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

Puerto Rican female

 

Decision Point One


Campral (acamprosate) 666 mg orally TID

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what the PMHNP should do next:


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

  • 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
Select what the PMHNP should do next:


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

Given her weight (less than 60 kg), Acamprosate (Campral) should have been started at 666 mg orally BID. Her side effects were most likely related to the high starting dose- higher than the drug should have been started at considering her body weight.

Although the anxiety is problematic side effect, it is not as serious as her suicidal ideation. The suicidal ideation is a side effect which should have signaled the need to discontinue the drug, and consider a different agent such as disulfiram.

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, 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.

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.


Discontinue Campral and begin Antabuse at 250 mg orally daily, decrease/taper Valium with the goal of discontinuation in the next 2 weeks. Refer to counseling for her ongoing gambling issue
Guidance to Student

Given her weight (less than 60 kg), Acamprosate (Campral) should have been started at 666 mg orally BID. Her side effects were most likely related to the high starting dose- higher than the drug should have been started at considering her body weight.

Although the anxiety is problematic side effect, it is not as serious as her suicidal ideation. The suicidal ideation is a side effect which should have signaled the need to discontinue the drug, and consider a different agent such as disulfiram.

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, 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.

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.


Decrease Campral to 666 mg orally BID, and maintain current dose of Valium. Refer to counseling for her ongoing gambling issue
Guidance to Student

Given her weight (less than 60 kg), Acamprosate (Campral) should have been started at 666 mg orally BID. Her side effects were most likely related to the high starting dose- higher than the drug should have been started at considering her body weight.

Although the anxiety is problematic side effect, it is not as serious as her suicidal ideation. The suicidal ideation is a side effect which should have signaled the need to discontinue the drug, and consider a different agent such as disulfiram.

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, 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.

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.


Discontinue Campral and begin Antabuse (disulfiram) 250 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Mrs. Perez states that the suicidal thoughts have abated, but reports that she has been feeling tired for several hours after taking the drug
  • reports that she has not been going to the casino, because she is afraid that she may be tempted to drink, and noticed that the last time she drank, she felt nauseous, and began to vomit, she also reported that it felt like her heart would “pound right out” of her chest. She does report that she is smoking more, however
Decision Point Three
Select what the PMHNP should do next:


Discontinue Antabuse and discuss smoking cessation options
Guidance to Student

Sedation occurs in many people taking disulfiram. Mrs. Perez is experiencing adverse effects when she consumes alcohol with this drug- which is the expected/intended therapeutic effect. As a “side effect”- she is avoiding the casino which is also helping. At this point, it is not appropriate to discontinue disulfiram. Despite the fact that controversy exists regarding how long someone should remain on this medication, she has only been on this drug for 4 weeks. Additional time on the medication would be prudent.

In order to treat the side effect of sedation, the drug should be changed to bedtime to minimize this side effect.

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.

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 should also be encouraged to establish herself with a local chapter of gamblers anonymous.


Continue Antabuse in the morning and discuss smoking cessation options
Guidance to Student

Sedation occurs in many people taking disulfiram. Mrs. Perez is experiencing adverse effects when she consumes alcohol with this drug- which is the expected/intended therapeutic effect. As a “side effect”- she is avoiding the casino which is also helping. At this point, it is not appropriate to discontinue disulfiram. Despite the fact that controversy exists regarding how long someone should remain on this medication, she has only been on this drug for 4 weeks. Additional time on the medication would be prudent.

In order to treat the side effect of sedation, the drug should be changed to bedtime to minimize this side effect.

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.

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 should also be encouraged to establish herself with a local chapter of gamblers anonymous.


Change Antabuse dose to bedtime and discuss smoking cessation options
Guidance to Student

Sedation occurs in many people taking disulfiram. Mrs. Perez is experiencing adverse effects when she consumes alcohol with this drug- which is the expected/intended therapeutic effect. As a “side effect”- she is avoiding the casino which is also helping. At this point, it is not appropriate to discontinue disulfiram. Despite the fact that controversy exists regarding how long someone should remain on this medication, she has only been on this drug for 4 weeks. Additional time on the medication would be prudent.

In order to treat the side effect of sedation, the drug should be changed to bedtime to minimize this side effect.

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.

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 should also be encouraged to establish herself with a local chapter of gamblers anonymous.


Decrease Campral to 666 mg orally BID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Mrs. Perez reports that the suicidal ideation is “still there” but not as bad. She reports that she is still afraid to go to the casino for fear that she may drink, which may cause those “horrible” side effects to come back
  • Client's anxiety has also decreased quite a bit since decreasing the dose to twice a day. She reports that she is still smoking cigarettes
Decision Point Three
Select what the PMHNP should do next:


Discontinue Campral and begin Antabuse 250 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.


Discontinue Campral and recommend psychotherapy for her gambling issue
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.


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.