Co-morbid Addiction (ETOH and Gambling)

Co-morbid Addiction (ETOH and Gambling)

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office 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 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. Co-morbid Addiction (ETOH and Gambling)

She states that she attempts to abstain from drinking but that 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 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 EXAM

The 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 disorder

Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female

Decision Point One Co-morbid Addiction (ETOH and Gambling)

Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Mrs. Perez said that she felt “wonderful” as she has not “touched a drop” to drink 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 have her concerned

Decision Point Two

Add on Chantix (varenicline) 1 mg orally BID

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client reports that she had to stop taking Chantix secondary to abnormal dreams, and agitation
• Client also reported feeling nauseous and also reported that she vomited several times after she began taking the drug

Decision Point Three

Re-start Chantix at 0.5 mg orally daily

Guidance to Student

Mrs. Perez was experiencing normal side effects associated with Vivitrol. She should be counseled regarding the potential side effects associated with Vivitrol, and reassured that they will most likely abate.

It should be noted that the problem that Mrs. Perez is experiencing from the Varenicline is most likely related to the starting dose. Recall that this drug should be initiated at 0.5 mg/day; after three days increase to 1 mg/day in two divided doses; after 4 days can increase to 2 mg/day in two divided doses. Side effects would most likely have been minimized or completely avoided had she been started at the appropriate starting dose. Therefore, it may be prudent to restart this drug at 0.5 mg orally daily, and uptitrate consistent with the manufacturers suggested titration schedule. It would not be appropriate to restart Mrs. Perez at 1 mg orally BID, as it would most likely result in a return of the unpleasant symptoms she experienced.

If Mrs. Perez is adverse to the idea of restarting Varenicline, the PMHNP could begin bupropion XL, 150 mg orally daily.

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.

Co-morbid Addiction (ETOH and Gambling)