Comorbid Addiction Patient Case Study

Case Study: A Puerto Rican woman with Comorbid Addiction

Background

 The patient is a 53-year old Puerto Rican woman who presented to the clinic with issues arising from alcohol use, spanning several years. This problem began after losing her father whom she was very close with. She has been attending Alcoholic Anonymous sporadically close to 24 years. Recently a gaming club has opened in her neighborhood and she has had problems with soberness. Patient reports getting a rush from gambling and drinking while at the club while gambling, to calm her nerves. Additionally, she has been smoking more than usual and has had to dip into her retirement account to pay off her gambling debts. Her weight has increased astronomically over a couple of years because of her unhealthy lifestyle. She is worried that her husband will find out about her indiscretions with her retirement account. Patient was diagnosed with gaming and alcohol use ailment.

Decision #1

Start patient on Naltrexone (Vivitrol) injection, 380 mg intramuscularly Q Four weeks.

 My choice of Vivitrol injection as the first decision is because Vivitrol, has better outcome with cravings, as against Antabuse (Kjome & Moeller, 2011). Naltrexone decreases both the gratifying feelings and desire of alcohol. (Kattimani & Bharadwaj, 2013). Most importantly I choose Vivitrol because of the dosing frequency of every 4 weeks as against daily doses of other medications. This ensures compliance and makes it easy for the patient to live a normal life. My anticipation is to decrease her alcohol use as it is not possible to have an instant and abruptly stop. Setting an unrealistic goal will be setting the patient up for failure. The function of Antabuse is to block the enzyme aldehyde dehydrogenase. With the presence of alcohol there is accumulation of acetaldehyde which results in an unpleasant reaction, known as disulfiram-ethanol reaction (DER). This brings about tachycardia, flushing, nausea, and vomiting (Skinner et al.,2014). This option was not chosen as patient will continue drinking irrespective of the uncomfortable adverse reaction. Also, Campral was not a choice because although it reduces cravings it is only effective on the long run when combined with support groups (Sachdeva & Choudhary & Chandra, 2015. Additionally, its treatment of alcohol withdrawal indications is not known.

Decision #2 is to augment with Valium (diazepam) 5 mg PO TID and PRN for anxiety

 After four weeks the patient comes for her first follow up appointment and reports feeling alright. She also endorses not drinking since getting the injection and leaving the hospital. She reports her urge to go gambling has decreased but she is still spending and lot of money when she goes. She cannot seem to stop smoking which is worrisome to her. Valium is identified as one of the chosen drugs for treating alcohol withdrawal, this is because diazepam and chlordiazepoxide have greater half-life meaning they can work for a number of days providing an easy path of treatment free from rebound signs such as seizures that is experienced with late withdrawal (Bharadwaj et al., 2012). It is vital that the patient be referred to a counselor that specializes in gambling,but the time is not right currently. She still needs to deal with her anxiety and smoke addiction. Any worsening of her concern may result in an increase in her betting or alcohol consumption. Chantix can be helpful in the treatment of smoking cessation, but addressing her anxiety is important as this may be the reason for her smoking.

Decision #3

Plan to keep patient on the present dose of Vivitrol. Reduce or cut down Valium with plans of discontinuing it 2 weeks. Initiate referral to a gambling counselor for her problems

 My plan is to continue the patient on her present dose, with the aim of discontinuing it in 2 weeks, since the patient was no more showing her earlier symptoms. Even though the client continues to ask for increased Valium, I do not think that this will be appropriate currently. Valium is seen as being usually safe when taken as prescribed for the treatment of a disorder but becomes harmful if it is abused. The consideration here is that patient has a history of substance abuse. Valium’s immediate effect action makes it valuable to use by the doctors, for short-term use and as PRN. With the decrease of her symptoms I would endorse psychotherapy because of her betting problems. I will also choose to keep patient on his present dose since Valium is not endorsed for long-term use because of the tendency of abuse. The use of valium on long term bases can result in chemical dependency and, addiction (Brett & Murnion, 2015).

Ethical Considerations

 Moral apprehensions in alcohol treatment are often multifaceted and multidimensional and might or not be addressed in regulations and professional ethics codes (Lachenmeier & Rehm, 2015). To work with substance abuse patients presents problems associated with individual beliefs, judgments, and values. The societal view of individuals with history of addictions is filled with emotion, misunderstandings, and prejudices that affects the care of those with substance abuse (Lachenmeier & Rehm, 2015). For instance, it is usual in a health care facility for a patient to be perceived negatively because his is an addict. The importance of leaving behind any prejudices in the treatment of your patients can never be over emphasized.

References

• Bharadwaj, B., Bernard, M., Kattimani, S., & Rajkumar, R. P. (2012). Determinants of success of loading dose diazepam for alcohol withdrawal: A chart review. Journal of Pharmacology & Pharmacotherapeutics, 3(3), 270–272. http://doi.org/10.4103/0976-500X.99440
• Brett, J., & Murnion, B. (2015). Management of benzodiazepine misuse and dependence. Australian Prescriber, 38(5), 152–155. http://doi.org/10.18773/austprescr.2015.055
• Kattimani, S., & Bharadwaj, B. (2013). Clinical management of alcohol withdrawal: A systematic review. Industrial Psychiatry Journal, 22(2), 100–108. http://doi.org/10.4103/0972-6748.132914
• Kjome, K. L., & Moeller, F. G. (2011). Long-Acting Injectable Naltrexone for the Management of Patients with Opioid Dependence. Substance Abuse: Research and Treatment, 5, 1–9. http://doi.org/10.4137/SART.S5452
• Lachenmeier, D. W., & Rehm, J. (2015). Comparative risk assessment of alcohol, tobacco, cannabis and other illicit drugs using the margin of exposure approach. Scientific Reports, 5, 8126. http://doi.org/10.1038/srep08126

• Sachdeva, A., Choudhary, M., & Chandra, M. (2015). Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. Journal of Clinical and Diagnostic Research: JCDR, 9(9), VE01–VE07. http://doi.org/10.7860/JCDR/2015/13407.6538

• Skinner, M. D., Lahmek, P., Pham, H., & Aubin, H.-J. (2014). Disulfiram Efficacy in the Treatment of               Alcohol Dependence: A Meta-Analysis. PLoS ONE, 9(2), e87366. http://doi.org/10.1371/journal.pone.0087366