SUBSTANCE ABUSE TREATMENT PLAN1

Substance Abuse Treatment Plan

Sergio Mancilla

Western Carolina University

Recreational Therapy 352-01

Jennifer Hinton

Case Study: Patient will be referred to as Kristen Jones. Information was taken from Pt. chart as well as from personal interviews.

Abstract: The patient is a 36 year old single Caucasian female presenting voluntarily for recovery treatment of prescription amphetamine and benzodiazepine use disorders. She was referred by another facility. She was admitted into the Acute Rehabilitation Services facility at this substance abuse treatment facility on February 27th, 2015, was admitted into the Comprehensive Clinical Track on Thursday, March 5th and plans on fully completing the Comprehensive Clinical Track program and discharging on March 19th, 2015. Since being in treatment, the patient has attended all Recreational Therapy sessions.

Key Words: Amphetamine dependence, benzodiazepine dependence, sedative (ambient) use disorder, stimulant (Adderall) use disorder, stimulant (cocaine) use disorder, borderline personality disorder, bipolar II disorder, posttraumatic stress disorder, unspecified eating disorder, stress, anxiety

Purpose Statement: The purpose of this case study is to review the diagnosis and treatment of this patient.

Biographic and Demographic Background/Psychiatric Assessment: Patient was born in 1978. It was stated in her chart that the pt. often gave conflicting and contradictory information. She believes she was sent here because she will abuse her own prescribed medications. She also admits to abusing her daughter’s Adderall. She states if she goes in anyone’s home, she will immediately go in their medicine cabinet and take any pills she can abuse. She states she had been prescribed Vistaril from Outreach Management for sleep. She states she felt it didn’t help, even though she was taking up to 12 Vistaril capsules at a time. She states she immediately took 4 Ambien tablets and kept taking them until she overdosed. She was admitted to a regional hospital for one week last winter. She was discharged from there to a shelter. She then went to her parent’s home for a week. She states her mother made her leave the home. She states that her mother told her that she had to leave because she wasn’t talking or being part of the family. Her father took her to emergency room and apparently alleged that she was suicidal. She does admit that during the weeks that she was out the hospital she cut on her legs. She states that cutting made her focus on the pain and not to worry about other problems in her life. When that hospital wouldn’t admit her, she went to a nearby crisis unit. She stayed there for 14 days and was discharged on February 14th. Since then, she had been at a shelter in Shelby for a couple of nights and then went back to the overflow shelter in Charlotte.

The patient states she has received mental health treatment since the age of 12. She states she can recall that she put a lamp cord around her neck at that age and was very depressed. She had been prescribed Trileptal, Wellbutrin, Vistaril and Risperdal before moving to North Carolina about a year ago. Outreach Management continued to prescribe these medications. While she was in the hospital, she switched to Cymbalta, which she was currently taking at 90 mg daily. She also was being prescribed Seroquel 300 mg po each evening and Trazodone 100 mg po each evening. She admits she was overtaking both the Seroquel and Trazodone. When she went into the crisis unit she states she told them her depression wasn’t getting any better, so they added Abilify. The patient has very significant current life stressors. After her recent overdose, the Dept. of Social Services got involved. They are currently investigating and the patient states they believe that her daughter has been molested. As of now, she is unable to return to her parent’s home where her 6 year old daughter is living. The patient admits to passive suicidal thoughts. She states she would not try to kill herself, but that she wishes at times someone else would try to kill her or hurt her badly enough that she would not have to deal with her problems. She admits to longstanding difficulty with eating disorders. She has had gastric bypass surgery in the past. She states that currently she will go for days eating very little. She also admits to purging. She states she has been picking at her scalp and she has several open and scabbing areas there presently. She states she has primarily been depressed but reports “manic” episodes that last for a day or two. She states that during those periods she is unable to sleep. She states that her thoughts are racing and she will often write a great deal. She states that she has been diagnosed with posttraumatic stress disorder while living in New York. She states that initially they believed that this was due to childhood trauma. She states in 2012, her daughter’s father and his wife broke into her home early morning hours and raped her. She states that she has recurrent intrusive thoughts of this event. She states she will have nightmares and frequently will awaken around 4:00 a.m., as this is when they broke into her home. She also reports a great deal of hypervigilance.

The patient reports she began using cocaine heavily around the age of 23. She would use cocaine daily. She first began by snorting it, then began smoking crack cocaine. Soon after that she began using intravenously. She reported that she has not used any cocaine since 2006. She reported having been in substance abuse treatment in the past.

The patient stated that she was taken from her biological mother at the age of 18 months. She was told that as a child she had been neglected and abused. From foster care, she was adopted by a single mother. The adoption was put off for a couple of years while the biological mother tried to regain custody. The pt. stated that her childhood was good until she was about 12. At the time her mother adopted another 6 year old girl. She states that girl had been abused and was violent and cruel. She states she was verbally and physically abusive to both her adoptive mother and to herself. She states that her adoptive mother became very depressed, stopped caring for herself and neglected her health. The patient graduated from high school. She states she has worked sporadically for a year or two at the most. She states she had CNA training and worked in a nursing home. She also has done childcare and worked as a cashier. She moved in and out of her mother’s home several times until the adoptive mother died in 2005. She was involved with the father of her child for only two months and he has never been involved in the child’s life. She has had several boyfriends and states that one lived with her off and on. She had been living in a distant state in government housing and was receiving food stamps. She states she found her biological mother in August 2014. Apparently the biological mother and stepfather allowed the patient and her daughter to move in with them in their hometown. Currently her biological mother has banned her from the home and there is a Department of Social Services investigation going on as well.

The patient has a very complicated psychiatric history. It does appear that she meets criteria for Bipolar II disorder with most recent episode depressed as well as Borderline personality disorder, posttraumatic stress disorder and unspecified eating disorder. She does report ongoing disordered eating and significant problems with insomnia. Her depression has been complicated by recent life stressors. She is denying active suicidal ideation. She does report a history of cutting in the past and cut her legs as recently as last month.

Patient’s medical diagnoses include; (1) chronic migraine headaches; (2) chronic back pain secondary to spinal stenosis.

Other condiditons that may be a focus of clinical attention include: (1) homeless; (2) unemployed; (3) department of social service involvement; (4) limited support network

Generally Excepted Terms:

Medical History: In 1998, she had a traumatic brain injury from an MVA. She in unaware of how long she had loss of consciousness for, and she was hospitalized for 1 week. She does have some memory and concentration problems, anxiety, and depression that she relates directly to this TBI. She also has some seizures; she says her first one was in 2004 and was related to cocaine. She has had several since then but cannot identify last one.

Physical examination:

Review of systems:

  • General: No fever or fatigue. She has lost about 30 pounds since January, 2015, from not eating. She states her weight at the time of her gastric bypass was 310 and admits that she has image problems and always feels fat.
  • Skin: No rashes, changing moles, or change in hair or nails. History of Methicillin Resistant Staphylococcus Aureus. She also has the abrasions on her scalp which are self inflicted.
  • HEENT:
  • Eyes: No change in vision, no double vision
  • Ears: No hearing loss, no ringing in ears.
  • Nose: No nasal congestion, hx fracture, nosebleeds, sinus problems, snoring hay fever.
  • Mouth: No mouth sores or bleeding gums
  • Throat: No difficulty swallowing, no hoarseness.
  • Respiratory: No cough, history of asthma or COPD, difficulty breathing, wheezing, hemotysis, or abnormal CXR, pulmonary embolus. She had pneumonia in 2012 after a gastric bypass. She smokes ten to twelve cigarettes a day.
  • Cardiovascular: No history of low blood pressure, Heart Murmurs, edema, palpitations, or chest pain or myocardial infarction. No history of thrombophlebitis, deep venous thrombosis. She had high blood pressure before her gastric bypass but that resolved after.
  • Hematological: No easy bleeding, or blood transfusions. She feels like she bruises easily and has been told she was anemic in the past.
  • Neurological: No history of fainting, stroke, numbness or tingling, dizziness, difficulty walking, tremor, or coordination problems. She has daily headaches. She has a history of a TBI. She also has a history of seizures of questionable etiology.
  • Musculoskeletal: No gout. She has osteoarthritis in her back. She has chronic back pain which is a 5 to 7 on a scale of 10 and is a result of the 1988 MVA. She also has some muscle cramps in her legs, toes, and feet on occasion.
  • Gastrointestinal: No heartburn, abdominal pain, hx of ulcers, lactose intolerance, diarrhea, liver problems, pancreatitis or jaundice. She has nausea and vomiting with the abdominal pain which occurs monthly and is of questionable etiology; she states there is nothing that really makes it worse or better. She presently has some constipation and is most recently having one hard stool a week. She also has some hemorrhoids and has had some rectal bleeding recently. She has had her gallbladder removed.
  • Endocrine: No polydipsia, polyuria, thyroid problems. She did have gestational diabetes.
  • Urological: She states she has had kidney stones for years; she cannot tell me the number of times she has had them but has them every two to three months. She has seen a urologist and he put her on some type of medication to dissolve the stones but she stopped it and she is unsure why. No problems with urination, incontinence, or history of UTI’s.
  • Genital/Sexual: No painful intercourse, no current vaginal infection, or pelvic inflammatory disease. History of HPV, and she is not sexually active at this time.
  • Gynecological: She has had ovarian cysts in the past, but no ectopic pregnancy.

Physical examination:

  • General appearance: Patient is well developed, overweight, in no acute distress, alert, and cooperative.
  • Vital Signs:
  • Height: 5 feet 2 inches
  • Weight: 149 lbs
  • BMI: 27
  • Temperature: 97.4
  • Pulse: 100
  • Respirations: 18
  • Blood pressure: 108/67

Traumatic Brain Injury (TBI) Screening

  • Positive
  • Difficulty remembering, anxiety, depression

Abnormal Involuntary Movement Scale (AIMS)

  • None

Bio-Psychosocial Assessment

  • Reason for Admission/Presenting Problems:
  • Pt. requesting rehab for ambient, adderal use disorder. She has had gastric bypass; history of eating disorder. Currently she has went without food for days or overeats and purges. Dx of PTSD, Bipolar II, and BPD.
  • Present Living Condition:
  • Since January, pt. has lived at a shelter, her parent’s home for 1 week, hospital “for 1 week”, Crisis Unit 14 days discharging on 2/14/15, Shelter x 2 nights, then overflow shelter.
  • Employment History:
  • Currently employed
  • Lost job(s) due to substance abuse
  • Lost job(s) due to mental health problems
  • Disabled
  • Additional Employment History:
  • Has experience as CNA in nursing home, childcare and worked as a cashier. Last worked October of 2012
  • Source of income:
  • Social service agencies; receives food/shelter from psych and SA admits
  • Patient’s employment goals:
  • Wants to go back to CNA work
  • Family/Childhood History:
  • Pt. was raised by adoptive mom
  • Family history of alcohol and substance abuse:
  • Mother—substance abuse, in remission
  • Father—biological dad substance abuse
  • Family history of mental illness
  • Mother—anxiety and depression
  • Family violence/abuse/sexual abuse: Pt. was reportedly neglected and abused until 18 months, also reports emotional and physical abuse by a younger adoptive sister.
  • Additional Family History: Pt. reports being taken from her biological mom at 18 months and was adopted by a singer mother. Pt. stated her childhood was good until age 12 when her adoptive mother became very depressed post the adoption of a sister, physically abused 6 year old. Pt. managed to graduate high school. She moved out of adoptive mothers home until the mother’s death in 2005.
  • Childhood symptoms: Received Mission Hospital treatment since suicide attempt (lampcord around neck) at age 12 due to depression.
  • Education History:
  • High school graduation—CNA licensure
  • Describe patient’s general experience, perception and attitude about school years: “I didn’t do very well in math; school okay I guess.”
  • Patient’s marital/relationship history: Boyfriend—longest relationship for 7 years. 2008-present. Never married.
  • Child—Emily. Female. Age 7. Custody. Currently living with pts. Mother
  • Current parental involvement: Yes until DSS involvement. Supervised visits. Case opened in January. Pt. unknowledgeable about specifics.
  • DDS is presently involved. SS got involved post pt. overdosed. They believed her 6 year old daughter has been molested; she cannot return to live with her parents as her daughter is there. (Daughter is 7 now). Doesn’t know what service plan is.
  • Additional Personal History:
  • Very limited social support. Has had one friend since March 2014.
  • Religion/Higher Power-Identity—Mormon
  • Consequences of addiction: “My daughter”
  • Adult History of Violence/Abuse
  • Domestic violence: several BF’s physically violent
  • Assault: 2012 reports her daughter’s dad and his wife broke into her home and both raped her
  • Rape: manager at work
  • Legal History:
  • Past arrests: Trespassing, assault, communicating threats in 2009. Completed and was dismissed.
  • Psychiatric Symptoms, Behavior Changes and Emotional Issues:
  • Reported by Patient
  • Sleep disturbance
  • Depression
  • Nightmares
  • Self Mutilation—cutting on self
  • Additional Clinical Information:
  • Eating disorder
  • PTSD symptoms
  • History of psychiatric and substance abuse outpatient and inpatient treatment
  • 1/11/15 to 1/18/15, Inpatient patient Psych for 10 days, Detox- 2004-1 week.
  • Additional Impressions: Ambien use, severe, adderal use, severe cocaine in early remission—Bipolar II moderate, most PTSD, Borderline Personality Disorder, recent episode depressed unspecified eating disorder.
  • Patient’s Abilities and Barriers:
  • Strengths:
  • Supportive family/friends: Bio-mom
  • History of employment
  • Challenges:
  • Limited family support
  • Homelessness
  • Unstable employment history
  • Limited financial resources
  • Co-occuring illness
  • Psychosocial Assessment/Summary:
  • State of Change, Treatment Goals and Recommendations
  • Contemplation—Pt. stated “they think I have a problem overtaking my meds.”

Current medications:

  • Seroquel 300 mg
  • Topamax 50 mg every eight hours
  • Abilify 5 mg daily
  • Indocin 50 mg tid
  • Trazodone 100 mg qhs
  • Cymbalta 90 mg daily

Allergies: She states she has trouble eating sometimes, and this is related to the gastric bypass and probably to anxiety. She states she may need a soft diet. She does admit that she has periods of anorexia. Environmental: Latex causes a rash. Medication: Sulfa causes shortness of breath and hives.

Admission Assessments/Screening:

Risk Factors Supplement

Suicidal

Meets criteria for Bipolar Disorder

Hopelessness

Recently homeless

DSS involvement

Past substance abuse

No history of significant relationship

Spotty (or no) work history

Childhood abuse

Past diagnosis of depression or schizophrenia

Chronic mental illness greater than five years

Previous acts of self harm

Borderline or Antisocial Personality Disorder

Chronic lability or impulsivity

Expresses purpose for living

Nursing Admission Assessment

  • Drug of choice: cocaine
  • Religious preference: Mormon
  • Report of Current/Past Health Problems

Headaches

Frequent Kidney Stones

Kidney/Bladder Disease and/or difficulty