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

Puerto Rican female

 

Decision Point One


Antabuse (Disulfiram) 250 mg orally every morning

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what the PMHNP should do next:


Continue current dose of Antabuse and begin Campral (acamprosate) 666 mg orally BID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Mrs. Perez reports that the metallic taste is “still there” but that it doesn’t bother her anymore
  • Client reports that she has managed to avoid alcohol as she is afraid of the side effects of the medications when she does drink
  • Client reports that over the course of the past two weeks, her cigarette consumption is “almost double—I’m up to almost 2 packs a day!”
Decision Point Three
Select what the PMHNP should do next:


Continue current doses of medications and discuss smoking cessation options
Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

There was no reason to add Campral (Acamprosate) to her current medication regimen. Although the two drugs do not have anything against interaction, it is simply a waste of money, and increases pill burden on the client. There is no reason at this point discontinue both medications. This would be an option in several weeks, once the client has demonstrated a pattern of abstinence.

At this point, the PMHNP should maintain the disulfiram, discontinue Acamprosate, and discuss smoking cessation options with the client in order to address the totality of addictions, and to enhance her overall health.

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


Discontinue Campral, but continue disulfiram and discuss smoking cessation options
Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

There was no reason to add Campral (Acamprosate) to her current medication regimen. Although the two drugs do not have anything against interaction, it is simply a waste of money, and increases pill burden on the client. There is no reason at this point discontinue both medications. This would be an option in several weeks, once the client has demonstrated a pattern of abstinence.

At this point, the PMHNP should maintain the disulfiram, discontinue Acamprosate, and discuss smoking cessation options with the client in order to address the totality of addictions, and to enhance her overall health.

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


Discontinue both medications and discuss smoking cessation options
Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

There was no reason to add Campral (Acamprosate) to her current medication regimen. Although the two drugs do not have anything against interaction, it is simply a waste of money, and increases pill burden on the client. There is no reason at this point discontinue both medications. This would be an option in several weeks, once the client has demonstrated a pattern of abstinence.

At this point, the PMHNP should maintain the disulfiram, discontinue Acamprosate, and discuss smoking cessation options with the client in order to address the totality of addictions, and to enhance her overall health.

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


Continue current dose of Antabuse and refer to counseling for ongoing gambling issues

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Mrs. Perez returns to your office in four weeks and reports that she has met with the counselor, but did not really like her. She did start going to a local meeting gamblers anonymous
  • Client stated that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group. She also reports that she is still smoking quite a bit
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, and discuss smoking cessation options
Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

Although controversy exists in the literature regarding how long to maintain a client on disulfiram, eight 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 in the therapeutic alliance can result in the client stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (as opposed to the client who receives 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.


Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group, and discuss smoking cessation options
Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

Although controversy exists in the literature regarding how long to maintain a client on disulfiram, eight 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 in the therapeutic alliance can result in the client stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (as opposed to the client who receives 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.


Discontinue disulfiram, and encourage Mrs. Perez to continue seeing her counselor, and to continue participating in the Gamblers Anonymous group. This would also be an appropriate time to discuss smoking cessation options
Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

Although controversy exists in the literature regarding how long to maintain a client on disulfiram, eight 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 in the therapeutic alliance can result in the client stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (as opposed to the client who receives 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.


Continue current dose of Antabuse and begin Wellbutrin (bupropion) XL 150 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Mrs. Perez reports that the side effects of the disulfiram have “gone” and that she is feeling much better
  • Client reports that she is still smoking, but reports that “it has dropped to only a couple of cigarettes a day.”
  • Client still reports that she is visiting the casino, but is not spending “as much money” as she had been in the past
Decision Point Three
Select what the PMHNP should do next:


Increase Wellbutrin XL to 300 mg orally daily
Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will probably experience “flushing,” tachycardia, nausea, and vomiting.

At this point, the PMHNP should maintain the current dose of each medication and refer the client to a counselor. Recall that there are no FDA approved medications for the treatment gambling addiction, and counseling is the mainstay of treatment for this particular disorder.

Nothing tells us at this point we should increase the bupropion. Recall that it could take as long as 12 weeks for this medication to exert its full therapeutic effect. Cognitive behavioral principles can also be employed to help Mrs. Perez stop smoking, in addition to the bupropion.

Although controversy exists in the literature regarding how long to maintain a client on disulfiram, eight weeks is probably too soon to consider discontinuation.


Maintain current doses of each medication and refer to counseling for her gambling
Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will probably experience “flushing,” tachycardia, nausea, and vomiting.

At this point, the PMHNP should maintain the current dose of each medication and refer the client to a counselor. Recall that there are no FDA approved medications for the treatment gambling addiction, and counseling is the mainstay of treatment for this particular disorder.

Nothing tells us at this point we should increase the bupropion. Recall that it could take as long as 12 weeks for this medication to exert its full therapeutic effect. Cognitive behavioral principles can also be employed to help Mrs. Perez stop smoking, in addition to the bupropion.

Although controversy exists in the literature regarding how long to maintain a client on disulfiram, eight weeks is probably too soon to consider discontinuation.


Continue Wellbutrin XL at 150 mg orally daily, but discontinue Antabuse
Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be for the PMHNP to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will probably experience “flushing,” tachycardia, nausea, and vomiting.

At this point, the PMHNP should maintain the current dose of each medication and refer the client to a counselor. Recall that there are no FDA approved medications for the treatment gambling addiction, and counseling is the mainstay of treatment for this particular disorder.

Nothing tells us at this point we should increase the bupropion. Recall that it could take as long as 12 weeks for this medication to exert its full therapeutic effect. Cognitive behavioral principles can also be employed to help Mrs. Perez stop smoking, in addition to the bupropion.

Although controversy exists in the literature regarding how long to maintain a client on disulfiram, eight weeks is probably too soon to consider discontinuation.