NURS 6630 Assignment 1: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction

Table of Contents

Assignment 1: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction

Impulsivity, compulsivity, and addiction are challenging disorders for patients across the life span. Impulsivity is the inclination to act upon sudden urges or desires without considering potential consequences; patients often describe impulsivity as living in the present moment without regard to the future (MentalHelp.net, n.d.). Thus, these disorders often manifest as negative behaviors, resulting in adverse outcomes for patients. For example, compulsivity represents a behavior that an individual feels driven to perform to relieve anxiety (MentalHelp.net, n.d.). The presence of these behaviors often results in addiction, which represents the process of the transition from impulsive to compulsive behavior.
In your role as the psychiatric nurse practitioner (PNP), you have the opportunity to help patients address underlying causes of the disorders and overcome these behaviors. 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 impulsivity, compulsivity, and addiction.

To prepare for this Assignment:

Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring therapy for impulsivity, compulsivity, and addiction.

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The Assignment: 5 pages

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, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

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Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Comorbid 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 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

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NURS 6630 Assignment 1: Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction

Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction

Addiction is a severe chronic disease that impairs the brain’s reward circuitry, culminating in drug-seeking and use despite its negative repercussions (Müller et al., 2020). Although the precise cause is unknown, external factors such as increased accessibility of addictive prescriptions and illicit and legal substances are commonly identified as the trigger. This syndrome is characterized by rare inebriation, exceptional financial exigency, a lack of desire, irritability, and agitation.

Pathological gambling (PG) is a kind of impulse control disorder characterized by chronic and repeated maladaptive behavior that interferes with personal, familial, and professional goals (Grant & Chamberlain, 2020). PG is frequently related to mood disorders such as bipolar disease, depressive episodes, and behavioral and anxiety problems. Pathological gamblers have high alcohol usage and dependency, cigarette addiction, and drug addiction. Males are more susceptible than females to acquiring this disorder. This research focuses on a case study of a Puerto Rican woman diagnosed with comorbid addiction. Its goal is to explore the best treatment approach for controlling this condition based on pharmacokinetic and pharmacokinetic parameters. The paper also examines ethical considerations in this case study and their influence on the treatment approach.

Case Study

Mrs. Perez, a 53-year-old Puerto Rican female, arrived at the clinic today with a report of comorbid alcoholism and gambling addiction. She admitted trying to stop drinking, but the confluence of living near a casino and the product’s availability prompted her to relapse and indulge in gambling continuously. She claimed that her gambling addiction commenced in her late teens, post her father’s death. It has affected her marriage and compelled her to borrow over $50,000 from her retirement account to cover her gambling bills, all without her husband’s consent. The patient claimed to gain up to 7lb due to his excessive drinking. She is exhibiting symptoms of depression, and her self-reported mood is sad. Her intuition and judgment are often excellent, but her impulse control is poor. She denied having suicidal or homicidal thoughts.

Decision #1

As PMNP, I may start the client on either Vivitrol 380mg IM for four weeks, Antabuse 250 PO OD, or Acampral 666mg PO nocte. I selected Vivitrol 380mg IM above other possibilities since it is FDA-approved for alcohol and opiate addiction. As an opioid antagonist, Vivitrol reduces alcohol cravings and binge drinking by inhibiting the dopaminergic reward system. Earlier research has also demonstrated that this medication dramatically reduces gambling desires and behaviors in compulsive gamblers (Guglielmo et al., 2021). This is because of its effect on opioid receptors in the brain. Furthermore, Vivitrol is a safer choice with minor adverse effects.

Acamprosate is another FDA-approved treatment for comorbid addiction and, therefore, a feasible option for the patient. Still, it was not chosen since it has not been proven to function in people who have not stopped drinking excessively (Guglielmo et al., 2021). As a result, it is not a viable option for Puerto Rican women who report regularly using alcohol. In a nutshell, it is far more successful at encouraging abstinence than reducing excessive drinking and desire. Moreover, it has various terrible side effects that may make therapy strenuous, increasing the likelihood of recurrence during treatment commencement. Though Antabuse is a possibility, it was not chosen in this situation due to a lack of scientific evidence supporting its efficacy in reducing alcohol cravings (Fairbanks et al., 2020). Furthermore, typical side effects such as throbbing headaches, dizziness, and flushing may cause compliance issues.

I made this decision to expect that Vivitrol would lessen or eliminate the client’s cravings for alcohol and gambling while having little to no undesirable side effects. After four weeks of therapy, the client reported feeling great since he had not consumed any alcohol since receiving the prescription. Despite fewer casino trips, she still smokes and spends much more money. In addition, she reported feeling anxious. This deviates from expectations due to the emergence of a significant side effect; additionally, the smoking issue was never addressed.

Decision 2#

In this case, I will refer the client to a counselor because recent studies have revealed that tobacco smoking and gambling typically co-occur. As a result, the best strategy to alleviate the impacts of gambling is to recommend the patient to a counselor for rehabilitation. This will help with the treatment of gambling addictions and other mental conditions such as anxiety and depression. Cognitive rehabilitation, in particular, may promote the client’s mental competence and self-control, making it more effective in lowering the client’s gambling habit, smoking, and anxiety (Rizeanu, 2018).

I hope this decision will considerably reduce the client’s gambling habit, anxiety, and smoking. After a 4-week follow-up, the patient reported no longer being anxious and had even begun going to a local gamblers anonymous meeting, wherein she felt emboldened. She also stated that she had visited the counselor but did not like her. My expectations were met; however, the individual did not reveal any gambling problems.

Decision 3#

At this decision point, there is an option to address the client’s issue with her counselor and incentivize her to continue attending Gamblers Anonymous meetings, encouraging the patient to continue seeing her counselor and Discontinuation of Vivitrol while enabling her to continue visiting the counselor and attending the group session. Based on the client’s outstanding therapeutic response to Vivitrol, I will choose to address her issue with the counselor and encourage her to continue attending Gamblers Anonymous sessions for better results.

Due to the drug’s success in treating comorbid alcohol addiction and gambling, as evidenced by the client’s report, discontinuing Vivitrol would be an impractical option. Furthermore, discontinuing this medication may relapse the client’s addiction (Otuonye et al., 2019). Advising the client to continue seeing her counselor without somehow resolving her concerns, on the other hand, may result in a breach of the therapeutic alliance, culminating in treatment discontinuance.

I hope this choice will inspire the client to keep attending Gamblers Anonymous meetings and be more inclined to see her counselor for more excellent outcomes. Moreover, I expect that visiting her counselor will result in a massive decline in her smoking and gambling habits.

Ethical Considerations with Treatment Plan

Designing a treatment approach for comorbid addiction demands the use of ethical concepts such as autonomy, nonmaleficence, and fairness. Because persons who are heavily addicted cannot self-determine or be autonomous, administering a drug that can abolish the power of dependency to re-establish personal autonomy is ethical (Hellman et al., 2022). Medications like naltrexone can be used to liberate the addicts from obsessive and coercive dimensions, augmenting the individual’s ability to be autonomous. Independent of the doctor-patient rapport, the treatment plan must be devised considering the client’s input and conveyed in a vocabulary that the patient understands. Furthermore, persons with gambling problems have a high likelihood of suicide due to actions such as building up massive bills on joint credit accounts. A physician must propose a rehabilitation program to fix some of the concerns.

Conclusion

Gambling disorder is a habit of conduct that negatively influences a person’s family, work, or private life. The gambling issue often begins in childhood or during adolescence. Individuals with this disease are also more likely to struggle with drug misuse or impulsivity. The most common co-occurring problem among those with gambling disorders is alcoholism. Comorbid addictions are often treated with medications. Drugs like naltrexone, FDA-approved therapy for alcohol and opiate addiction, have been demonstrated to be helpful in the treatment of gambling disorders.

References

Fairbanks, J., Umbreit, A., Kolla, B. P., Karpyak, V. M., Schneekloth, T. D., Loukianova, L. L., & Sinha, S. (2020, September). Evidence-based pharmacotherapies for alcohol use disorder: clinical pearls. In Mayo Clinic Proceedings (Vol. 95, No. 9, pp. 1964-1977). Elsevier.

Grant, J. E., & Chamberlain, S. R. (2020). Gambling and substance use: Comorbidity and treatment implications. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 99, 109852.

Guglielmo, R., Kobylinska, L., & de Filippis, R. (2021). Topiramate, Naltrexone, and Acamprosate in the Treatment of Alcohol Use Disorders.

Hellman, M., Egerer, M., Stoneham, J., Forberger, S., Männistö-Inkinen, V., Ochterbeck, D., & Rundle, S. (2022). Addiction and the brain: Knowledge, beliefs and ethical considerations from a social perspective. Springer Nature.

Müller, T. E., Fontana, B. D., Bertoncello, K. T., Franscescon, F., Mezzomo, N. J., Canzian, J., … & Rosemberg, D. B. (2020). Understanding the neurobiological effects of drug abuse: Lessons from zebrafish models. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 100, 109873.

Otuonye, I. S., Banken, R., Kumar, V. M., & Pearson, S. D. (2019). Effectiveness and Value of Extended-Release Opioid Agonists and Antagonists for Addiction Treatment of Opioid Use Disorder: A Summary from the Institute for Clinical and Economic Review’s New England Comparative Effectiveness Public Advisory Council. Journal of Managed Care & Specialty Pharmacy, 25(6), 630-634.

Rizeanu, S. (2018). Cognitive-behavioral therapy for gambling addiction. Cognitive Behavioral Therapy and Clinical Applications, 61-81.

Learning Resources

Required Readings (click to expand/reduce)

Kelly, J. E., & Renner, J. A. (2016). Alcohol-Related disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.
Renner, J. A., & Ward, N. (2016). Drug addiction. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.

Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders: Treatment improvement protocol series, no. 32. 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. Journal of Psychosocial Nursing & Mental Health Services, 54(4), 15.

Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375–381. https://doi.org/10.1111/j.1365-2125.2012.04457.x

Hulvershorn, L. A., Schroeder, K. M., Wink, L. K., Erickson, C. A., & McDougle, C. J. (2015). Psychopharmacologic treatment of children prenatally exposed to drugs of abuse. Human Psychopharmacology, 30(3), 164–172. https://doi.org/10.1002/hup.2467

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. https://doi.org/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. https://doi.org/10.1080/15504263.2012.648439

Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., Olvera, R., Swann, A. C., & Soares, J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry, 55(6), 1337–1341. https://doi.org/10.1016/j.comppsych.2014.04.018

Rubric Detail

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Name: NURS_6630_Week10_Assignment1_Rubric

Excellent

Point range: 90–100 Good

Point range: 80–89 Fair

Point range: 70–79 Poor

Point range: 0–69
Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient. 9 (9%) – 10 (10%)
The response accurately, clearly, and fully summarizes in detail the case for the Assignment.

The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient. 8 (8%) – 8 (8%)
The response accurately summarizes the case for the Assignment.

The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient. 7 (7%) – 7 (7%)
The response inaccurately or vaguely summarizes the case for the Assignment.

The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient. 0 (0%) – 6 (6%)
The response inaccurately and vaguely summarizes the case for the Assignment, or is missing.

The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.
Decision #1 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. 18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided. 16 (16%) – 17 (17%)
The response accurately explains the decision selected.

The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided. 14 (14%) – 15 (15%)
The response inaccurately or vaguely explains the decision selected.

The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided. 0 (0%) – 13 (13%)
The response inaccurately and vaguely explains the decision selected.

The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.
Decision #2 (1–2 pages)