NURS 6630 Week 8 Assignment Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult,100% CORRECT

NURS 6630 Week 8 Assignment Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult Alicia Buck NURS 6630: Psychopharmacological Approaches to Treat Psychopathology Dr.Letterio January 24th, 2021 Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult Insomnia is classified by difficulty initiating sleep, difficulty maintaining sleep, sleep disturbances that cause significant distress (social, occupational, educational, academic, or behavioral), and symptoms present for three months or more (American Psychiatric Association, 2013). According to the DSM-IV, insomnia is only diagnosed when the patient’s sleep disturbances cannot be better explained by a medical condition such as narcolepsy, sleep apnea, substance abuse, or be caused by a medication (American Psychiatric Association, 2013). Research indicates that 10-15 % of the population suffers from insomnia. The difficulty in diagnosing and treating insomnia is that it is often associated with depression and anxiety (American Psychiatric Association, 2013 & Baglioni et al., 2011). Drug therapy often must address both issues for the patient to be successful and achieve remission. The following paper aims to discuss the decision process used to formulate a treatment plan for a 31-year-old male patient experiencing difficulty falling asleep and staying asleep. The patient’s history indicates that he has always had trouble with sleep but has seen an increase in sleep disturbances since the loss of his fiancé six months ago. The patient has even fallen asleep on his job as a forklift operator. The patient’s medical history also includes opiate abuse as well as his current admission to using alcohol nightly. The patient has tried over the counter sleep aids and has experienced unpleasant side effects. Some ethical considerations that will be discussed for this patient are his drug and alcohol abuse history and his job as a forklift driver. Both will impact what drug therapy is being prescribed. This paper will discuss several different pharmacological options for treating the patient and how each one is either appropriate or not. Decision # 1 The first decision was to start the patient on Trazodone 50 mg at bedtime. Trazodone was chosen due to its effectiveness in treating both insomnia and depression, as well as its low potential for abuse (IBM Corporation, 2021). According to the DSM-IV, if insomnia is accompanied by a comorbid disorder such as depression, treatment needs to target both conditions (American Psychiatric Association, 2013). While the patient does not have an official diagnosis of depression, he has had a significant adverse life event (loss of his fiancé) that puts him at risk of developing depression and is displaying signs of depression (e.g., sleep disturbances following a death of a loved one) (Ancelin et al., 2015). Studies show that Trazodone is effective in inducing and maintaining sleep in patients with depressive symptoms as well as insomnia (Gözükırmızı et al., 2004). According to Abdelmesseh et al. (2017), Trazodone’s use for insomnia has surpassed its usage as an antidepressant and is one of the most common medications chosen off-label for insomnia. The expected outcome of starting the patient on Trazodone was that he would show a decrease in difficulty initiating sleep and sleep disturbances and would be more likely to stay asleep all night (Gada & Generali, 2015). It was also hoped that the patient would no longer have issues staying awake at work and be able to perform his job as a forklift operator safely. One ethical consideration at this point is the patient’s opiate abuse history and current alcohol use. It is pertinent that the patient is counseled on the dangers of mixing alcohol with Trazodone and being informed on possible adverse effects. Another consideration would be that Trazodone is sedating, and the patient operates a forklift. According to IBM Corporation (2021), patients should be advised against driving or any activity that requires alertness and coordination until they know how Trazodone will affect them. Zolpidem and Hydroxyzine were not chosen due to their adverse effect of increased CNS depression when mixed with alcohol (IBM Corporation, 2021). Since the patient has a history of opiate abuse and has self-reported drinking nightly, both medications would not be appropriate. Deglin et al. (2013) discuss using Zolpidem cautiously in patients with a history of drug and alcohol abuse due to the risk of abuse. Special consideration was taken when choosing a drug for this patient because of his drug abuse history. Decision # 2 The patient returned after two weeks and stated that the Trazodone was working well for him, but he was experiencing a prolonged erection 15 minutes after waking, which is causing him embarrassment. The decision was made to decrease the Trazodone to 25 mg due to the unwanted side effects. Research indicates that most priapism incidences occur at doses of Trazodone 50 mg or higher (Deolanker et al., 2021 & Roy, 2015). The patient shows a response to the Trazodone as indicated by the patient stating it is working well for him, but he is experiencing priapism, so it is imperative to assess for possible causes such as his alcohol use. Studies show that using drugs and alcohol while on Trazodone can increase the patient’s risk of experiencing priapism (Castrellon et al., 2006). Counseling the patient on the increased risk of priapism when combining alcohol and Trazodone is critical to avoid further incidences of priapism. The choice to continue the Trazodone at 50 mg was not made due to the patient experiencing adverse effects. Since the patient has displayed improvement in his sleep, it is appropriate to continue the Trazodone, but with him experiencing priapism, it wise to decrease his dose to see if the side effects will diminish. The choice to discontinue the Trazodone and start suvorexant was not made due to the patient showing a response to Trazodone. Switching drug therapies when a patient is showing a positive response is not appropriate. A study conducted by Hanya et al. (2018) indicated that patients switching to suvorexant experienced rebound insomnia. Many patients in the study also discontinued the suvorexant due to its inefficiency (Hanya et al., 2018). It is hoped by decreasing the dosage of Trazodone to 25 mg, the priapism will diminish, and the patient will continue taking the Trazodone and see improvement in his sleep. Research shows that a lower dose of Trazodone can still be effective and even cause fewer side effects due to the drug’s short half-life (Abdelmesseh et al., 2017). Patients are often discouraged when adverse effects occur and discontinue treatment. The patient was previously using alcohol to get him to sleep, and the hope is that he would not return to that. Decision # 3 The patient returns in two weeks and states that the Trazodone has worked well for his insomnia, but sometimes the current dose of 25 mg does not seem like it helps him sleep through the night (Laureate Education, 2021). The decision was made to continue the Trazodone at 25 mg, encourage sleep hygiene, and then follow up in four weeks (Laureate Education, 2021). Since the patient is experiencing a positive response from the Trazodone, it is not appropriate to discontinue or switch drugs. Encouraging good sleep hygiene is essential for this patient because of his admitted alcohol use. Brower (2015) discusses how patients dependent on alcohol can display poor sleep habits, possibly adding to their insomnia. Before a patient is diagnosed with insomnia, an assessment of their sleep hygiene should be conducted, as well as be re-assessed throughout drug therapy (Arnardottir et al., 2017). The choice to continue the Trazodone at 25 mg and re-evaluate in four weeks was also made due to the patient experiencing adverse effects at 50 mg. It is hoped that maintaining the patient at 25 mg and assessing for and counseling on good sleep hygiene that the patient will return in four weeks and report no adverse effects and a significant decrease in sleep disturbances. The choice to discontinue Trazodone and start ramelteon or Hydroxyzine was not made due to the patient showing a good response to the Trazodone. Ramelteon was not chosen specifically due to its additive effect when mixed with alcohol (IBM Corporation, 2021). Hydroxyzine was not chosen specifically because of its mechanism of action. Hydroxyzine is prescribed for multiple purposes and exerts bronchodilating, antispasmodic, antihistaminic, analgesic, and antiemetic effects, which would be problematic for this patient with his drug and alcohol abuse history (IBM Corporation, 2021). Ethical Considerations The most important ethical consideration is the patient’s history of opiate abuse and his current alcohol use. Many drugs for the treatment of insomnia interact negatively with alcohol. It will be essential to be direct and honest with the patient before beginning drug therapy that his relationship with alcohol may be contributing to his insomnia and most certainly will affect his treatment. Another ethical consideration for the patient is that the Trazodone being prescribed is being done so off-label. Patients may not understand the reasoning behind using a drug off-label and may be scared to start treatment. It is imperative that the risk versus the benefits be explained to the patient and the patient be included in the decision process. The last ethical consideration to discuss is the increased risk of suicidal thoughts or behaviors in insomnia patients (Au et al., 2019). The patient struggles with several factors (loss of a loved one, alcohol abuse, and sleep issues) that all put him at an increased risk, so frequent follow-ups should be made (Black & McCall, 2013). It is crucial to detect early on if the patient is displaying suicidal thoughts or behaviors. Conclusion In summary, Trazodone was chosen for its low potential of abuse and its effectiveness at treating insomnia (IBM Corporation, 2021). Zolpidem was not selected due to its potential for abuse and increased risk of CNS depression (IBM Corporation, 2021). With the patient’s history of drug abuse and current, self-reported alcohol abuse, the typical hypnotic drugs used for insomnia were not ideal for this patient. Hydroxyzine was also not chosen because of its side effect profile and potential for abuse (IBM Corporation, 2021). The patient did experience an unpleasant side effect of Trazodone, priapism. Since the patient reported that Trazodone was helping him sleep, the dose was decreased in hopes of stopping the priapism while still improving the patient’s insomnia. Given that the patient continued to report that the Trazodone was working well after each follow-up, it was not decided to switch to any other medication. After decreasing the Trazodone to 25 mg, the patient had no further complaints of priapism. The expectation that the priapism would subside, and that the patient would continue to see improvement was realized. References Abdelmesseh, M., Chang, T., Dang, J., Danovitch, I., Ishak, W. W., Jaffer, K. Y., Loera, N., Steiner, A. J., & Vanle, B. (2017). Trazodone for insomnia: A systematic review. Innovations in Clinical Neuroscience, 14(7-8), 24–34. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. Ancelin, M. L., Carrière, I., Chaudieu, I., Norton, J., Ritchie, K., & Zhang, X. (2015). Risk factors for late-onset generalized anxiety disorder: results from a 12-year prospective cohort (the ESPRIT study). Translational Psychiatry, 5(3), e536. Arnardottir, E.S., Baglioni, C., Bassetti, C., Bjorvatn, B., Deleanu, O.‐C., Dolenc Groselj, L., Ellis, J.G., Espie, C.A., Fröjmark, M., Garcia‐Borreguero, D., Gjerstad, M., Gonçalves, M., Hertenstein, E., Jansson‐ Jennum, P.J., Leger, D., Nissen, C., Parrino, L., Paunio, T., Pevernagie, D., Riemann, D., Spiegelhalder, K. Strazisar, B., Verbraecken, J., Weeß, H.‐ G., Wichniak, A., Zavalko, I., & Zoetmulder, M. (2017), European guideline for the diagnosis and treatment of insomnia. J Sleep Res, 26, 675-700. Au, A., Bishop, T. M., Hur, K., Kane, C., Lavigne, J. E., & Pigeon, W. R. (2019). Prescription medications for the treatment of insomnia and risk of suicide attempt: A comparative safety study. Journal of General Internal Medicine, 34(8), . Black, C. G., & McCall, W. V. (2013). The link between suicide and insomnia: theoretical mechanisms. Current Psychiatry Reports, 15(9), 389. Castrellon, R., Jaghab, K., Mayans, J., Padder, T., & Skodnek, K. (2006). Priapism following Trazodone use in a patient using drugs and alcohol: A case study. The Internet Journal of Mental Health, 3(1). Deglin, J. H., Sanoski, C. A., & Vallerand, A. H. (2005). Davis’s drug guide for nurses (13th ed.). F A Davis Company. Deolanker, J., Luu, T., Sadeghi-Nejad, H., & Shah, T. (2021). Pretreatment screening and counseling on prolonged erections for patients prescribed Trazodone. Investigative and Clinical Urology, 62(1), 85. Gada, D. J., & Generali, J.A. (2015). Trazodone: Insomnia (Adults). Hospital Pharmacy, 50(5), 367–369. Gözükırmızı, E., Guilleminault, C., Kaynak, D., & Kaynak, H. (2004). The effects of Trazodone on sleep in patients treated with stimulant antidepressants. Sleep Medicine, 5(1), 15–20. Hanya, M., Hatano, M., Inagaki, R., Iwata, N., Kamei, H., Matsuzaki, H., & Yamada, S. (2018). 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