Question

Laura is a very successful businesswoman in the high-stress high-powered world of corporate finance. She has been referred to you by the company’s employment assistance program. You are the company's occupational nurse. Laura presents herself as a no nonsense business professional. She is frank and honest about the events that has brought her to your office. Laura tells you that although she tells herself that she will only have one or two glasses with dinner, she usually finishes the whole bottle. “About five years ago I started having trouble sleeping and started to take a tranquilizer (5 mg of Valium ) I normally take one or two pills every two to four times a week to help her sleep through the entire night.” In the morning she drinks at least 3 to 4 cups of coffee daily, even on the weekends. She noticed that her sleeping problems developed around the same time her Dad died. He was only in his early 50’s and they were very close. His death hit her hard and she says she wanted to give in to a big depression. However, she fought it and lost herself in her work. She makes it a point to work out at least three times a week in the morning before going to work. In addition to the above medications, Laura is also prescribed Xanax as needed for panic attacks and diet pills to control her weight. Over the last year she has become more reclusive. She can barely make it to business dinners and after-work functions. Lately however, she has noticed that she has been steadily increasing her use of wine. Before, she would only have a few glasses with dinner but now “....more often than not I finish off the bottle before going to bed. I just can’t seem to stop. A lot of times I will come home and tell myself that I’ll only have one glass and no more but by the time I go to bed, the bottle is empty and I’m deciding whether I should open another or not. I never used to drink to excess or take anti-anxiety medication before. Now I can’t seem to stop drinking or taking these ‘downers’ at social events. I can’t seem to control when I take them and things are happening that I’m not too happy about. Of course the alcohol adds to my weight problem. Then I have to increase my Xanax to calm my nerves and also take my Valium to make sure I get a full nights sleep. It has become a very vicious circle. All this has been going on for year,s but last week put the “cherry on the pie.” Laura tells you that last week she was to meet the firm's top client at a business luncheon. She could not get out of bed that morning. It took all her willpower to get up and get dressed. As it was, she was still 20 minutes late, "which is inexcusable." She was so nervous and sick, she had to excuse herself in the middle of her presentation. In the bathroom she took another Xanax to calm her nerves. Then at the luncheon she could not stop herself from ordering several glasses of wine and had to be assisted to her car after the meeting was over. "My client spoke to my boss and other staff and then canceled his account with me! The next day I met with my boss and he recommended (ordered) I make an appointment with our EAP program (or be terminated.) I’m really scared. Work is all I have. I can’t afford to blow it. Do you mind if I smoke?" Case Study #1 Questions 1. What would your initial assessment of Laura be? Identify risk factors for Laura's substance abuse and addiction. It's important for nurses to be able to recognize the signs of an active substance user. Describe the signs of substance abuse seen in this case study. 2. Identify the substances that Laura is abusing and the effects of these substances on the brain and other organs. What would you say Laura’s main drug of choice is and do you think she will need to be placed in a detoxification program to address this problem? 3. Based on Laura’s emotional situation and the medications she is taking, what if any dangers do you need to be aware of? 4. Based on the information Laura has given you who would you need to contact to advise them of Laura’s situation and what would you need from Laura to make these contacts? 5. If Laura’s boss calls your office to find out how Laura is doing how would you respond to his inquiry? What are his rights to know if Laura did keep her appointment with you? 6. What additional diagnosis issue(s) might Laura have? State the rationale. How would you confirm this possibility? 7. What ethical issues may need to be addressed in this case? How would you handle this as the nurse for Laura?

Answer 1

Ans) 1. Substance Abuse Dependency. Laura exhibits all the classic symptoms of addiction/dependency:
a. Cravings: The psychological need to have a drink to calm her down, relieve her stress and
unwind. i.e. Drinking for emotional / psychological relief.
b. Loss of Control: Once Laura begins drinking. Intending to have just one glass of wine with
dinner, she unintentionally finishes the bottle. Laura is aware of her loss of control. She is
becoming more isolated and avoiding social events unless they are absolutely necessary. She is avoiding her social life in order to be at home were she can drink without risking her
relationships with friends and business associates.
c. Tolerance: Laura is aware that her consumption of these drugs has increased and that she is no longer able to control her drinking or her antianxiety medication Xanax
In combination, alcohol and a benzodiazepine can have a synergistic effect on the CNS. This creates an increase in tolerance and also pushes the user closer toward a potentially lethal drug overdose.
d. Continued Use Despite Negative Consequences: Despite Laura’s awareness that she has been increasing her drug use and that it was getting out of control for her, she continued to use. This cost her a valuable client and possibly her job. It was only at her boss’s insistence that she contact the company’s EAP program that Laura is even in your office at this time.
Given the above information, it seems fairly certain that Laura has moved from the habitual
stage of this disease and is now in the abuse/dependency stage of alcoholism.
2 From the medical / drug history Laura has given you it would appear that she has become
dependent on alcohol and benzodiazepines and in all likelihood will need a medical detox. You
would always want to get a medical evaluation to confirm if your assessment is correct. A
referral to a physician certified in addiction medicine should be a routine part of any substance abuse assessment. Ruling out any other medical information at this point, it seems that the safest course of action to treat Laura would be to place her in an in-patient hospital detoxification program.

- Failing this arrangement, then an outpatient medical detoxification and recovery.program would be a second option. However, because this is Laura’s first attempt at detoxification, and her statements on her previous inability to stop her drug use on her own, the counselor would be advised to set up a contingency contract with Laura before placing her in an out-patient program.

- This contract would acknowledge that should Laura fail to achieve stability in the out-patient program she would then seek treatment in an in-patient program. Laura is also taking a fair amount of stimulants too. Prescription diet pills for weight control, caffeine, and nicotine. These may or may not complicate the treatment picture and you would want to get a medical opinion on these medications as well. It would be prudent to also alert her treating physician about your concerns. It would also be important that Laura be counseled as to the potential that she may experience some weight gain while going through the detox process.

- Reassure her that this is normal out come at first and that controlling her weight will become
easier when she is not taking in all the alcohol. Recommend a good nutritional program with
exercise based on the recommendations of her doctor and /or nutritionist.

3. The danger is the potential for an accidental overdose. You will need to educate the client as to the synergistic effects of alcohol and benzodiazepines.

- The purpose of the detoxification is to
slowly and safely withdraw her from these medications and lower the risk of such an event occurring. The other danger is intentional suicide. Laura is facing what may seem to her some overwhelming life tasks. Loss of an important client, possible loss of her job, embarrassment in being referred to an employee assistance program, the stigma of being an alcoholic, and needing treatment, and unresolved grief over the death of her father. All these and other issues may appear to Laura, at this point in time, just too much and she may toy with the possibility of suicide. Also, depressant medications and drugs will skew her view of her situation making it appear more hopeless than it really is. The counselor or case worker needs to constantly monitor Laura’s statements and affect for clues that she may be contemplating suicide.

4. Laura will need to sign several releases of information so counselors and other treatment
providers can contact one other. This allows for a freer exchange of information regarding
Laura’s situation. It would be necessary that Laura’s doctor(s), those prescribing her
benzodiazepines and diet pills, to be informed of her being placed in an alcohol treatment
program.

- Since Laura is here at the request of her employer, he or she, will also have a right to
receive minimum information as to whether or not Laura is in treatment compliance and keeping her appointments with the EAP program. With regard to issues of patient confidentiality, two sets of rules usually apply. Those of state law, found in the civil codes pertaining to business and professional standards of practice and professional codes of conduct and ethics.

- A counselor must be especially aware of what the state laws are regarding a patient’s right to confidentiality in the state where they practice. Another superseding body of laws that pertain to a patient’s right to confidentiality when they are receiving treatment for substance abuse, is the Federal Rules of Confidentiality.

- This set of laws apply to any federal moneys that support that treatment program. It can even be a non-profit tax exempt organization. In these cases then, the Federal Rules and Regulations will apply and take precedent over state laws.

- Be sure you know and are familiar with these laws. In cases where the two sets of laws conflict, courts have consistently held with the law that provides the greater protection to the confidentiality of the patient.

5. In the case of Laura and her employer, the employer has the right to know or obtain a limited amount of information regarding Laura’s treatment compliance. The employer does not have the right to more detailed personal information on Laura.

- That she is keeping her appointments
when into a treatment program, expected length of that program, and if she participated
satisfactorily in that program is all an employer needs to know. Laura is within her rights to
refuse signing such a release. But she should then be aware that by denying the right for her
employer to receive this information gives her employer the right to terminate her employment.

6. There is certainly the possibility that Laura may have several dual diagnosis issues. It would be important to begin a process of ruling out both Axis I and Axis II diagnoses as she becomes more stabilized in her treatment program. Medical physicians and psychiatrists split on when to begin intervention regarding a dual diagnosis patient. Suggest beginning medications for major depression or bipolar disorder as soon as there is a reasonable suspicion that this component exists and will influence treatment outcome. i.e., if that antidepressant medication will help that
person remain in treatment longer, then why wait. Other equally experienced physicians feel it is necessary to wait to get a clearer picture of the patient before beginning a trial of medications.

- It is vital that such decisions be left to the medical experts.
The therapist’s and counselor’s job would be to pass on any changes they see in the patients
affect or demeanor to the medical staff so they can do further evaluations or tests, if necessary.
- In Laura’s case there are strong indications that she never had the time to grieve the death of her father whom she was very close to. What can start out as uncomplicated bereavement, if not processed properly, can move into depression.

- In Laura’s case this may have occurred as she
began self-medicating her grief with alcohol and benzodiazepines.
- There is also just a hint that Laura’s father may have been an alcoholic. Getting a good family
history and genogram would be one way to explore this possibility. If this is true, then Laura
may be genetically predisposed to alcoholism. You also want to decide whether Laura is Bipolar (I or II), Cyclothymic, has Major Depression or Dysthymia. Laura is using Xanax
for anxiety.
Is this a panic disorder? She reports having become less social in recent months. Certainly this
can be part of the overall isolation that occurs when a person moves into alcohol dependency.
But, you would want to rule out whether she is also suffering from Social Phobia, Panic
Disorder with or without Agoraphobia, or Agoraphobia without a history of Panic Disorder.
Another question is “What part does her diet pill, caffeine, and nicotine use and abuse play in
this picture.” Regarding Laura’s sleep medication, several more questions will need to be clarified. To what extent has her alcohol abuse and other substance use caused her sleep
disorder. Alcohol is known to suppress REM sleep and disturb the normal sleep cycle. i.e.
Substance-Induced Sleep Disorder. However, you would want to rule out other possibilities such
as; Insomnia, Sleep Terror Disorder, Parasomnia NOS, or Sleep Disorder Due to General
Medical Conditions. All the above will issues will certainly complicate the substance abuse
treatment picture for Laura.