Question: Mrs. Dudek is a 55-year-old with a history of extreme trigeminal neuralgia (aka TMJ) which was treated long-term with an

Mrs. Dudek is a 55-year-old with a history of extreme trigeminal neuralgia (aka TMJ) which was treated long-term with an acetaminophen-oxycodone combination drug and diazepam, the former for pain, and the latter for muscle relaxation. Initially, the combination of medications seemed to work somewhat, but she found herself needing to increase the dose every so often. Mrs. Dudek has seen numerous specialists, including a neurologist and psychiatrist, to help with management of her long-term nerve pain. She was trialed on carbamazepine and amitriptyline; however, she reported ‘horrendous’ side effects, so these were discontinued.

During this time, Mrs. Dudek’s husband died suddenly from a massive heart attack. She began using larger doses of her diazepam for anxiety that developed in the wake. In a short amount of time (about 8 weeks), she increased her diazepam from 40mg/day to 90mg/day, but still complained of feeling weak and shaky. She also complained of difficulty sleeping, early awakening, at times taking an ‘extra bit’ of diazepam to fall back to sleep. Absenteeism from work began occurring more frequently as she would awaken feeling ‘hung over’ and exhausted. Mrs. Dudek had no complaints about eating, but she did have trouble with concentration, and found little pleasure in life with her husband gone, and in so much pain and discomfort. In order to gain access to her sedative medication, she ‘doctor shopped’ which was very effective.

Mrs. Dudek’s anxiety continued to escalate so she was sent to see a cardiologist who conducted a full cardiac evaluation and found her heart function to be normal. She goes to see her PCP about the continued symptoms of anxiety, feeling weak in the knees, and some developing blurry vision. The PCP stated that she was taking too much anti-anxiety medication, and this could be the reason for some of her symptoms. Mrs. Dudek was further told that she should consider an inpatient hospitalization to help with a controlled taper off diazepam. Reluctantly, she agreed and voluntarily entered an inpatient psychiatric hospitalization for detox. She was still routinely taking 90mg/day diazepam. Once in the hospital, and as the diazepam was reduced, the anxiety was so profound, that she couldn’t take it, and signed herself out of the hospital AMA. She was there for 6 days and her dose at the time of her departure was 50mg/day.

Once at home, she quickly ran out of diazepam as she was only able to lower the dose by about 5mg/day. She therefore took only 10mg/day for 2 days, and none in the past 24 hours. You are the PMHNP in the ER where she arrives begging for more diazepam. Upon examination, you note that her hands are shaking, she says she feels weak in her knees, her pulse is rapid (>100bpm), she is anxious, she says she is unable to sleep, nauseated, and appears to be responding to internal stimulation.  Follow the instructions in Canvas to complete the Addiction Management exercise.

Instructions

You will be assigned a substance use disorder (SUD) case to investigate in order to gain confidence in the subject matter, but also to development competency in treating patients with various problems related to such.

To do so, you will

1. review the case study, 
2. provide a diagnosis based on DSM-5 criteria (including MET, and NOT MET designations using APA formatting),
3. identify and review current national/international guidelines on your assigned SUD (HINT: see Class Tools),
4. determine if these alone are sufficient for you to diagnose and manage your patient's SUD (why or why not),
5. determine best evidence-based treatment, including a written prescription of your desired medication management,
6. identify a psychotherapy that is appropriate for your patient (provide rationale), 
7. determine appropriate follow-up and necessary referrals for ongoing substance use, and
8. provide peer-reviewed references and textbooks used for your research. APA formatting applies to this endeavor with appropriate title page, page numbers, double-spacing, and in-text citations.