A 53-year-old Puerto Rican woman presented with comorbid alcohol and gambling addictions. She had a history of alcohol use disorder since her teens and had been attending Alcoholics Anonymous on and off for 25 years. Recently, she began frequent gambling at a new nearby casino which exacerbated her drinking. She was given a naltrexone injection and referred to counseling for her gambling issues which helped reduce her anxiety and led her to participate in Gamblers Anonymous meetings. Her counselor relationship required further exploration to improve treatment of her gambling addiction.

1. The Case Study: A Puerto Rican Woman With Comorbid
Addiction (and decision made)
Required Media
Laureate Education (2016c). Case study: A Puerto Rican woman
with comorbid addiction [Interactive media file]. Baltimore,
MD: Author
Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female
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.

2. 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
Decision Point One
Select what the PMHNP should do (3 Available Medications)
Naltrexone (Vivitrol) 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

3. Decision Point One (Decision Selected)
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 (3 Available Medications/Decisions)Select
what the PMHNP should do next: (3 Available
Medications/Decisions)
Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety
Refer to a counselor to address gambling issues
Add on Chantix (varenicline) 1 mg orally BID
Decision Point Two (Decision Selected)
Refer to a counselor to address gambling issues
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Client reports that the anxiety that she had been experiencing
is gone
· Client reports that she has met with the counselor, but did not
really like her. She did start going to a local meeting gamblers
anonymous. She stated that last week, for the first time, she
spoke during the meeting. She reports feeling supported in this
group

4. Decision Point Three (3 Available Medications/Decisions)Select
what the PMHNP should do next: (3 Available
Medications/Decisions)
Explore the issue that Mrs. Perez is having with her counselor,
and encourage her to continue attending the Gamblers
Anonymous meetings
Encourage Mrs. Perez to continue seeing her current counselor
as well as continuing with the Gamblers Anonymous group
Discontinue Vivitrol. Encourage Mrs. Perez to continue seeing
her counselor and to continue participating in the Gamblers
Anonymous group
Decision Point Three (Decision Selected)
Explore the issue that Mrs. Perez is having with her counselor,
and encourage her to continue attending the Gamblers
Anonymous meetings
Guidance to Student
Although controversy exists in the literature regarding how long
to maintain a client on Vivitrol, four weeks is probably too soon
to consider discontinuation. The psychiatric mental health nurse
practitioner should explore the issues that Mrs. Perez is having
with her counselor. As you will learn in future courses, ruptures
and the therapeutic alliance can result in clients stopping
therapy. Clearly, if the client does not continue with therapy,
the likelihood of the gambling problem spontaneously remitting
is lower (than had the client continued to receive therapy).
Recall that there are no FDA approved treatments for gambling
addiction, and the mainstay of treatment for this disorder is
counseling. Since Mrs. Perez reports good perceived support
from the gamblers anonymous meetings, she should be
encouraged to continue her participation with this group.
The PMHNP needs to discuss smoking cessation options with
Mrs. Perez in order to address the totality of addictions, and to
enhance her overall health.

5. The End
Assignment: Assessing and Treating Clients with Impulsivity,
Compulsivity, and Addiction
The 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 stop to complete the following:
· Decision #1
· Which decision did you select?
· Why did you select this decision? Support your response with
evidence and references to the Learning Resources.
· What were you hoping to achieve by making this decision?
Support your response with evidence and references to the
Learning Resources.
· Explain any difference between what you expected to achieve
with Decision #1 and the results of the decision. Why were they
different?
· Decision #2
· Why did you select this decision? Support your response with
evidence and references to the Learning Resources.
· What were you hoping to achieve by making this decision?
Support your response with evidence and references to the
Learning Resources.
· Explain any difference between what you expected to achieve
with Decision #2 and the results of the decision. Why were they
different?
· Decision #3
· Why did you select this decision? Support your response with
evidence and references to the Learning Resources.
· What were you hoping to achieve by making this decision?

6. Support your response with evidence and references to the
Learning Resources.
· Explain any difference between what you expected to achieve
with Decision #3 and the results of the decision. Why were they
different?
Learning Resources
Note: To access this week’s required library resources, please
click on the link to the Course Readings List, found in
the Course Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through the Walden
Library using this link. This link will take you to a log-in page
for the Walden Library. Once you log into the library, the Stahl
website will appear.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology:
Neuroscientific basis and practical applications (4th ed.). New
York, NY: Cambridge University Press.
To access the following chapters, click on the Essential
Psychopharmacology, 4th ed tab on the Stahl Online website
and select the appropriate chapter. Be sure to read all sections
on the left navigation bar for each chapter.
· Chapter 14, “Impulsivity, Compulsivity, and Addiction”
Stahl, S. M., & Grady, M. (2012). Stahl’s illustrated substance
use and impulsive disorder New York, NY: Cambridge
University Press.
To access the following chapter, click on the Illustrated Guides
tab and then the Substance Use and Impulsive Disorders tab.
· Chapter 10, “Disorders of Impulsivity and Compulsivity”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New
York, NY: Cambridge University Press.

7. To access information on the following medications, click on
The Prescriber’s Guide, 5th ed tab on the Stahl Online website
and select the appropriate medication.
Review the following medications:
For insomnia
For obsessive-compulsive disorder
· Citalopram
· clomipramine
· escitalopram
· fluoxetine
· fluvoxamine
· paroxetine
· sertraline
· venlafaxine
· vilazodone
For alcohol withdrawal
· chlordiazepoxide
· clonidine
· clorazepate
· diazepam
· lorazepam
· oxazepam
For bulimia nervosa and binge eating
· fluoxetine
· topiramate
· zonisamide
For alcohol abstinence
· acamprosate
· disulfiram
For alcohol dependence
· nalmefene

8. · naltrexone
For opioid dependence
· buprenorphine
· naltrexone
For nicotine addiction
· bupropion
· varenicline
Book Excerpt: Substance Abuse and Mental Health Services
Administration. (1999). Treatment of adolescents with
substance use disorders. Treatment Improvement Protocol
Series, No. 32. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK64350/
· Chapter 1, “Substance Use Among Adolescents”
· Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”
· Chapter 7, “Youths with Distinctive Treatment Needs”
University of Michigan Health System. (2016). Childhood
trauma linked to worse impulse control in adulthood, study
finds. Retrieved from
https://www.sciencedaily.com/releases/2016/01/160120201324.
htm
Note: Retrieved from Walden Library databases.
Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014).
Pharmacological treatments in pathological gambling. British
Journal of Clinical Pharmacology, 77(2), 375–381.
doi:10.1111/j.1365-2125.2012.04457.x
Note: Retrieved from Walden Library databases.
Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing
opioid abuse in older adults: Clinical considerations and
challenges. Journal of Gerontological Nursing, 42(4), 10–15.
doi:10.3928/00989134-20160314-04
Note: Retrieved from Walden Library databases.
Salmon, J. M., & Forester, B. (2012). Substance abuse and co-
occurring psychiatric disorders in older adults: A clinical case

9. and review of the relevant literature. Journal of Dual Diagnosis,
8(1), 74–84. doi:10.1080/15504263.2012.648439
Note: Retrieved from Walden Library databases.
Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-
Soares, G. B., Hatch, J. P., & ... Soares, J. C. (2014).
Impulsivity in children and adolescents with mood disorders and
unaffected offspring of bipolar parents. Comprehensive
Psychiatry, 55(6), 1337–1341.
doi:10.1016/j.comppsych.2014.04.018
Note: Retrieved from Walden Library databases.
Required Media
Laureate Education (2016c). Case study: A Puerto Rican woman
with comorbid addiction [Interactive media file]. Baltimore,
MD: Author
Note: This case study will serve as the foundation for this
week’s Assignment.
Note: Support your rationale with a minimum of three academic
resources. While you may use the course text to support your
rationale, it will not count toward the resource requirement.
Submission and Grading Information
To submit your completed Assignment for review and grading,
do the following:
· Please save your Assignment using the naming convention
“WK8Assgn+last name+first initial.(extension)” as the name.
· Click the Week 8 Assignment Rubric to review the Grading
Criteria for the Assignment.
· Click the Week 8 Assignment link. You will also be able to
“View Rubric” for grading criteria from this area.
· Next, from the Attach File area, click on the Browse My
Computer button. Find the document you saved as
“WK8Assgn+last name+first initial.(extension)” and
click Open.
· If applicable: From the Plagiarism Tools area, click the
checkbox for I agree to submit my paper(s) to the Global

10. Reference Database.
· Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 8 Assignment Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 8 Assignment draft and review the
originality report.
Submit Your Assignment by Day 7
To submit your Assignment:
Week 8 Assignment
Making Connections
Now that you have:
· Assessed clients presenting with impulsivity, compulsivity,
and addiction
· Developed personalized plans of therapy for clients with
impulsivity, compulsivity, and addiction
· Examined factors that influence pharmacokinetic and
pharmacodynamic processes in clients requiring therapy for
impulsivity, compulsivity, and addiction
· Explored ethical and legal implications of prescribing therapy
to clients with impulsivity, compulsivity, and addiction
Next week, you will build on your assessment and treatment
skills as you examine clients presenting for therapy for ADHD.
To go to the next week:
Week 9