Week 6.
Unit 6

Evidence-Based Practice 2. Peer response. Due 12-7-23. 400w. 4 reference.

Peer Response

Instructions:

Please respond to at least 2 of your peer’s posts with substantive comments using the following steps:

· Construct a response – ideally one who utilized the same EBP interventions that you did and one who did not.

· Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.

· References and citations should conform to APA standards.

· Remember: Please respect the opinions of others, even if their views differ. In other words, disagree professionally and respectfully.

· Plagiarism is never acceptable – give credit when credit is due – cite your sources.

Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.

Please review the rubric to ensure that your response meets the criteria. Collaboration points will be forfeited if you fail to meet the response post guidelines.

Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.

Janie B.

Unit 6: Discussion Evidence-Based Practice

Plan (P):

Diagnostics:

1.
Insomnia –

· Labs: CBC w/ diff, CMP to rule out underlying medical causes (Krystal et al., 2019)

· Sleep Study to rule out OSA (Krystal et al., 2019).

· Perform PHQ9 and GAD 7 as patient is at increased risk (Krystal et al., 2019).

2.
Alcohol Use Disorder–

· Labs: hepatic panel, bilirubin, AST, ALT, GGT.

· Perform AUDIT screening tool to assess for risk of ETOH withdrawal (Kranzler & Soyka, 2018).

Therapeutic:

1.
Insomnia-

· Medication: Ramelteon 8mg PO nightly/ quantity 30 tablets/ Refill: 0 (Krystal et al., 2019)

· Cognitive Behavioral Therapy (CBT) (Krystal et al., 2019)

2.
Alcohol Use Disorder-

· Drinking cessation (Kranzler & Soyka, 2018).

· Medication: Start Naltrexone 50mg PO daily/ quantity: 30 tablets / Refill: 0 / re: To decrease EtOH cravings/ Tx of alcohol dependence (Kranzler & Soyka, 2018).

· Cognitive Behavioral Therapy (CBT) (Kranzler & Soyka, 2018).

Educational: information clients need in order to address their health problems. Include follow up care. Anticipatory guidance and counseling.

1.
Insomnia- Sleep hygiene education, including but not limited to: keeping the bedroom dark, quiet, and cool, avoiding sleep-disturbing substances such as caffeine and alcohol, and establishing a wind-down routine (Krystal et al., 2019). Relaxation techniques can be learned via CBT (Krystal et al., 2019). Side effects of Ramelteon include headache, sedation, fatigue, and nausea (Krystal et al., 2019).

2.
Alcohol Use Disorder– Start naltrexone today, and slowly attempt to decrease the amount of beer that is consumed each night. Side effects of Naltrexone include somnolence, nausea, vomiting, decreased appetite, abdominal pain, and dizziness (Kranzler & Soyka, 2018). Follow up in 7 days to discuss progress and medication management. Signs and symptoms of ETOH withdrawal include increased anxiety or irritability, depressed mood, decreased appetite, restlessness, shakiness or tremors, sweating, chills, and headaches (NIAAA, n.d.). Seek emergent care if symptoms increase. Follow up on therapy referral to treat the root cause of alcohol use.

Consultation/Collaboration:

1.
Insomnia– Refer to sleep specialist (neurologist, somnologist) to obtain thorough sleep history, rule out OSA, sleep latency, and possible contributing factors to insomnia (Krystal et al., 2019).

2.
Alcohol use disorder– Refer to Mental Health Therapist CBT to help identify feelings and situations related to drinking, as well as develop coping skills (NIAAA, n.d.).

Strength of the Evidence Presented in the Article(s)

The 
Diagnosis and Pharmacotherapy of Alcohol use Disorder article presents a meta-analysis of medication treatment in AUD and discusses a comparison of evidence-based practice treatments. Studies show that naltrexone increases the likelihood of not drinking from 13.6% to 77.8% (Kranzler & Soyka, 2018). Naltrexone combined with therapy is a proven EBP treatment for patients who screen positive for AUD (Kranzler & Soyka, 2018).

The assessment and management of insomnia: An update article covers a wide variety of EBP non-medication and medication treatments upon which efficacy is compared. While Ramelteon is not necessarily considered a first-line treatment for insomnia, it does not have significant abuse potential as do most other medications for insomnia, which is a factor I considered heavily when developing a plan for this patient.

References

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder. 
JAMA, 
320(8), 815. 

https://doi.org/10.1001/jama.2018.11406Links to an external site.

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: An update. 
World Psychiatry, 
18(3), 337–352. 

https://doi.org/10.1002/wps.20674Links to an external site.

 Reply

Christina R.

Plan:

Insomnia:

Diagnostics: n/a, but plan to obtain further history on patient’s sleep schedule, environment, and habits. It is important to determine if the patient has a routine and environment that encourage sleep and if he naps during the day (Krystal, et al., 2019). Would also like to further assess his anxiety, using interview at the GAD-7 screen. It is important to determine whether the anxiety is occurring throughout the day or only in relation to sleep. It may be helpful for the patient to keep a sleep diary. “This can be very useful for the diagnosis of insomnia and is core to the treatment, because it helps to characterize the specific nature of the sleep problem, delineate maladaptive behaviors and provide an indicator of treatment outcome” (Krystal, et al., 2019).

Therapeutic: Will not treat with medication until the patient can discontinue using alcohol. If insomnia persists after cognitive behavioral therapy and discontinuing alcohol, will consider a non-benzodiazepine like zolpidem 5mg, one tab before bed, as needed, when able to get 7-8 hours of rest. If this medication is prescribed the patient should be cautioned that using it with alcohol comes with considerable risks, so he should never use the medication when he has been drinking. 

Educational: Patient should be educated on proper sleep hygiene. Although proper sleep habits will not cure all insomnia, it is important to have a dark and quiet environment and a proper routine (Krystal, et al., 2019). It is also important to avoid television in bed and use of the mobile phone. A wind-down routine is also encouraged, as it can help with the circadian rhythm and the patient should be advised to not spend excess time in bed (Krystal, et al., 2019). 

Consultation/Collaboration: Plan to refer to cognitive behavior therapy, as this is the first line of recommended treatment for insomnia, especially in the presence of heavy alcohol use (Geoffrey, et al., 2020). Usually four to seven sessions are adequate. Evidence does show cognitive behavioral therapy to be highly successful in treating insomnia. 

Alcohol use 

Diagnostics: CMP, use of a screening tool like CAGE or AUDIT may be helpful. Further interviewing and assessment will need to take place to determine how problematic the alcohol use or whether he is just using it to sleep. The CMP will assess liver function and electrolytes. 

Therapeutic: No therapeutics are necessary at this time. The patient will be encouraged to discontinue alcohol use, if the patient is struggling with alcohol cessation, therapeutics can be considered. “Because the heterogeneity of alcohol use disorder makes it highly unlikely that one single treatment will work for all individuals, it is important to provide a menu of options for pharmacological and behavioral therapies to both clinicians and patients,” (Witkiewitz, et al., 2019). Acamprosate 666 mg three times daily can be prescribed if needed. Research shows a decrease in drinking in 86% of patients. The patient should be educated that the most common side effects are fatigue and diarrhea.  Vitamins and supplements may be considered if the patient is deficient, considering Vitamin B and Vitamin D. 

Educational: Encourage abstinence. Educate patient that insomnia can be relate to alcohol use. Alcohol can affect the quality of sleep. Heavy drinkers are at an increased risk for many chronic medical problems. The patient should be educated that alcohol use decreased work productivity and an increase in mental health concerns (Witkiewitz, et al., 2019). 

Consultation/Collaboration: Cognitive behavioral therapy will also help address the patient’s alcohol use. The patient may also consider support groups or meetings, which have shown success in continued abstinence (Witkiewitz, et al., 2019). The evidence provided, shows cognitive behavioral therapy and support groups and meetings to have a good success. 

Geoffroy, P. A., Lejoyeux, M., & Rolland, B. (2020). Management of insomnia in alcohol use disorder. 
Expert opinion on pharmacotherapy, 
21(3), 297–306. https://doi.org/10.1080/14656566.2019.1705279

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. 
World psychiatry : official journal of the World Psychiatric Association (WPA), 
18(3), 337–352. 

https://doi.org/10.1002/wps.20674Links to an external site.

Witkiewitz, K., Litten, R. Z., & Leggio, L. (2019). Advances in the science and treatment of alcohol use disorder. 
Science advances, 
5(9), eaax4043. https://doi.org/10.1126/sciadv.aax4043