Introduction
The patient is a 53-year-old female diagnosed with alcohol use disorder and gambling disorder. According to the patient, her problems with alcohol began in adolescence after the death of her father. Childhood trauma is often the cause of impulsive behavior, including substance use disorder in later life (Childhood Trauma Linked to Worse Impulse Control, 2016).
The patient states that she was able to control the problem by attending Alcoholics Anonymous. However, after a casino opened in her area, coping with the disorder became more difficult (Comorbid Addiction, n.d.). In addition to alcohol dependence, the patient developed a gambling disorder associated with her tendency to engage in impulsive behavior.
The patient uses alcohol as a means of calming the excitement while gambling. Comorbid conditions are a relatively common issue among individuals with a history of impulsivity (Sanches et al., 2014). This creates the need to address patients’ issues to eliminate diagnosed disorders comprehensively.
In addition, the patient reports that her smoking has increased over the past 2 years, which is of concern to her (Comorbid Addiction, n.d.). The woman also gained weight due to increased alcohol consumption. This condition is common among patients with a long history of alcohol use disorder (Substance Abuse and Mental Health Services Administration, 1999). Considering that the patient’s smoking increases while gambling, solving this problem and addressing the client’s concerns is a possible way to overcome her disorders.
The general assessment of the patient’s psychological state revealed no significant deviations from normal. Coherent speech, spatial orientation, and appropriate clothing indicate the absence of cognitive development impairments (Comorbid Addiction, n.d.). In addition, the patient denies the presence of hallucinations or obsessive and suicidal thoughts. Depressed mood and avoidance of eye contact may be associated with long-term alcohol abuse (Substance Abuse and Mental Health Services Administration, 1999). Moreover, the client has identified impulsive behavior, which may impact the course of treatment and its outcomes.
Decision 1
The patient’s concerns require a complex intervention. However, the first line of treatment will be aimed at eliminating the problem of alcohol abuse. The medication chosen was Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks.
Although this treatment is not the most common treatment for alcohol use disorder, it is approved by the U.S. Food and Drug Administration (FDA) as an alternative medication intervention (Avery, 2022). The purpose of this drug is due to its rapid action and long-lasting effect. Furthermore, the patient states that she can abstain from drinking alcohol, which is essential for the prescription of Vivitrol, which has a maintenance effect (Naltrexone, n.d.).
Other treatment options, like Antabuse (disulfiram) 250 mg orally daily and Campral (acamprosate) 666 mg orally three times/day, were rejected due to potential adverse effects. These medications may have a strong sedative effect, which can cause anxiety in the patient given her impulsiveness (Avery, 2022). In addition, drinking even a small dose of alcohol while taking these drugs can lead to serious consequences and death. This factor should be considered when prescribing due to the instability of the patient’s success in overcoming alcohol dependence and the high likelihood of relapse.
This solution aims to solve the problem of alcohol use disorder in women. Moreover, the use of Vivitrol is expected to yield positive long-term results due to its maintenance effect (Naltrexone, n.d.). However, this intervention does involve some ethical considerations.
First, it is essential to educate the patient about all treatment alternatives and their associated risks and benefits. Secondly, a woman’s impulsive behavior requires more careful monitoring of her condition due to the increased risks of returning to previous behavior. Moreover, abrupt withdrawal from alcohol after prolonged use can lead to severe withdrawal with worsening emotional well-being and increased anxiety (Substance Abuse and Mental Health Services Administration, 1999). The patient must be informed of possible side effects and provide consent to initiate treatment.
Decision 2
After the first intervention, the patient noticed significant positive changes in the treatment of alcohol use disorder. This necessitates continued Vivitrol injections for maintenance of abstinence (Naltrexone, n.d.). However, the patient’s main complaint during the second meeting was an ongoing gambling disorder. To solve this problem, the patient was referred to a counselor. Since there is no FDA-approved treatment for this disorder, counseling is the best option.
Additionally, the client reports that her anxiety has increased since using Vivitrol. This phenomenon is likely transient and is due to withdrawal (Substance Abuse and Mental Health Services Administration, 1999). Therefore, proposed alternatives like adding on Valium (diazepam) 5 mg orally TID/PRN/anxiety or Chantix (varenicline) 1 mg orally BID were rejected. First, additional medication cannot be used to reverse the side effects of previous interventions (Substance Abuse and Mental Health Services Administration, 1999). Secondly, these drugs can cause dependence and the need to increase the dose.
The chosen solution is aimed at developing strategies for the treatment of gambling disorder. The lack of approved medication options makes counseling the optimal intervention at this stage. Moreover, it can help control the patient’s impulsive behavior (Sanches et al., 2014). Ethical considerations include informing the patient about the future treatment plan, as well as the associated risks and benefits. The monitoring of the patient’s condition will help to control increased anxiety.
Decision 3
After 4 weeks, the patient reported that her anxiety had disappeared. This means that this condition was caused by a sharp withdrawal from alcohol after prolonged use and was a passing stage in treatment. In addition, the patient noted that she did not like the meeting with the counselor, which creates a need to analyze the details of this meeting to identify the problem. Gamblers Anonymous’ visits to meetings have had a positive impact on the client, which is a reason to encourage them to continue attending. The alternative option of continuing meetings with the current counselor will not be effective since the patient has indicated her reluctance to continue them.
Additionally, discontinuing Vivitrol after eight weeks may be a relatively early decision that may undo the results achieved (Avery, 2022). Therefore, continuing medication intervention every four weeks, along with visiting Gamblers Anonymous, is the best option for improving the woman’s condition. Moreover, this decision complies with ethical standards regarding patient autonomy, as counseling was canceled at the client’s request.
Conclusion
To summarize, comorbid addictions are quite common among patients with impulsivity. Despite the need to address several issues, the most effective option is to eliminate the disorders gradually. To overcome alcohol abuse, the patient was offered Vivitrol. It is an FDA-approved medication that helps resolve the issue quickly and maintains long-term results (Avery, 2022).
Anxiety, which began after the first four weeks of treatment, is a common side effect observed after quitting alcohol. In addition, counseling was chosen for the treatment of gambling disorder. Although these meetings did not give the expected result, Gamblers Anonymous’s visits had a positive impact on the client’s impulsiveness. In the future, it is necessary to continue to monitor the woman’s condition for timely discontinuation of Vivitrol and to offer other counselors for enhanced treatment.
References
Avery J. (2022). Naltrexone and alcohol use. The American Journal of Psychiatry, 179(12), 886–887.
Childhood Trauma Linked to Worse Impulse Control. (2016). Journal of Psychosocial Nursing & Mental Health Services, 54(4), 15-17.
Comorbid Addiction (ETOH and Gambling). 53-year-old Puerto Rican Female. (n.d.). Comorbid Addiction (ETOH and Gambling).
Naltrexone (Rx). (n.d.). Medscape.
Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., Olver, R., Swan, 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.
Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders: Treatment improvement protocol series.