Comorbid Addiction (ETOH and Gambling) 53-year-old Puerto Rican Female
Administer Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks.
RESULTS OF DECISION POINT ONE
The client returns to the clinic after four weeks.
Mrs. Perez expresses feeling “wonderful” as she has refrained from consuming alcohol since receiving the injection.
The client reports reduced frequency of casino visits, but when she goes, she spends significant amounts of money on gambling.
Mrs. Perez continues to smoke and is experiencing some anxiety issues.
Decision Point Two
Add Valium (diazepam) 5 mg orally TID/PRN for anxiety.
RESULTS OF DECISION POINT TWO
The client returns to the clinic after four weeks.
Mrs. Perez initially benefited greatly from the Valium, describing it as a “miracle drug.” However, she occasionally takes it earlier than scheduled due to difficulty waiting between doses.
She requests an increase in Valium dose or frequency.
Decision Point Three
Continue current dose of Vivitrol, decrease/taper Valium with the goal of discontinuation in the next 2 weeks. Refer to counseling for her ongoing gambling issue.
Guidance to Student
Anxiety is a known side effect of Vivitrol, and it may be transient in Mrs. Perez’s case. However, benzodiazepines like Valium should not be initiated in clients with alcohol or substance dependencies, and long-term use is discouraged.
The appropriate action is to maintain the current Vivitrol dose while gradually reducing and eventually discontinuing Valium within the next two weeks. The persistence of anxiety as a side effect of Vivitrol should be assessed.
Increasing Valium dosage or maintaining the current dose is not advisable. Instead, Mrs. Perez should be referred for counseling to address her gambling addiction, as there are no FDA-approved medications for gambling disorder.
Adding medication to treat the side effect of another medication is generally discouraged unless the side effect is transient. For clients with multiple addictive disorders, benzodiazepines should be used with caution, if at all.
Mrs. Perez should also be referred to a counselor specialized in treating gambling disorder and encouraged to join a local Gamblers Anonymous chapter.
Additionally, smoking cessation options should be discussed with Mrs. Perez to address all her addictions and improve overall health.
Client returns to clinic in four weeks
Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since receiving the injection Case Study: A Puerto Rican Woman With Comorbid Addiction
Client 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 has her concerned
Decision Point Two
Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety
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 an increase the Valium dose or frequency
Decision Point Three
Continue current dose of Vivitrol, decrease/taper Valium with the goal of discontinuation in the next 2 weeks. Refer to counseling for her ongoing gambling issue
Guidance to Student
Anxiety 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 that point, you would need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists Case Study: A Puerto Rican Woman With Comorbid Addiction.
Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current 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.
You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health Case Study: A Puerto Rican Woman With Comorbid Addiction.
