Assignment: Decision Tree in the Case of a 31 Year-Old Man with Insomnia and a History of Opiate Use

Assignment: Decision Tree in the Case of a 31 Year-Old Man with Insomnia and a History of Opiate Use

Assignment: Decision Tree in the Case of a 31 Year-Old Man with Insomnia and a History of Opiate Use

BACKGROUND
This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.
SUBJECTIVE
Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.

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MENTAL STATUS EXAM
The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation and is future oriented.

Introduction to the case (1 page)
• Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
• Which decision did you select?
Decision Point One:— Trazodone 50 mg po at bedtime
RESULTS OF DECISION POINT ONE
Patient returns to clinic in 2 weeks
Patient states medication works well but gives him an unpleasant side effect of an erection lasting approximately 15 minutes after waking
Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning
Patient denies auditory/visual hallucinations and is future oriented

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Decision Point Two:—-Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose
RESULTS OF DECISION POINT TWO
Patient returns to clinic in 2 weeks
Patient states priapism has diminished over time
Patient denies auditory/visual hallucinations and is future oriented
Patient states trazodone is effective at 50 mg dose but sometimes wakes up following day with next-day drowsiness
Patient denies auditory/visual hallucinations and is future oriented
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

Decision Point Three:—-Continue dose. Explain to patient he may split the 50 mg tablet in half. The decreased dose should minimize next-day drowsiness. Follow up in 4 weeks

• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

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Decision Tree in the Case of a 31 Year-Old Man with Insomnia and a History of Opiate Use

 Sleep-Wake Disorders are a separate category of disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. Hypersomnolence, disorder, insomnia, narcolepsy, and sleep arousal disorder are some of the conditions that fall into this diagnostic group and have certain symptoms in similarity with insomnia (APA, 2013; Sadock et al., 2015). This paper’s pharmacotherapeutic decision tree is about a 31-year-old man who has been diagnosed with a disturbance in sleep patterns. The purpose of the paper is to choose the most appropriate medication for the patient’s condition at each of the three decision points.  

Patient Background

 The patient reports in the subjective history section that he has been suffering from sleeplessness for the past six years. The problem, though, has become more severe and relentless in recent months. His sleeplessness symptoms, like those of many other psychiatric conditions, have begun to impede his ability to function in the areas of self-care, work, and interpersonal interactions. The patient claims that he experienced a sudden loss of his lover six months prior, and that is when the sleep problems began. The patient also claims that he was in an accident a while back, which resulted in the prescription of opioid painkillers to relieve his pain. According to his primary care physician’s notes, he developed opioid dependence as a result of this and began abusing the medicine.

 He claims he has not taken any opiates in the last four years. He acknowledges that he is currently consuming alcohol on a regular basis since it is the only way he can sleep. According to the patient, the diphenhydramine that had been prescribed for him previously for insomnia did not seem to help. He appears well-dressed and dressed appropriately for the time of day and weather during the full mental evaluation. His language is clear, coherent, focused, and goal-oriented. He does not have any tics or peculiarities, and he denies having suicidal or homicidal thoughts. He has no hallucinations or delusions. Most significantly, his judgment and understanding remain intact. The diagnosis of Insomnia Disorder is made based on the above information and reference to the diagnostic criteria in the DSM-5 (APA, 2013; Sadock et al., 2015). The pharmacotherapeutic decisions below will be based on this.

Decision Point 1

 For this first decision point, there are three medications that are offered for a decision to be made as to which of them is the best for the patient. They are trazodone (Desyrel) 50-100 mg once a day at bedtime, zolpidem (Ambien) 10 mg at bedtime, or hydroxyzine (Atarax) 50 mg every day at bedtime. The decision that is taken is to commence the patient with insomnia on trazodone (Desyrel) 50 mg orally daily at bedtime. This choice is made based on evidence from the available current literature that points to the fact that trazodone is effective in managing insomnia (Stahl, 2017). A systematic review by Jaffer et al. (2017) found that 95.5 percent of the studies they reviewed indicated that trazodone had been effective in reducing the symptoms of insomnia in the patients studied.

 The other two choices were not selected because of extensive side effects profile. This is despite the fact that zolpidem (Ambien) is approved for treating insomnia by the Food and Drug Administration or FDA. Hydroxyzine (Atarax) is known to cause dryness of the mouth or xerostomia as well as dry conjunctiva or xerophthalmia (Stahl, 2017). It was hoped by taking the above decision that the patient would start getting quality sleep within the first four weeks of treatment with the trazodone (Desyrel). The bioethical principle that prevailed at this decision point is beneficence (Haswell, 2019). Choosing trazodone was the best option for the maximum benefit of the patient. Also, avoiding the other medications such as hydroxyzine (Atarax) was informed by the bioethical principle of nonmaleficence or primum non nocere. The medication would cause the patient harm that is known in the form of xerostomia and xerophthalmia.

Decision Point 2

 The patient comes back after two weeks of taking the trazodone (Desyrel) 50 mg every night by mouth at bedtime. He reports progress in that he is able to sleep better already. This means that the therapeutic effect of the choice medication was already manifesting itself. However, there was a problem in that he was unlucky to get the side effect of priapism, especially in the mornings before going to work. According to the patient, the unwarranted erection may last up to 15 minutes making him get late for work. He reported no other side effect of trazodone (Desyrel) at this point in time.

            Three options are presented for a decision to be made at this second decision point. They are reassurance of the patient that the priapism will go away after sometime; discontinuation of trazodone (Desyrel) and commencement of suvorexant (Belsomra) 10 mg daily at bedtime; or a reduction of the dose of trazodone to 25 mg orally every day at bedtime. The decision taken from amongst the three options is not to stop the trazodone (Desyrel), but to decrease its dose from 50 mg to 25 mg orally every day at bedtime. The reason for taking this decision is that the therapeutic effect of trazodone is already apparent and this is what counts. To control the side effect of erection in the mornings, reducing the dose by half would be the best strategy (Stahl, 2017). With time, it is hoped that the priapism would wane and stop. The bioethical principle of nonmaleficence is respected by reducing the trazodone dose. At the same time, beneficence is upheld. With the option that involved stoppage of the trazodone, it would have been an unsound clinical decision since trazodone was already showing efficacy. The hope in making the decision of reducing trazodone by half in dose is that the priapism will be controlled while at the same time the therapeutic effect of the trazodone would be maintained.

Decision Point 3

            The patient comes for review in another two weeks and reports much progress as hoped. He says that he is sleeping better now and claims that the 25 mg of trazodone is not enough. He denies hallucinations or a continuation of the earlier problem of unwanted erection in the mornings. In a nutshell he was doing much better now and was tolerating the treatment. A decision is to be made on the three last options provided at this last decision point. The three are stoppage of the trazodone and commencement of ramelteon (Rozerem) 8 mg at bedtime daily then following up in four weeks; continuation of the same dose of trazodone (Desyrel) 25 mg but teaching the patient to start practicing sleep hygiene with follow up in four weeks; or discontinuation of trazodone and commencement of hydroxyzine (Atarax) 50 mg daily at bedtime then following up in four weeks.

            At this decision point, the option taken is to continue with the trazodone at the current dose of 25 mg orally every day at bedtime. This is to be accompanied by patient education on the importance of sleep hygiene and practicing of the same. The reason for making this decision is that it is the only one that makes clinical sense out of the three. With the patient already doing well on the daily trazodone 25 mg orally every bedtime, it would be clinically imprudent to discontinue it and commence a different medication. This would violate nonmaleficence as these others medications may bring the patient less efficacy and more side effects. This time round, the patient is to continue with the medication but practice sleep hygiene then come back after four weeks for review instead of two weeks.

            Having a bedroom atmosphere and daily practices that encourage consistent, undisturbed sleep is considered good sleep hygiene. Having a consistent sleep schedule, a comfortable and distraction-free bedroom, a soothing pre-bed ritual, and developing healthy behaviors during the day can all help a patient with insomnia achieve optimal sleep hygiene (ASA, 2022; CDC, 2016). Not taking coffee before bed, not listening to music in the bedroom, and not having a television in the bedroom are just some of the sleep hygiene factors that this patient is advised to take into consideration even as he continues with his trazodone 25 mg orally every bedtime. The decision is motivated by beneficence as a bioethical principle – doing what will benefit the patient most. The hope in making the above decision is that the patient gets used to proper sleep hygiene and stops taking medication for the insomnia in the long term.

Conclusion

            Making treatment decisions concerning medications for mental illnesses requires critical thinking and an understanding of the evidence available to support drug choices. This evidence is about efficacy and needs to be current. In the above case, there was level I evidence in support of the use of trazodone (Desyrel) to treat this 31 year-old’s insomnia. All he needed to do was to accompany it with good sleep hygiene.

References

American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

American Sleep Association [ASA] (2022). Sleep hygiene tips. https://www.sleepassociation.org/about-sleep/sleep-hygiene-tips/

Centers for Disease Control and Prevention [CDC] (July 15, 2016). Tips for better sleep. https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.html 

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Jaffer, K.Y., Chang, T., Vanle, B., Dang, J., Steiner, A.J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W.W. (2017). Trazodone for insomnia: A systematic review. Innovations in Clinical Neuroscience, 14(7-8), 24-34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/#:~:text=The%20majority%20of%20these%20studies,in%20the%20treatment%20of%20insomnia

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6^th ed. Cambridge University Press.