case study:
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
Antabuse (disulfiram) 250 mg orally daily
Campral (acamprosate) 666 mg orally three times/day
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Upon return Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse
She is also reporting that she is having “out of control” anxiety
Decision Point Two
Select what you should do next:
Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms
Discontinue Campral and begin Antabuse (disulfiram) 250 mg orally daily
Decrease Campral to 666 mg orally BID
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Mrs. Perez states that the suicidal thoughts have abated but reports that she has been feeling tired for several hours after taking the drug
She reports that she has not been going to the casino because she is afraid that she may be tempted to drink, and she noticed that the last time she drank, she felt nauseous and began to vomit. She also reported that it felt like her heart would “pound right out” of her chest.” She does report that she is smoking more, however
Decision Point Three
Select what you should do next:
Discontinue Antabuse and discuss smoking cessation options
Continue Antabuse in the morning and discuss smoking cessation options
Change Antabuse dose to bedtime and discuss smoking cessation options
Guidance to Student
Sedation occurs in many people taking Antabuse. Mrs. Perez is experiencing adverse effects when she consumes alcohol with this drug, which is the expected/intended therapeutic effect. As a “side effect” she is avoiding the casino, which is also helping. At this point, it is not appropriate to discontinue Antabuse. Despite the fact that controversy exists regarding how long someone should remain on this medication, the client has only been on this drug for 4 weeks. Additional time on the medication would be prudent.
To minimize the side effect of sedation, the administration of the drug should be changed to bedtime. In all cases, you need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions and to enhance her overall health.
Additionally, it should be noted that although Mrs. Perez reports that she has been avoiding the casino secondary to her fear that she will drink, this “fear” has not actually treated her gambling addiction. This particular addiction has resulted in considerable personal financial cost to Ms. Perez. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and she should also be encouraged to establish herself with a local chapter of Gamblers Anonymous.

Assignment;
Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to
this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision,
make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary
literature.
Introduction to the case (1 page)
Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when
prescribing medication for this patient.
Decision #1 (1 page)
Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources
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
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.
Decision #2 (1 page)
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources
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
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.
Decision #3 (1 page)
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources
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
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 (1 page)
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