course materials

1. Examine Case Study: A Puerto Rican Woman With Comorbid Addiction.
The Assignment:Examine Case Study: A Puerto Rican Woman With Comorbid Addiction.
You will be asked to make three decisions concerning the medication to prescribe to this
client. Be sure to consider factors that might impact the client’s pharmacokinetic and
pharmacodynamic processes.At each decision point stop to complete the
following:· Decision #1·o Which decision did you select?o Why did you select this decision?
your response with evidence and references to the Learning Resources.o What were you
hoping to achieve by making this decision? your response with evidence and references to
the Learning Resources.o Explain any difference between what you expected to achieve
with Decision #1 and the results of the decision. Why were they different?· Decision #2·o
Why did you select this decision? your response with evidence and references to the
Learning Resources.o What were you hoping to achieve by making this decision? your
response with evidence and references to the Learning Resources.o Explain any difference
between what you expected to achieve with Decision #2 and the results of the decision.
Why were they different?· Decision #3·o Why did you select this decision? your response
with evidence and references to the Learning Resources.o What were you hoping to achieve
by making this decision? your response with evidence and references to the Learning
Resources.o Explain any difference between what you expected to achieve with Decision #3
and the results of the decision. Why were they different?Note: your rationale with a
minimum of three academic resources no more than five years old. Co-morbid Addiction
(ETOH and Gambling)53-year-old Puerto Rican FemaleBACKGROUNDMrs. Maria Perez is a
53 year old Puerto Rican female who presents to your office today due to a rather
“embarrassing problem.” SUBJECTIVEMrs. Perez admits that she has had “problems” with
alcohol since her father died in her late teens. She reports that she has struggled with
alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the
past 25 years. She states that for the past two years, she has been having more and more
difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her
home. Mrs. Perez states that she and a friend went to visit the new casino during their grand
opening at which point she was “hooked.” She states that she gets “such a high” when she is
gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes
games. She states that this often gives way to more drinking and more reckless gambling.
She also reports that her cigarette smoking has increased over the past two years and she is
concerned about the negative effects of the cigarette smoking on her health.She states that
she attempts to abstain from drinking but that she gets such a “high” from the act of

2. gambling that she needs a few drinks to “even out.” She also notices that when she drinks,
she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines.
She also reports that she has gained weight from drinking so much- she currently weights
122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.Mrs. Perez is
quite concerned today because she has borrowed over $50,000 from her retirement
account to pay off her gambling debts. She is very concerned because her husband does not
know that she has spent this much money. MENTAL STATUS EXAMThe client is a 53 year
old Puerto Rican female who is alert, oriented to person, place, time, and event. She is
dressed appropriately for the weather and time of year. Her speech is clear, coherent, and
goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you
make eye contact with her, she looks away or looks down. She demonstrates no noteworthy
mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to
content of conversation & self-reported mood. She visual or auditory hallucinations, no
delusional or paranoid thought processes are readily appreciated. Insight and judgment are
grossly intact, however, impulse control is impaired. She is currently denying suicidal or
homicidal ideation.Diagnosis: Gambling disorder, alcohol use disorderDecision Point
One:Select what the PMHNP should do:Naltrexone (Vivitrol) injection, 380 mg
intramuscularly in the gluteal region every 4 weeksRESULTS OF DECISION POINT
ONEClient returns to clinic in four weeksMrs. Perez said that she felt “wonderful” as she has
not “touched a drop” to drink since receiving the injectionClient reports that she has not
been going to the casino, as frequently, but when she does go she “drops a bundle”
(meaning, spends a lot of money gambling)Client She is also still smoking, which has her
concerned. She is also reporting some problems with anxiety, which also have her
concernedDecision Point Two:Select what the PMHNP should do next:Add on
Valium(diazepam) 5 mg orally TID/PRN/anxietyRESULTS OF DECISION POINT TWOClient
returns to clinic in four weeksMrs. 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 earlyClient is asking today for you to increase the valium dose
or frequencyDecision 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 issueGuidance to StudentAnxiety 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

3. 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.