The patient, a 53-year old female of Puerto Rican descent, presents with comorbid addictions – gambling and alcohol. Ms. Perez has struggled with the problem of alcoholism since her 20's. She got hooked to alcoholism when her father died. Regarding the gambling addiction, she was hooked to the vice when she accompanied her friend to a casino. According to her, gambling makes her high. During the sessions, she takes alcohol to reduce her nervousness due to the high-stake games. In the end, she finds herself drinking more and more, which forces her into reckless gambling. She is concerned about her two addictions, for they are slowly making her addicted to cigarettes, a habit that has increased sharply over the last two years. Also, the two addictions have caused side effects such as weight gain, irresponsible financial choices, and trouble in her marriage. Although she appears a decent woman, she presents with symptoms of depression such as a sad mood and nervousness. This paper illustrates three clinical decisions regarding the patient’s treatment by considering the potential pharmacokinetic and pharmacodynamics effects of the choices.
Decision One
Ms. Perez was diagnosed with gambling disorder and alcohol use disorder (AUD). Therefore, the first decision was to prescribe Antabuse 250mg orally every morning. According to Galbicsek (2019), Disulfiram , which is commonly sold under the brand name, Antabuse , is a medication that can treat chronic alcoholism by discouraging the consumption of alcohol. The Food and Drug Administration (FDA) approved Disulfiram in 1951, and it was the only drug available for treating alcoholism at the time. Although there are approved drugs currently in the market, Antabuse is administered orally, meaning patients are more likely to comply with the dose as opposed to those that are administered intramuscularly.
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Patients with AUD tend to either abuse or depend on alcohol for them to function properly. However, Antabuse reduces the problem of AUD by interfering with the normal functioning of the enzyme that is involved in the metabolism of alcohol ( Winslow et al., 2016). During the metabolism process, enzyme alcohol dehydrogenase first converts alcohol or ethanol to acetaldehyde (Das, 2016). Later, another enzyme, aldehyde dehydrogenase, converts acetaldehyde to acetic acid. Antabuse interferes with the process of converting acetaldehyde to acetic acid by inhibiting aldehyde dehydrogenase. Das (2016) further notes that the drug does not influence the rate of elimination of alcohol in the body. However, by stopping the conversion of acetaldehyde to acetic acid, it increases the concentration of acetaldehyde in the body after alcohol consumption. The high concentration of this chemical leads to unpleasant reactions, including headache, nausea, confusion, and so on.
The reason why Naltrexone (Vivitrol) injection was not selected is that many patients have low tolerance levels for intramuscularly injections, which might reduce the levels of compliance with the dose. Primarily, this drug acts as a "competitive antagonist at opioid receptors," and it can pose a serious danger to alcoholics since ethanol can modify opiate receptors. As a result, Naltrexone is known to cause impaired thinking and enhances anxiety (Das, 2016), meaning it might not work out well for Ms. Perez, given her depression. Likewise, the option of Campral (Acamprosate) was not appropriate as per the patient's needs. According to Das (2016), the drug is not efficient in stopping alcohol dependence among patients who have not detoxified themselves or those who have not yet abstained from alcohol. As such, it is only suitable for patients who are no longer alcohol-dependent at the start of use, and this is not the case for Ms. Perez.
The expectation for choosing Antabuse was that it would be more convenient for the patient than the next best option, Naltrexone, since the adherence levels for oral medications are higher than those of injections. This would gradually limit the issue of gambling addiction since the patient reports that she normally drinks to cope with the “high-stake” games. Also, given her current state, Antabuse will not put her health in jeopardy for the development of new complications. Eventually, when she stops gambling, her intake of cigarettes will also reduce.
After four weeks of using Antabuse, the results showed mixed results. First, the alcohol intake levels dropped as expected, but the patient did not stop going to the casino, and her smoking had increased. However, these differences might be her way of trying to compensate for the withdrawal symptoms being experienced.
Decision Two
Here, the decision was to continue the current dose of Antabuse and begin Wellbutrin XL 150mg daily. Wellbutrin ( bupropion) is an antidepressant drug mainly used for treating major depression. The choice was informed by the fact that Wellbutrin is known to treat nicotine addiction as well as depression. Unlike other depressants, it is classified as an aminoketone owing to its unique pharmacological capability of inhibiting the reuptake of both noradrenaline and dopamine (Patel et al., 2016). Valium (diazepam) 5 mg was not chosen due to its many side effects, such as hallucinations and restlessness (Editorial Staff, 2019). On the other hand, Chantix (varenicline) was not a viable option in that despite being effective in smoking cessation, ait has an adverse effect, including suicidal thoughts (Burke et al., 2016).
The effectiveness informed the choice for decision two of Antabuse in reducing alcohol dependence during the previous stage. Also, Wellbutrixin has less harmful side effects meaning the patient is likely to comply with her dose. As expected, the withdrawal symptoms due to the use of Disulfiram had vanished, and the level of smoking had reduced significantly.
Decision Three
The patient was advised to continue with her current dose of each drug. She was also referred to a counselor for her gambling addiction. Ms. Perez no longer experiences the side effects of Antabuse as experienced in the first four weeks of treatment. This is an indication that her body is not experiencing any withdrawal symptoms, for it is now free from acetaldehyde. Swift and Leggio (2009) contend that the use of Disulfiram alongside psychosocial treatment is an effective way of increasing its efficacy. For instance, the counselor can stress the importance of the continued use of the medication or even teach the patient on the consequences of alcohol dependence. In turn, the patient will be more inclined to finish their dose. The efficacy of involving a professional counselor in treating the gambling disorder is that counselors use various counseling methods depending on the client’s needs. Currently, cognitive-behavioral therapy (CBT) comprising is the best way to deal with the problem. The approach is suitable to Ms. Perez, for it offers coping mechanisms for reinforcing positive gains and preventing relapse ( Rizeanu, 2017) .
The choices for the decision were informed by the fact that Antabuse takes up to 12 weeks for it to exert its full therapeutic effects. CBT was also a good option since it can help the patient learn the importance of adhering to the two medications while at the same time helping the client come up with ways of coping with and preventing relapse of smoking and gambling addictions.
References
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Das, J. (2016). Drugs to treat alcohol dependence – A perspective. Journal of Addiction and Dependence, 2 (2). https://doi.org/10.15436/2471-061X-16-021.
Editorial Staff. (2019). Long-term use and severe addiction to valium . American Addiction Centers. https://americanaddictioncenters.org/valium-treatment/long-term
Galbicsek, C. (2019). Disulfiram. Alcohol Rehab Guide. https://www.alcoholrehabguide.org/treatment/disulfiram/
Patel, K., Allen, S., Haque, M. N., Angelescu, I., Baumeister, D., & Tracy, D. K. (2016). Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. Therapeutic Advances in Pharmacology, 6 (2): 99–144. doi: 10.1177/2045125316629071
Rizeanu, S. (2017). Cognitive-behavioral therapy for gambling addiction . Intechopen. https://www.intechopen.com/books/cognitive-behavioral-therapy-and-clinical-applications/cognitive-behavioral-therapy-for-gambling-addiction
Swift, R., & Leggio, L. (2009). Adjunctive pharmacotherapy in the treatment of alcohol and drug dependence. In Peter M. (Ed.), Evidence-Based Addiction Treatment. Academic Press.
Winslow, B., Onysko, M., & Hebert, M. (2016). Medications for alcohol use disorder . American Academy of Family Physicians. https://www.aafp.org/afp/2016/0315/p457.pdf
