Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female

Puerto Rican female

 

Decision Point One


Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what the PMHNP should do next:


Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety

RESULTS OF DECISION POINT TWO

  • 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
  • Client is asking today for you to increase the valium dose or frequency
Decision Point Three
Select what the PMHNP should do next:


Continue current dose of Vivitrol, increase Valium to 10 mg orally TID/PRN/anxiety. Refer to counseling for her ongoing gambling issue
Guidance to Student

Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication, and like other side effects, the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol, or other substance dependencies. Additionally, benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perez’s case.

The most appropriate course of action in this case would be to continue the current dose of Vivitrol, while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At this point, we need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists.

Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current dose of Valium. Additionally, the client should be referred for counseling to help with her gambling addiction, as there are no FDA approved medications gambling disorder.

Medication should never be added treat side effect of another medication, unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a client with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures).

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.

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.


Continue current dose of Vivitrol, decrease/taper Valium with the goal of discontinuation in the next 2 weeks. Refer to counseling for her ongoing gambling issue
Guidance to Student

Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication, and like other side effects, the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol, or other substance dependencies. Additionally, benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perez’s case.

The most appropriate course of action in this case would be to continue the current dose of Vivitrol, while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At this point, we need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists.

Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current dose of Valium. Additionally, the client should be referred for counseling to help with her gambling addiction, as there are no FDA approved medications gambling disorder.

Medication should never be added treat side effect of another medication, unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a client with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures).

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.

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.


Continue current dose of Vivitrol and maintain current dose of valium. Refer to counseling for her ongoing gambling issue
Guidance to Student

Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication, and like other side effects, the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol, or other substance dependencies. Additionally, benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perez’s case.

The most appropriate course of action in this case would be to continue the current dose of Vivitrol, while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At this point, we need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists.

Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current dose of Valium. Additionally, the client should be referred for counseling to help with her gambling addiction, as there are no FDA approved medications gambling disorder.

Medication should never be added treat side effect of another medication, unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a client with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures).

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.

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.


Refer to a counselor to address gambling issues

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports that the anxiety that she had been experiencing is gone
  • Client reports that she has met with the counselor, but did not really like her. She did start going to a local meeting gamblers anonymous. She stated that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group
Decision Point Three
Select what the PMHNP should do next:


Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetings
Guidance to Student

Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, four weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As you will learn in future courses, ruptures and the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA approved treatments for gambling addiction, and the mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the gamblers anonymous meetings, she should be encouraged to continue her participation with this group.

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.


Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group
Guidance to Student

Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, four weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As you will learn in future courses, ruptures and the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA approved treatments for gambling addiction, and the mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the gamblers anonymous meetings, she should be encouraged to continue her participation with this group.

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.


Discontinue Vivitrol. Encourage Mrs. Perez to continue seeing her counselor and to continue participating in the Gamblers Anonymous group
Guidance to Student

Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, four weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As you will learn in future courses, ruptures and the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA approved treatments for gambling addiction, and the mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the gamblers anonymous meetings, she should be encouraged to continue her participation with this group.

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.


Add on Chantix (varenicline) 1 mg orally BID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports that she had to stop taking Chantix secondary to abnormal dreams, and agitation
  • Client also reported feeling nauseous and also reported that she vomited several times after she began taking the drug
Decision Point Three
Select what the PMHNP should do next:


Re-start Chantix at 0.5 mg orally daily
Guidance to Student

Mrs. Perez was experiencing normal side effects associated with Vivitrol. She should be counseled regarding the potential side effects associated with Vivitrol, and reassured that they will most likely abate.

It should be noted that the problem that Mrs. Perez is experiencing from the Varenicline is most likely related to the starting dose. Recall that this drug should be initiated at 0.5 mg/day; after three days increase to 1 mg/day in two divided doses; after 4 days can increase to 2 mg/day in two divided doses. Side effects would most likely have been minimized or completely avoided had she been started at the appropriate starting dose. Therefore, it may be prudent to restart this drug at 0.5 mg orally daily, and uptitrate consistent with the manufacturers suggested titration schedule. It would not be appropriate to restart Mrs. Perez at 1 mg orally BID, as it would most likely result in a return of the unpleasant symptoms she experienced.

If Mrs. Perez is adverse to the idea of restarting Varenicline, the PMHNP could begin bupropion XL, 150 mg orally daily.

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.


Discontinue Chantix and start Bupropion XL 150 mg orally daily
Guidance to Student

Mrs. Perez was experiencing normal side effects associated with Vivitrol. She should be counseled regarding the potential side effects associated with Vivitrol, and reassured that they will most likely abate.

It should be noted that the problem that Mrs. Perez is experiencing from the Varenicline is most likely related to the starting dose. Recall that this drug should be initiated at 0.5 mg/day; after three days increase to 1 mg/day in two divided doses; after 4 days can increase to 2 mg/day in two divided doses. Side effects would most likely have been minimized or completely avoided had she been started at the appropriate starting dose. Therefore, it may be prudent to restart this drug at 0.5 mg orally daily, and uptitrate consistent with the manufacturers suggested titration schedule. It would not be appropriate to restart Mrs. Perez at 1 mg orally BID, as it would most likely result in a return of the unpleasant symptoms she experienced.

If Mrs. Perez is adverse to the idea of restarting Varenicline, the PMHNP could begin bupropion XL, 150 mg orally daily.

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.


Re-start Chantix at 1 mg orally BID and educate Mrs. Perez regarding side effects
Guidance to Student

Mrs. Perez was experiencing normal side effects associated with Vivitrol. She should be counseled regarding the potential side effects associated with Vivitrol, and reassured that they will most likely abate.

It should be noted that the problem that Mrs. Perez is experiencing from the Varenicline is most likely related to the starting dose. Recall that this drug should be initiated at 0.5 mg/day; after three days increase to 1 mg/day in two divided doses; after 4 days can increase to 2 mg/day in two divided doses. Side effects would most likely have been minimized or completely avoided had she been started at the appropriate starting dose. Therefore, it may be prudent to restart this drug at 0.5 mg orally daily, and uptitrate consistent with the manufacturers suggested titration schedule. It would not be appropriate to restart Mrs. Perez at 1 mg orally BID, as it would most likely result in a return of the unpleasant symptoms she experienced.

If Mrs. Perez is adverse to the idea of restarting Varenicline, the PMHNP could begin bupropion XL, 150 mg orally daily.

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.