Assessing And Treating Clients With Impulsivity And Compulsi

Assessing and Treating Clients with Impulsivity, Compulsivity and Addiction

Pharmacotherapy practice for treating substance use disorders is often referred to as medication-assisted treatment (MAT) (Sharp et al., 2018). In this approach, specific medications approved by the Food and Drug Administration (FDA) are used in combination with counseling and behavioral therapies to treat substance use disorders (Sharp et al., 2018). These medications function by reducing cravings, mitigating withdrawal symptoms, occupying brain receptors associated with drug use (acting as agonists or partial agonists), blocking the rewarding sensations linked to substance use (antagonists), or inducing negative feelings when the substance is taken (SAMHSA, 2016).

Although MAT has been primarily utilized for opioid use disorder, it is also employed in the treatment of alcohol use disorder (AUD), gambling disorder, and smoking cessation, especially when these conditions co-occur. This paper focuses on pharmacotherapy approaches to manage AUD, gambling disorder, and tobacco addiction in a 53-year-old Puerto Rican woman, Mrs. Maria Perez, whose case exemplifies the complexities involved in treating multiple comorbid addictive behaviors.

Case Scenario and Initial Pharmacotherapy Decision

Mrs. Perez is a 53-year-old Puerto Rican woman seeking care for her ongoing struggles with alcohol, gambling, and smoking, compounded by significant financial and emotional distress. Her history reveals that she has had problems with alcohol since her late teens, and her drinking worsened over the past two years, especially following her exposure to a newly opened casino near her residence. Her gambling behavior has escalated, leading to creditors, including borrowing over $50,000 from her retirement account, which her husband does not know about. She reports that she enjoys the "high" from gambling and often uses alcohol to self-medicate during high-stakes gambling sessions, which exacerbates her gambling and health issues, including weight gain and increased cigarette smoking. This pattern indicates a dangerous cycle of compulsive behaviors that threaten her physical, mental, and financial health.

During her mental status exam, she appeared alert and oriented, with an appropriate affect but some avoidant eye contact. She demonstrated grossly intact insight and judgment but impaired impulse control, with current denial of suicidal or homicidal ideation. Her diagnosis includes gambling disorder and alcohol use disorder, with concerns about smoking and anxiety. The treatment initially involved administering Disulfiram (Antabuse) 250 mg daily and scheduling follow-up after four weeks.

Decision Point One: Pharmacological Strategy for Alcohol Use Disorder

Given her history and current presentation, the selected pharmacotherapy was naltrexone (Vivitrol) 380 mg IM every four weeks. Naltrexone is FDA-approved for AUD, acting as a mu-opioid receptor antagonist, which reduces the rewarding effects of alcohol and cravings (Stahl, 2017). Its mechanism involves modulation of opioid systems and suppression of the hypothalamic-pituitary-adrenal axis to decrease alcohol consumption (Canidate et al., 2017). The injectable form improves adherence by reducing dosing frequency, which is particularly advantageous in patients with compliance challenges.

Initially, disulfiram was avoided because, although effective in promoting abstinence, it is contraindicated in patients who are not abstinent and can cause severe reactions if the patient consumes alcohol (Yahn et al., 2013). Acamprosate was not chosen initially because it is most effective after achieving abstinence and is less suitable in ongoing heavy drinking behaviors (Yahn et al., 2013). The primary goal is to support abstinence and reduce relapse risk.

Follow-up and Potential Risks

One month later, Mrs. Perez reports no side effects from naltrexone and has maintained sobriety since the injection. She is ambivalent about her gambling and smoking behaviors but expresses motivation to address her addictions. Her mental state remains stable; however, her concern about continued gambling and financial repercussions persists. These observations reinforce the importance of combining pharmacotherapy with behavioral interventions.

Decision Point Two: Addressing Gambling Behavior and Comorbidities

The subsequent decision involved referring Mrs. Perez for counseling to treat gambling disorder and addressing her smoking and anxiety. For gambling, evidence-based interventions include cognitive-behavioral therapy (CBT), which targets distorted beliefs and maladaptive coping mechanisms (American Psychiatric Association, 2016). While there are no FDA-approved medications specifically for gambling disorder, pharmacological agents such as selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, or opioid antagonists may be beneficial, especially in comorbid psychiatric conditions (Grant et al., 2017).

Mrs. Perez’s motivation to quit smoking was also recognized. Varenicline (Chantix), a partial agonist at nicotinic acetylcholine receptors, can significantly reduce cravings and withdrawal symptoms (Stahl, 2017). The starting dose is typically 0.5 mg daily for three days, then increased to 1 mg BID (Stahl, 2017). Initiating at a lower dose minimizes adverse effects such as nausea, agitation, or sleep disturbances, especially given her previous behavioral health challenges.

Furthermore, anxiety was being managed with Valium (diazepam). Mrs. Perez found immediate relief with Valium but reports taking it early or excessively. This pattern raises concerns about dependence, especially with her history of substance use disorder. Therefore, the plan was not to increase or extend Valium use but to explore alternative anxiolytics with lower abuse potential or non-pharmacologic interventions like relaxation techniques. The goal is to safely manage her anxiety while minimizing the risk of benzodiazepine dependence.

Follow-up and Future Considerations

Mrs. Perez reported significant relief from Valium initially; however, the concern was her potential dependence and the need for a more sustainable anxiety management plan. Combining psychoeducation, behavioral strategies, and possibly non-addictive medications like buspirone could be considered (Niaura, 2017). Additionally, ongoing support for her smoking cessation efforts, including counseling and pharmacotherapy, was prioritized.

Decision Point Three: Reassessing Pharmacotherapy and Psychosocial Support

The decision involved encouraging Mrs. Perez to continue attending Gamblers Anonymous meetings and exploring her relationship with her counselor, as well as assessing her readiness to quit smoking. Addressing her concerns about her relationship with her therapist and reinforcing her commitment to sobriety are crucial steps. The importance of ongoing counseling cannot be overstated, as behavioral therapies provide essential skills and emotional support for relapse prevention (American Psychiatric Association, 2016).

In terms of pharmacotherapy, considering her ongoing suicidal ideation and adverse reactions, the discontinuation of medications like acamprosate was warranted. Alternative medications, such as naltrexone, should be continued or re-initiated to support her abstinence. Additionally, smoking cessation medications, such as varenicline, should be incorporated once her acuity regarding mental health stabilizes, and her motivation is clear. The comprehensive approach integrates medication management, counseling, peer support, and lifestyle modifications.

Conclusion

In managing complex cases like Mrs. Perez’s, personalized treatment plans that combine pharmacologic and psychosocial interventions are essential. Pharmacotherapy choices should consider the patient’s clinical status, comorbidities, and risk factors. Naltrexone effectively reduces alcohol cravings and supports abstinence, while behavioral therapies address gambling behavior. Smoking cessation medications and behavioral strategies can improve overall health outcomes. Ongoing assessment and adjustments are vital to achieving sustained recovery and preventing relapse in co-occurring addictive behaviors (Garbutt et al., 2014).

References

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