Pharmacotherapy

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 practice, specific medications approved by the Federal Drug Administration (FDA) are used in combination with counseling and behavioral therapies in treatment of a substance use disorder (Sharp et al, 2018) Medications can reduce the cravings and other symptoms associated with withdrawal from a substance by occupying receptors in the brain associated with using that drug (agonists or partial agonists), block the rewarding sensation that comes with using a substance (antagonists), or induce negative feelings when a substance is taken ( SAMHSA, 2016). MAT has been primarily used for the treatment of opioid use disorder but is also used for alcohol use disorder and the treatment of some other substance use disorders. This paper focuses on pharmacotherapy approaches to the treatment of alcohol use disorder, gambling disorder and smoking addiction in a 53 year- old female of Puerto origin.

Case Scenario

Decision Number One

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

Rationale: Pharmacotherapy should be used in patients with alcohol use disorder who have current, heavy use and ongoing risk for consequences from use, motivated to reduce alcohol intake and do not have medical contraindications to the individual drug choice (SAMHSA, 2016). As the 53-year-old female has acknowledged that she has a drinking problem and has tried the psychosocial approach with alcoholics anonymous(AA) without success, adding medication such as naltrexone would be warranted as next step. In random clinical trials (RCTs) naltrexone medication has been shown to reduce heavy drinking and enhance the likelihood of abstinence ( Garbutt et al.,  2014)

Naltrexone is mu opioid receptor antagonist, can be in form of oral ( Revia) and injection( Vivitrol) ( Stahl, 2017). Naltrexone is FDA approved to treat alcohol dependence, blockade of effects of exogenously administered opioids (oral) and prevention of relapse to opioid dependence (Stahl, 2017).  Naltrexone reduces alcohol consumption through modulation of opioid systems, thereby reducing the reinforcing effects of alcohol and opioids (cravings, rewarding effects). Moreover, naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress ethanol consumption.

The recommended naltrexone injectable (Vivitrol) suspension is 380mg and should be administered via intramuscular (IM)injection to the gluteal area using the provided 1.5-inch 20-gauge needle(Drugs.com, 2017).  Vivitrol is extensively metabolized in humans, and elimination half-life of naltrexone via injection is 5–10 days (Drugs. com, 2017) Common side effects of naltrexone are nausea, headache, and dizziness, joint or muscle pain which subside with continued use. Special considerations include that Vivitrol should not be given to patients taking opioids, and if opioids are required to treat pain, naltrexone should be discontinued. Naltrexone is contraindicated in acute hepatitis or liver failure.

The advantage usage is that naltrexone can be initiated while the individual is still drinking (Canidate et al., 2017) This allows treatment for alcohol use disorder to be provided in community-based practice at the point of maximum crisis without the need for enforced abstinence or detoxification, thus beneficial for the client. Additionally, depot preparations of naltrexone may improve adherence by reducing the frequency of medication administration from daily to monthly and by achieving a steady therapeutic level of medication, thus avoiding peak effects that can exacerbate adverse events.

The reason I did not select disulfiram (Antabuse) which by intent leads to adverse effects ( nausea, vomiting, metallic taste, tachycardia) when combined with alcohol intake, was that it should only be used by abstinent patients in the context of treatment intended to maintain abstinence. In regards to Acamprosate, I did not select the medication because research indicates that Acamprosate should be used once abstinence is achieved (Yahn, Witterson, & Olive, 2013).

The main goal of prescribing medication for treatment for alcohol use disorder is abstinence, which remains a primary treatment focus. However, a decrease of heavy drinking can be accepted as an alternative treatment goal, especially if unwanted risks (health, social and financial) are reduced.

The client returns four weeks after the injections, she has been sober since receiving an injection, she denies any side effects from medications. The main chief complaint is gambling, but the client is also concerned about her smoking and anxiety.

Decision Two

Refer to a Counselor for Gambling Issues 

Rationale:  Several different types of therapy are used to treat gambling disorder, including cognitive behavior therapy, psychodynamic therapy, group therapy and family therapy (American Psychiatric Association, 2016) As recent, there is no FDA approved pharmacotherapy for gambling disorder. But, pharmacotherapy approaches to problem gambling can be effective when directed toward the patient’s comorbid psychiatric condition such as bipolar disorder, obsessive-compulsive disorder(OCD), and substance abuse.

The client was concerned about her smoking and appeared to be motivated to stop smoking, hence adding medication to assist her to quit would have been a reasonable approach to avoid health complications (e.g cardiovascular, pulmonary) associated with smoking. However, I did not select the answer as the starting dosage (Varenicline 1mg PO BID) was slightly higher than the recommended starting dose. Initial 0.5 mg/day; after 3 days increase to 1 mg/day in two divided doses; after 4 days can increase to 2 mg/day in two divided doses (Stahl, 2017). Starting at a higher would have increased the possibilities of adverse effects such nausea, vomiting and even agitation.

Adding Diazepam (Valium) would not be a good option, as Valium is an addictive benzodiazepine with longer-lasting effects than other drugs in its class. In the light of the client’s history of substance use disorder and addiction, adding another addictive substance such as valium would cause more harm.

The client returns in four weeks report that anxiety has gone. Client reports not liking the therapist, but she has joined the gambling anonymous group.

Decision Number Three

Explore the issue that Mrs. Lopez is having with her counselor, and encourage her to continue attending Gamblers Anonymous meetings

Rationale: Despite that Mrs. Lopez did not have a good relationship with the counselor, but she remained committed to fighting her addiction by joining the Gamblers Anonymous group. Still, counseling remains the main approach to gambling addiction treatment, hence exploring the issues that Mrs. Lopez had with a counselor would help to guide the next step in treatment. Also, smoking cessation needs to be explored at this time. Assessing the client’s willingness to quit is the first step as smokers differ in their readiness to change their tobacco use (Niaura, 2017). Understanding the smokers’ perspectives is essential to providing useful assistance.

Ethical and Legal Implications in Prescribing Medications to Treat Substance Use Disorders.

In order to optimize care of clients with substance use disorder, health professionals are encouraged to learn and appropriately use routine screening techniques, clinical laboratory tests, brief interventions, and treatment referrals ( Garbutt, 2014). Using screening tools such as CAGE Questionnaire for alcohol use dependence would be ideal in guiding treatment approach. Additionally, the client’s autonomy and confidentiality must be maintained before prescribing medications to treat an addiction. When a legal or medical obligation exists for  a health professional to test clients for substance use disorder, there is an ethical responsibility to notify clients of this testing and make a reasonable effort to obtain informed consent ( Garbutt, 2014)