Insomnia

31-year-old Male

BACKGROUND

This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.

SUBJECTIVE

Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.

MENTAL STATUS EXAM

The patient is alert and oriented to person, place, time, and event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.

Point One

Select what you should do:

· Zolpidem: 10 mg daily at bedtime

· Trazodone 50 mg po at bedtime

· Hydroxyzine: 50 mg daily at bedtime

Decision Point One

Trazodone 50 mg po at bedtime

Results of decision point one

· Patient returns to clinic in 2 weeks

· Patient states medication works well but gives him an unpleasant side effect of an erection lasting approximately 15 minutes after waking

· Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning

· Patient denies auditory/visual hallucinations and is future oriented

Point Two

Select what you should do next:

· Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose

· Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at bedtime

· Decrease trazodone to 25 mg daily at bedtime

Decision Point Two

Decrease trazodone to 25 mg daily at bedtime

Results of decision point two

· Patient returns to clinic in 2 weeks

· Patient states trazodone is very effective for sleep

· Patient states sometimes the 25 mg dosage isn’t quite enough to help him sleep through the night

· Patient denies auditory/visual hallucinations and is future oriented

Point Three

Select what you should do next:

· Discontinue trazodone. Initiate therapy with ramelteon 8 mg nightly at bedtime. Follow up in 4 weeks

· Continue dose. Encourage sleep hygiene. Follow up in 4 weeks

· Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks

Decision Point Three

Continue dose. Encourage sleep hygiene. Follow up in 4 weeks

Guidance to Student

Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn’t practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.

Comorbid Addiction (ETOH and Gambling) 53-year-old Puerto Rican Female

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

Decision Point One

Vivitrol (naltrexone) 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 says she feels “wonderful” as she has not “touched a drop” of alcohol 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 has her concerned

Decision Point Two

Select what you should do next:

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

Refer to a counselor to address gambling issues

RESULTS OF DECISION POINT TWO

·  Mrs. Perez returns in 4 weeks and reports that the anxiety that she had been experiencing is gone.

·  She reports that she has met with the counselor, but she did not really like her.

·  She also started going to a local meeting of Gamblers Anonymous. She states that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group.

Decision Point Three

Select what you should do next:

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

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, 8 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 will be covered in more depth in future courses, ruptures in 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. 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.

You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.