Summary of the Case Study
The patient in the case study suffers from alcohol use disorder, a reduced ability to regulate or stop alcohol use. The individual experiences the impairment despite awareness of the alcohol’s health, occupational and social repercussions (Carvalho et al., 2019). The National Survey on Drug Use and Health mentions that the disorder affects approximately 11.3% of adults ages 18 and above. The risk factors linked to alcohol use disorder include a family alcohol abuse history, mental disorders such as depression, experienced trauma, and taking alcohol at an early age. The Diagnostic and Statistical Manual for Mental Health Disorders (DSM-5) diagnostic criteria state that the patients must demonstrate at least two symptoms that cause considerable functional impairment (Moehring et al., 2019). For instance, they take alcohol for unintended more extended periods or increased quantity. The persons find difficulties in their constant desires to control or reduce alcohol. They spend significant time in actions that contribute to alcohol use. The continued alcohol use or craving interferes with their home, school or work obligations.
The patient in the case study is a woman aged 53 years with demonstrated alcohol use disorder. Mrs Perez has had a long history of alcohol use since she mentions that he has experienced addiction challenges since her 20s. She has had difficulties controlling alcohol use for 25 years, which worsened following the launch of the “Rising Sun” casino next to her residence. The alcohol abuse problem has adversely impacted her health, social and economic well-being and decisions. The effect is evident from her weight gain from 115 lbs. to 122 lbs. and settling gambling debts using more than $50,000 borrowed from the retirement account. The mental status assessment shows normal function except for impaired impulse control. She has good orientation, alertness and judgement, and no hallucinations, delusional or paranoid thought processes or suicidal ideations. Treatment decisions involve applying different pharmacotherapy options to assist the patient in controlling the alcohol use problem.
Decision Point One
Considering the available choices, the most appropriate first decision is to initiate treatment with Naltrexone 380 mg. The medication is given through a four-weekly intramuscular injection. The Foods and Drugs Administration approves Naltrexone for managing alcohol dependence and blocking administered opioid effects (Kirchoff et al., 2021). The drug competitively attaches to opioid receptors to reduce endogenous opioid effects in the body, such as drug craving. Research shows that alcohol increases the activity of endogenous opioids, and the opiate systems partly mediate alcohol’s rewarding effects (Conway, Mikati & Al-Hasani, 2022). Naltrexone attenuates cravings in persons with alcohol dependence and blocks pleasures related to alcohol. Patients with alcohol dependence disorder given Naltrexone can effectively abstain from alcohol use or reduce the quantity taken. Common side effects of Naltrexone include vomiting and nausea, which clinicians can avoid by administering the drug after alcohol detox procedures. Naltrexone lacks addictive properties and withdrawal symptoms, which favours its use in treating addiction issues. Therefore, it benefits the patient who smokes while playing at the slot machine. Heavy alcohol users release excess dopamine, which makes them more sensitive to the dopamine reduction effects of Naltrexone, which assists in smoking cessation.
The alternative decision would be to initiate treatment with 250 mg oral disulfiram, given once daily. Disulfiram competitively binds to and inhibits the aldehyde dehydrogenase enzyme. The enzyme is usually involved in the oxidative metabolism of alcohol, which converts acetaldehyde to acetate. Therapeutic disulfiram concentrations in individuals taking alcohol lead to higher serum acetaldehyde levels. The higher serum acetaldehyde results in tachycardia, nausea, facial flushing, palpitations and diaphoresis (Burnette et al., 2022). The symptoms of aggregation, referred to as disulfiram alcohol reaction, present unpleasant experiences that discourage persons from taking alcohol. The consideration to use of disulfiram was not suitable since it is not the first-line medicine to treat alcohol dependence. Besides, its tablet formulation promotes non-adherence since it requires more frequent administration compared to Naltrexone given once a month.
Another alternative decision was to start the patient on 666 mg of oral acamprosate. The drug is commonly used to maintain alcohol abstinence, particularly in individuals who have gone through alcohol detoxification. It balances the inhibitory and excitatory pathways altered during chronic alcohol use and reduces the physiological and psychological discomfort that accompanies withdrawal. Acamprosate does not undergo hepatic metabolism and hence can be given to patients with liver disease, commonly reported in persons with alcohol dependence (Caputo, Domenicali & Bernardi, 2019). However, acamprosate adverse reactions, including nausea, abdominal pain, diarrhoea and pruritus, make this option unsuitable. Various clinical trials conclude that acamprosate is not more effective than disulfiram and Naltrexone. Furthermore, combining acamprosate with other active alternatives does not improve its activity.
The first therapy decision is geared towards ensuring the patient reduces her alcohol consumption. Decreased alcohol cravings and intake would restore normal social, economic and health status. For example, she would reduce gambling, misuse of finances and weight gain. The goals will likely be realized since the patient would tolerate the drug and experience minimal side effects. The patient confirmed the treatment expectations as she reported a “wonderful” experience and had successfully practised alcohol abstinence since starting her medication. She has also reduced her casino visits and associated gambling. Nevertheless, issues concerning anxiety and persistent smoking required attention.
Decision Point Two
During the scheduled appointment, there was concern about the patient’s smoking habits and anxiety. The issues likely contributed to gambling, which still interfered with aspects of her social life. Smoking is associated with adverse health impacts. The most appropriate decision in her case would be to introduce psychotherapy techniques, including cognitive behavioural therapy (CBT). The approach incorporates behavioural and cognitive aspects to assist patients in identifying and fixing abnormal thought patterns that contribute to their behaviours, such as gambling and smoking (Magill et al., 2019). CBT provides the patient with the requisite coping skills to adopt alternative behaviours and thoughts promoting well-being.
The alternative choice involves prescribing 5 mg of diazepam three times daily as needed for anxiety management. Diazepam effectively reduces the patient’s anxiety, but there would still be questions concerning whether the option will stop the gambling behaviour. Gambling was the primary contributor to Mrs Perez’s anxiety; hence, eliminating the behaviour will directly reduce the anxiety without increasing drug use. The last choice was to add a drug that could control the patient’s cigarette smoking, such as oral varenicline. Varenicline is a partial agonist at the nicotine receptor, and a dose of 1 mg twice daily treats smoking addiction (Zawertailo et al., 2019). The decision was unsuitable because the patient has demonstrated appreciable response and tolerance to Naltrexone. Other techniques to arrest gambling tendencies will also assist in smoking cessation.
Following the second decision to use psychotherapy techniques, the expected outcome would include reduced participation in gambling, anxiety and smoking. Mrs Perez confirmed during the four-weekly appointment that the anxiety had reduced. The support network was instrumental in reducing gambling behaviour and anxiety symptoms. The support groups provided a promising avenue for expressing her concerns and receiving encouraging solutions (Witkiewitz et al., 2020). Despite the excellent response to counselling sessions, there appeared to be developing issues between Mrs Perez and her therapist.
Decision Point Three
An assessment conducted during the patient’s appointments showed notable treatment progress and decreased gambling behaviour and anxiety. Her disagreement with the therapist required special attention to achieve the desired outcome. The objective would be to ensure Mrs Perez is comfortable with the gambling sessions and strengthen her relationship with her therapist. There was a need to conclusively address elements causing the conflicts to ensure the sessions proceeded as expected. Social groups and networks empower individuals and improve psychological functioning through shared experiences.
The alternative decision would be to advise the patient to proceed with her counselling and group sessions. The decision cannot be considered since it fails to resolve the conflict between Mrs Perez and her therapist, which can affect the treatment outcome. The final decision involved stopping naltrexone treatment and recommend continued counselling and group sessions. However, this decision would constitute premature naltrexone withdrawal before the patient experiences its optimal benefits. Discontinuing the drug before the 12 weeks recommended period increases the risk of relapse (Adhikari et al., 2020). Still, there was essential to resolve the issue between Mrs Perez and her therapist to ensure a positive outcome from the therapy session.
Ethical Considerations
The ethical considerations in the case scenario include treating the patient with dignity and respect. Clinicians should establish therapeutic alliances with patients with alcohol use disorder to understand their issues. They should promote the patient’s well-being by employing evidence-based treatment methods regardless of socioeconomic status, ethnicity and race. Whenever appropriate, they should effectively utilize the available resources and referral systems for the patient to receive high-quality care (Haahr et al., 2020). Professionals should also promote patient autonomy by involving them in all treatment decisions. They should also avoid disclosing treatment information to other parties without seeking the patient’s informed consent.
Conclusion
The patient in the case study experiences alcohol use disorder, which interferes with her social, health and financial status. Decisions are considered using different pharmacological and non-pharmacological approaches to treat alcohol addiction and influence behaviour change. Naltrexone has proven effective in managing alcohol dependence, with fewer side effects. Therefore, it is more favourable than other choices, such as disulfiram and acamprosate. Cognitive behavioural therapy is beneficial in reinforcing coping strategies that reduce undesirable behaviours such as drug use and gambling. Clinicians and therapists must always establish a good relationship to enhance patient participation in therapy programs. Professionals should be cognizant of ethical issues that may arise during treatment and must act in the patient’s best interest.
References
Adhikari, S., Tulachan, P., Ojha, S. P., Chapagai, M., Dhungana, S., & Pant, S. B. (2020). Comparison of Disulfiram and Naltrexone in Cases of Alcohol Dependence Syndrome. Ethnicity, 36(92.3), 0-602. https://doi.org/10.33314/jnhrc.v18i1.1921
Burnette, E. M., Nieto, S. J., Grodin, E. N., Meredith, L. R., Hurley, B., Miotto, K., … & Ray, L. A. (2022). Novel agents for the pharmacological treatment of alcohol use disorder. Drugs, 82(3), 251–274. https://doi.org/10.1007/s40265-021-01670-3
Caputo, F., Domenicali, M., & Bernardi, M. (2019). Diagnosis and treatment of alcohol use disorder in patients with end‐stage alcoholic liver disease. Hepatology, 70(1), 410-417. https://doi.org/10.1002/hep.30358
Carvalho, A. F., Heilig, M., Perez, A., Probst, C., & Rehm, J. (2019). Alcohol use disorders. The Lancet, 394(10200), 781-792. https://doi.org/10.1016/S0140-6736(19)31775-1
Conway, S. M., Mikati, M. O., & Al-Hasani, R. (2022). Challenges and new opportunities for detecting endogenous opioid peptides in reward. Addiction neuroscience, 100016. https://doi.org/10.1016/j.addicn.2022.100016
Haahr, A., Norlyk, A., Martinsen, B., & Dreyer, P. (2020). Nurses’ experiences of ethical dilemmas: A review. Nursing ethics, 27(1), 258-272. https://doi.org/10.1177/0969733019832941
Kirchoff, R. W., Mohammed, N. M., McHugh, J., Markota, M., Kingsley, T., Leung, J., … & Chaudhary, R. (2021). Naltrexone initiation in the inpatient setting for alcohol use disorder: a systematic review of clinical outcomes. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 5(2), 495-501. https://doi.org/10.1016/j.mayocpiqo.2021.01.013
Magill, M., Ray, L., Kiluk, B., Hoadley, A., Bernstein, M., Tonigan, J. S., & Carroll, K. (2019). A meta-analysis of cognitive-behavioural therapy for alcohol or other drug use disorders: Treatment efficacy by contrast condition. Journal of Consulting and clinical psychology, 87(12), 1093. https://psycnet.apa.org/doi/10.1037/ccp0000447
Moehring, A., Rumpf, H. J., Hapke, U., Bischof, G., John, U., & Meyer, C. (2019). Diagnostic performance of the alcohol use disorders identification test (AUDIT) in detecting DSM-5 alcohol use disorders in the general population. Drug and alcohol dependence, 204, 107530. https://doi.org/10.1016/j.drugalcdep.2019.06.032
Witkiewitz, K., Montes, K. S., Schwebel, F. J., & Tucker, J. A. (2020). What is recovery? Alcohol Research: Current Reviews, 40(3). https://doi.org/10.35946%2Farcr.v40.3.01
Zawertailo, L., Ivanova, A., Ng, G., Le Foll, B., & Selby, P. (2020). Safety and efficacy of varenicline for smoking cessation in alcohol-dependent smokers in concurrent treatment for alcohol use disorder: a pilot, randomized placebo-controlled trial. Journal of Clinical Psychopharmacology, 40(2), 130–136. DOI: 10.1097/JCP.0000000000001172
write