BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing problem.”

SUBJECTIVE

Mrs. 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 2 years, she has been having more and more difficulty maintaining her sobriety since the opening of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its 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 2 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 she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much,” but she 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 borrowed over $50,000 from her retirement account to pay off her gambling debts, and her husband does not know.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert and 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. When 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 and self-reported mood. She denies visual or auditory hallucinations, and 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 disorder

Decision Point One

Select what you should do:

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks (I chose this)

RESULTS OF DECISION POINT ONE

• 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
• 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

Select what you should do next:
Refer to a counselor to address gambling issues (I chose this)

RESULTS OF DECISION POINT TWO

• Mrs. Perez returns in 4 weeks and reports that the anxiety that she had been experiencing is gone.
• She reports that she has met with the counselor, but she did not really like her.
• She also started going to a local meeting of Gamblers Anonymous. She states that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group.

Decision Point Three

Select what you should do next:

• Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetings (I chose this)
• Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group. Discontinue Vivitrol.
• Encourage Mrs. Perez to continue seeing her counselor and to continue participating in the Gamblers Anonymous group

Guidance to Student
Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, 8 weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor.  Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA-approved treatments for gambling addiction. The mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the Gamblers Anonymous meetings, she should be encouraged to continue her participation with this group.

You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.

Questions: Detail explanation

Decision #3 

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references.
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion 

• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

ANSWER

A Comprehensive Approach to Treating Gambling Disorder and Alcohol Use Disorder

Introduction

The case of Mrs. Maria Perez presents a complex scenario involving dual diagnoses of gambling disorder and alcohol use disorder. In decision point three, we are tasked with addressing Mrs. Perez’s concerns with her counselor and encouraging her to continue attending Gamblers Anonymous meetings. This essay will provide a detailed explanation of the decision, reasons for not selecting alternative options, desired outcomes, and the ethical considerations impacting the treatment plan and communication with patients.

Decision #3: Explore the Issue with Mrs. Perez’s Counselor and Encourage Gamblers Anonymous Participation

Why this decision

The primary reason for selecting this decision is to address the core issues that Mrs. Perez has with her counselor and to encourage her continued participation in Gamblers Anonymous. Mrs. Perez has shown progress since starting with the counselor, as she has become more comfortable speaking at Gamblers Anonymous meetings, which suggests that the group offers valuable support. It is crucial to explore her concerns about the counselor and work towards resolving them, as a positive therapeutic relationship is essential for effective counseling.

Reasons for not selecting other options

Option two, discontinuing Vivitrol, is premature, given the relatively short duration of treatment. Discontinuing the medication could jeopardize her sobriety.
Option three, encouraging Mrs. Perez to continue with both her counselor and Gamblers Anonymous, is a valid approach. However, in this scenario, exploring her issues with the current counselor and encouraging her to maintain the Gamblers Anonymous meetings are immediate priorities.

Desired outcomes

The goal is to address Mrs. Perez’s concerns with her counselor, ensure that she receives effective therapy, and maintain her engagement with Gamblers Anonymous. Through this approach, we aim to:
Strengthen Mrs. Perez’s commitment to recovery.
Enhance her trust in the counseling process.
Continue providing support for her gambling addiction.
Promote a collaborative therapeutic relationship between Mrs. Perez and her counselor.

Ethical considerations

Ethical considerations play a significant role in this decision. The ethical principles of autonomy, beneficence, and non-maleficence must guide our actions. Autonomy is respected by addressing Mrs. Perez’s concerns with her counselor, allowing her to make an informed decision about her therapy. Beneficence is upheld by promoting effective treatment and recovery. Non-maleficence ensures that discontinuing Vivitrol, a beneficial medication, is not done prematurely, preventing potential harm.

Conclusion

In this complex case, a comprehensive approach that focuses on exploring and addressing Mrs. Perez’s concerns with her counselor and encouraging her continued participation in Gamblers Anonymous is the most appropriate decision at this juncture. By maintaining a collaborative and supportive therapeutic relationship, we can enhance her chances of recovery and the successful management of both gambling and alcohol use disorders. Ethical considerations are fundamental in guiding our actions and ensuring the best possible care for Mrs. Perez.