D. (2004). 3 Age-related changes in pharmacokinetics and

pharmacodynamics: 3 basic principles and practical applications. British Journal of Clinical Pharmacology, 57(1), 6–14. Retrieved from: 3https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884408/

6 National Alliance on Mental Illness. (2017). 3 What Is Sertraline and What Does It

Treat? Retrieved from: 7 https://www.nami.org/learn-more/treatment/mental-health-medications/sertraline-(Zoloft)

Unützer, J., & Park, M. (2012). 3 Older Adults with Severe, Treatment-Resistant

 

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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.

Diagnosis: Gambling disorder, alcohol use disorder

Decision Point One

Antabuse (Disulfiram) 250 mg orally every morning ON 

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

E

·  Client returns to clinic in four weeks

·  Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

·  Clientis She is also reporting that she is having “out of control” anxiety.. 

Decision Point Two

 

Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms

RESULTS OF DECISION POINT TWO 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

• Client returns to clinic      in four weeks
• Mrs. Perez reports that      when she first received the valium, it helped her tremendously. She states      “I was like a new person- this is a miracle drug!” However, she reports      that she has trouble “waiting” between drug administration times and      sometimes takes her valium early. She is asking today for you to increase      the valium dose or frequency
• Although she reports that      her anxiety is gone, she still reports suicidal ideation, but states “with      that valium stuff, who cares?”;;;;;;;; 
• Decision Point Three
•  
   
• Add on Wellbutrin (bupropion) XL 150 mg orally daily
• Guidance to Student

   

• Given her weight (less than 60      kg), Campral should have been started at 666 mg orally BID. It is possible      that the higher dose may be responsible for the severity of the symptoms      that Mrs. Perez is experiencing.
• Technically, the drug should      have been stopped (not simply decreased) once Mrs. Perez reported suicidal      ideation. Even with the decrease in dose, she is still having suicidal      ideation, which indicates the need to discontinue the drug. Although      controversy exists regarding how long to use pharmacologic approaches to      treatment of alcohol dependence, 8 weeks is probably insufficient,      therefore, the drug should not simply be discontinued without using a      different agent in its place.
• Mrs. Perez should be started on      Antabuse at 250 mg orally daily and referred to psychotherapy to address      her gambling issue.
• In all cases, 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. The decision      to begin Wellbutrin XL 150 mg orally daily may help achieve this goal, but      this choice does not address her abstinence from alcohol.
• Additionally, it should be      noted that although Mrs. Perez reports 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 Ms. Perez. Mrs. Perez      needs to be referred to a counselor who specializes in the treatment of      gambling disorder, and she should also be encouraged to establish herself      with a local chapter of Gamblers Anonymous.
• 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.
• At each decision point stop to      complete the following:
• Decision #1
• Which decision did you select?
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #1 and the results of the      decision. Why were they different?
• Decision #2
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #2 and the results of the      decision. Why were they different?
• Decision #3
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #3 and the results of the      decision. Why were they different?

   

edit this or redo other assignment. 

  

Assessing and Treating Clients with Impulsivity, Compulsivity and Addiction 

Pharmacotherapy practice to treating substance use disorders is often referred to as medication assisted treatment (MAT) (Sharp et al., 2018). In this practice, specific medications approved by Federal Drug Administration (FDA) are used in combination with counseling and behavioral therapies in treatment of a substance use disorder (Sharp et al, 2018) Medications can reduce the cravings and other symptoms associated with withdrawal from a substance by occupying receptors in the brain associated with using that drug (agonists or partial agonists), block the rewarding sensation that comes with using a substance (antagonists), or induce negative feelings when a substance is taken ( SAMHSA, 2016). MAT has been primarily used for the treatment of opioid use disorder but is also used for alcohol use disorder and the treatment of some other substance use disorders. This paper focuses on pharmacotherapy approaches to treatment of alcohol use disorder, gambling disorder and smoking addiction in a 53 year- old female of Puerto origin. 

Case Scenario 

Decision Number One

Naltraxone (Vivitrol) injection, 380 mg intramuscularly in gluteal region every four weeks.

Rationale: Pharmacotherapy should be used in patients with alcohol use disorder who have current, heavy use and ongoing risk for consequences from use, motivated to reduce alcohol intake and do not have medical contraindications to the individual drug choice (SAMHSA, 2016). As the 53 year-old female has acknowledged that she has a drinking problem and has tried psychosocial approach with alcoholic anonymous(AA) without success, adding medication such as naltrexone would be warranted as next step. In random clinical trials (RCTs) naltrexone medication has been shown to reduce heavy drinking and enhance the likelihood of abstinence ( Garbutt et al.,  2014)

 Naltraxone is mu opioid receptor antagonist, can be in form of oral ( Revia) and injection( Vivitrol) ( Stahl, 2017). Naltraxone is FDA approved to treat alcohol dependence, blockade of effects of exogenously administered opioids (oral) and prevention of relapse to opioid dependence (Stahl, 2017).  Naltrexone reduces alcohol consumption through modulation of opioid systems, thereby reducing the reinforcing effects of alcohol and opioids (cravings, rewarding effects). Moreover, naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress ethanol consumption. 

The recommended naltrexone injectable (vivitrol) suspension is 380mg and should be administered via intramuscular (IM)injection to the gluteal area using the provided 1.5 inch 20-gauge needle(Drugs.com, 2017).  Vivitrol is extensively metabolized in humans, and elimination half-life of naltrexone via injection is 5–10 days (Drugs. com, 2017) Common side effects of naltrexone are nausea, headache, and dizziness, joint or muscle pain which subside with continued use. Special considerations include that vivitrol should not be given to patients taking opioids, and if opioids are required to treat pain, naltrexone should be discontinued. Naltrexone is contraindicated in acute hepatitis or liver failure. 

The advantage usage is that naltrexone can be initiated while the individual is still drinking (Canidate et al., 2017) This allows treatment for alcohol use disorder to be provided in community-based practice at the point of maximum crisis without the need for enforced abstinence or detoxification, thus beneficial for the client. Additionally, depot preparations of naltrexone may improve adherence by reducing the frequency of medication administration from daily to monthly and by achieving a steady therapeutic level of medication, thus avoiding peak effects that can exacerbate adverse events.

  The reason I did not select disulfiram (Antabuse) which by intent leads to adverse effects ( nausea, vomiting, metallic taste, tachycardia) when combined with alcohol intake, was that it  should only be used by abstinent patients in the context of treatment intended to maintain abstinence. In regards of Acamprosate, I did not select the medication because research indicates that Acamprosate should be used once abstinence is achieved (Yahn, Witterson, & Olive, 2013). 

The main goal of prescribing medication for treatment for alcohol use disorder is abstinence, which remains a primary treatment focus. However, decrease of heavy drinking can be accepted as an alternative treatment goal, especially if unwanted risks (health, social and financial) are reduced. 

The client returns four weeks after the injections, she has been sober since receiving injection, she denies any side effects from medications. The main chief complaint is gambling, but client is also concerned about her smoking and anxiety. 

  Decision Two

  Refer to a Counselor for Gambling Issues 

Rationale:  Several different types of therapy are used to treat gambling disorder, including cognitive behavior therapy, psychodynamic therapy, group therapy and family therapy (American Psychiatric Association, 2016) As recent, there is no FDA approved pharmacotherapy for gambling disorder. But, pharmacotherapy approaches for problem gambling can be effective when directed toward the patient’s comorbid psychiatric condition such as bipolar disorder, obsessive compulsive disorder(OCD), and substance abuse.  

  The client was concerned about her smoking and appeared to be motivated to stop smoking, hence adding medication to assist her to quit would have been a reasonable approach to avoid health complications (e.g cardiovascular, pulmonary) associated with smoking. However, I did not select the answer as the starting dosage (Varenicline 1mg PO BID) was slightly higher than recommended starting dose. Initial 0.5 mg/day; after 3 days increase to 1 mg/day in two divided doses; after 4 days can increase to 2 mg/day in two divided dose(Stahl, 2017) . Starting at a higher would have increased the possibilities of adverse effects such nausea, vomiting and even agitation.  

  Adding Diazepam (Valium) would not be a good option, as Valium is an addictive benzodiazepine with longer-lasting effects than other drugs in its class. In the light of the client’s history substance use disorder and addiction, adding another addictive substance such as valium would cause more harm. 

The client returns in four weeks, reports that anxiety has gone. Client reports not liking the therapist, but she has joined gambling anonymous group.

Decision Number Three

 Explore the issue that Mrs Lopez is having with her counselor, and encourage her to continue attending Gamblers Anonymous meetings

Rationale: Despite that Mrs. Lopez did not have a good relationship with the counselor, but she remained committed to fighting her addiction by joining Gamblers Anonymous group. Still, counseling remains the main approach in gambling addiction treatment, hence exploring the issues that Mrs. Lopez had with counselor would help to guide the next step in treatment. Also, smoking cessation needs to be explored at this time. Assessing the client’s willingness to quit is the first step as smokers differ in their readiness to change their tobacco use (Niaura, 2017). Understanding the smokers’ perspectives is essential to providing useful assistance. 

Ethical and Legal Implications in Prescribing Medications to Treat Substance Use Disorders.

 In order to optimize care of clients with substance use disorder, health professionals are encouraged to learn  and appropriately use routine screening techniques, clinical laboratory tests, brief interventions, and treatment referrals ( Garbutt, 2014). Using screening tools such as CAGE Questionnaire for alcohol use dependence, would be ideal in guiding treatment approach. Additionally, client’s autonomy and confidentiality must be maintained before prescribing medications to treat an addiction. When a legal or medical obligation exists for  a health professional to test clients for substance use disorder, there is an ethical responsibility to notify clients of this testing and make a reasonable effort to obtain informed consent ( Garbutt, 2014)

References

American Psychiatric Association. (2016). What Is Gambling Disorder? Retrieved from https://www.psychiatry.org/patients-families/gambling-disorder/what-is-gambling-disorder

Canidate, S. S., Carnaby, G. D., Cook, C. L., & Cook, R. L. (2017). A Systematic Review of Naltrexone for Attenuating Alcohol Consumption in Women with Alcohol Use Disorders. Alcoholism: Clinical and Experimental Research, 41(3), 466-472. Retrieved from https://web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=14&sid=183cffb8-9da8-48b2-a1b7-66c14f735856%40sessionmgr101

Drugs.com. (2017). Vivitrol Dosage Guide – Drugs.com. Retrieved from https://www.drugs.com/dosage/vivitrol.html

Garbutt, J. C., Greenblatt, A. M., West, S. L., Morgan, L. C., Kampov-Polevoy, A., Jordan, H. S., & Bobashev, G. V. (2014). Clinical and biological moderators of response to naltrexone in alcohol dependence: a systematic review of the evidence. Addiction, 109(8), 1274-1284. Retrieved from https://web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=8&sid=41ca863e-175d-45ae-ba36-43317c3c58e5%40sessionmgr4008

Niaura, R. (2017). Learning From Our Failures in Smoking Cessation Research | Nicotine & Tobacco Research | Oxford Academic. Retrieved from https://academic.oup.com/ntr/article/19/8/889/3888613

SAMHSA. (2016). Treatments for Substance Use Disorders | SAMHSA – Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/treatment/substance-use-disorders

Sharp, A., Jones, A., Sherwood, J., Kutsa, O., Honermann, B., & Millett, G. (2018). Impact of Medicaid Expansion on Access to Opioid Analgesic Medications and Medication-Assisted Treatment. American Journal of Public Health, 108(5), 642-648. Retrieved from https://web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=5&sid=21e9426c-0afa-475e-9a9a-e1872d98830d%40sess

Stahl, S. M. (2017). Essential psychopharmacology: The prescriber’s guide : antipsychotics and mood stabilizers. Cambridge: Cambridge University Press.

Yahn, S. L., Watterson, L. R., & Olive, M. F. (2013). Safety and Efficacy of Acamprosate for the Treatment of Alcohol Dependence. Substance Abuse: Research and Treatment, 7. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3565569/

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