Assignent Solutionnurs

Opioid Use Disorder
Peter Winters, a 46-year-old white
minister, was referred to a psychiatry outpatient department by his PCP for
depressive symptoms and opioid misuse in the setting of chronic right knee
pain. Mr. Winters injured his right knee playing basketball 17 months earlier.
His mother gave him several tablets of hydrocodone-acetaminophen that she had
for back pain, and he found this helpful. When he ran out of the pills and his
pain persisted, he went to the emergency room. He was told he had a mild sprain
and given a 1-month supply of hydrocodone-acetaminophen. He took the pills as
prescribed for 1 month, and his pain resolved.
After stopping the pills, however,
Mr. Winters began to experience a recurrence of the pain in his knee. He saw an
orthopedist, who ordered imaging studies and determined there was no structural
damage. He was given another 1-month supply of hydrocodone-acetaminophen. This
time, however, he needed to take more than prescribed to ease the pain. He also
felt dysphoric and “achy” when he abstained from taking the medication and
described a “craving” for more opioids. He returned to the orthopedist, who
referred to a pain specialist.
Mr. Winters was too embarrassed to
go to the pain specialist, believing that his faith and strength should help
him overcome the pain. He found it impossible to live without the pain
medication, however, because of the pain, dysphoria, and muscle aches when he
stopped the medication. He also began to “enjoy the high” and experienced
intense cravings. He began to frequent emergency rooms to receive more opioids,
often lying about the timing and nature of his right knee pain, and even stole
pills from his mother on two occasions. He became preoccupied with trying to
find more opioids, and his work and home life suffered. He endorsed low mood,
especially when contemplating the impact of opioids on his life but denied any
other mood or neurovegetative symptoms. Eventually, he told his PCP about his opioid
use and low mood and was referred to an outpatient psychiatry clinic.
Mr. Winters had a history of two
lifetime major depressive episodes that were treated successfully with
escitalopram by his PCP. He also had a history of an alcohol use disorder when
he was in his 20’s. He managed to quit on his own after a family intervention.
He smoked two packs of cigarettes daily. His father suffered from depression,
and “almost everyone” on his mother’s side of the family had “issues with
addiction.” He had been married to his wife for 20 years and they had two
school-age children. He had been a minister in his church for 15 years. Results
of a recent physical examination and laboratory testing performed by his PCP
had been within normal limits.
On mental status examination, Mr.
Winters was cooperative and did not exhibit any psychomotor abnormalities. He
answered most questions briefly, often simply saying “yes” or “no.” Speech was
of a normal rate and tone, without tangentiality or circumstantiality. He
reported that his mood was “lousy,” and affect was dysphoric and constricted.
He denied symptoms of paranoia or hallucinations. He denied any thoughts of
harming himself or others. Memory, both recent and remote, was grossly intact.
Avery, J., & Ross, S. (2014). Case
16.4, Knee pain. In J.W. Barnhill (Ed.), DSM-5 Clinical Cases (pp.
260-262). Arlington, VA: American Psychiatric Association Publishing.
Questions for
Case Study
1. What would be the primary focus of your initial work with
the client/family?
2. What further information do you need regarding the client’s
opioid use and depression and impact on family?
3. What symptoms and data support the diagnosis of opioid use disorder,
and would your focus of treatment be on depression or opioid use disorder?
4. What screening tools could be used for substance use
disorders?
5. What do you think is the communication style of this family
based on the data provided?
6. What type of therapy would you recommend for the individual
and what would be the goals of therapy?
7. What type of therapy would you recommend for the family and
what would be the goals of therapy?
8. What medication and treatment recommendations would you
order?
9. What are your biases about substance use disorders with
individuals such as this client?
10. What recommendations/services should you include in
discharge planning for the client and family?