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  1. Ritchie Metcalf



    Ritchie Metcalf is a 66-year-old Caucasian man whose wife has encouraged him to seek treatment. He has never been in therapy before and has no history of depression or anxiety. However, his alcohol use has recently been getting in the way of his marriage and interfering with his newly retired life. He describes drinking increasing amounts over the last year, currently consuming approximately a six-pack of beer per day. He notes that this amount “doesn’t give me the same buzz as it used to.” He denies ever experiencing “the shakes” or any other withdrawal symptoms if he skips a day of drinking.

    Ritchie comments that his wife, Sandra, is his biggest motivation to decrease his alcohol use. She tells him that he gets argumentative and irritable when he drinks, although he usually does not remember these incidents. Twice, he has fallen while intoxicated, causing bruises both times and once hitting his head.

    From your perspective as Ritchie’s psychiatric nurse practitioner, answer the following questions in a two- to three-page double-spaced paper (not including the reference page) and in APA format. Include at least three peer-reviewed, evidence-based references.

    What screening tool could you use for Ritchie?
    What assessment questions would you ask regarding his alcohol use?
    If Ritchie and Sandra want to use medication to help with alcohol cravings, what are his options? Create a table that compares and contrasts at least three medications for alcohol use and/or cravings. Choose one medication, explain why you recommend it for Ritchie, and list the prescribing information. Are there any special considerations in prescribing it for Ritchie?
    Ritchie and Sandra are both interested in community support groups. Please list one community support group that Ritchie could attend in your area and one community support group for Sandra in your area.
    What type of individual therapy would be appropriate for Ritchie?









Subject Nursing Pages 4 Style APA


Ritchie Metcalf















            Ewing’s (1984), CAGE (Cut down, Annoyed, Guilty, and Eye-opener) alcohol questionnaire could be used a screening tool for Ritchie. Assessments questions that could be derived from the CAGE alcohol questionnaire include the following (Johns Hopkins Medicine, 2021).


  1. Have you ever felt or thought that you should cut down on your alcohol consumption (Ewing et al., 1984)?
  2. Have you ever felt a sense of guilt or bad about your drinking (Ewing et al., 1984)?
  3. Have you ever had a drink as a first-thing in the morning so as to get rid of hangover or to steady your nerves or act as an eye-opener (Ewing et al., 1984)?

Ritchie could not be asked if other people have annoyed him by criticizing his drinking since he states that his wife (Sandra) gets irritable and argumentative when he drinks (Ewing et al., 1984). 


            Three medications (disulfiram, acamprosate, and naltrexone) are available to help manage Ritchie’s cravings for alcohol since they are the only medications that have been approved by the U.S. Food and Drug Administration (Witkiewitz, Litten, & Leggio, 2019). Review Table 1 below.

Table 1: Comparison of Medications to Manage Alcohol Craving


Mode of Action

Adverse Effects



Acetyl dehydrogenase inhibitor (Witkiewitz et al., 2019). 

Headache, tachycardia, vomiting, and nausea (Witkiewitz et al., 2019).

Efficacy mainly depends on the motivation of the patient to adhere to the medication plan and/or on supervised administration, given that disulfiram is effective due the potential threat of an aversive reaction when taken together with alcohol (Witkiewitz et al., 2019).


Opioid receptor antagonist (Witkiewitz et al., 2019).

Headache, nausea, sleep problems, and dizziness (Witkiewitz et al., 2019).

Naltroxone lowers craving for alcohol and is the most effective drug for use to reduce heavy drinking.

Selected Medication: Naltrexone

            Naltrexone is described as the most effective medication for management of patients with craving for alcohol (Witkiewitz et al., 2019). Ritchie should be educated and informed that he will be taking 50 mg PO once per day together with food; since it has been demonstrated to be most effective if taken that way. Dosage can also include 50 mg once per day on week days and 100 mg OP on Saturdays or 100 mg PO once every other day (Prescribers’ Digital Reference (PDR), 2021).

Naltrexone therapy should be continued for about 3 to 6 months for it to be effective. Ritchie should not exceed maximum acceptable dosage of 150 mg per day PO. Assessment should be performed to include liver and kidney function. In case of severe hepatic function, naltrexone dosage should be increased by a 10-fold. Similarly, naltrexone dosages may need to be adjusted if Ritchie present with any form of renal impairment (PDR, 2021).

            Naltrexone is contraindicated if Ritchie has history of naltrexone hypersensitivity. Besides, in case he has hypersensitivity to nalmefene or naloxone; the drug will be contraindicated since they are similar structural properties to naltrexone (PDR, 202S1). Ritchie should be assessed and monitored since naltrexone is associated with increased risk suicide, depression, suicidal ideation, and attempted suicide (PDR, 2021). In addition, naltrexone causes other adverse effects such as peptide ulcer, atrial fibrillation, myocardial infarction, ejaculation dysfunction, constipation, thrombosis, and pulmonary embolism (PDR, 2021).

 Support Groups

            Ritchie should be referred to the Alcoholics Anonymous (AA) group in Tampa, Florida. The group can help Ritchie to work though shared issues as well as common concerns with a licensed counselor or group leader. The group allows for one to receive as well as give guidance and support for the continued sobriety while working with peers to overcome alcoholism (The Recovery Village and Alcohol Rehab, 2021). Al-Anon Family Groups (2020), is an available community resource for Sandra (Ritchie’s wife). Al-Anon Family Groups (2020) are meant for people who are concerned about the drinking behavior or others. Individual therapy would be appropriate for Ritchie so as to address psychosocial, physical, economic, and other issues that may influence his drinking behavior (Bradley et al., 2017).





Mechanism of action is not fully described; however, it modulates hyperactive glutamatergic states, by probably acting on the N-methyl-D-aspartate receptor agonist (Witkiewitz et al., 2019).

Diarrhea, nausea, vomiting, headache, stomachache, and dizziness (Witkiewitz et al., 2019).

Large-scale trials have shown that acamprosate effects cannot be distinguished from those of a placebo. However, it is useful in prevention of relapse and promoting abstinence in already detoxified individuals (Witkiewitz et al., 2019).



Al-Anon Family Groups. (2020). Who are Al-Anon members? https://al-anon.org/

Bradley, K. A., Ludman, E. J., Chavez, L. J., Ruedebusch, S. J. et al. (2017). Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary Care (CHOICE) trial. Addiction Science & Clinical Practice, 12, Article number: 15. https://ascpjournal.biomedcentral.com/articles/10.1186/s13722-017-0080-2

Ewing, J. A. (1984). Detecting Alcoholism. The CAGE Questionnaire. JAMA, 252(14), 1905-7. https://pubmed.ncbi.nlm.nih.gov/6471323/

Prescribers’ Digital Reference. (2021). Naltrexone – drug summary. https://www.pdr.net/drug-summary/Vivitrol-naltrexone-1199

The Recovery Village and Alcohol Rehab. (2021).  AA meetings and NA meetings in Tampa, Florida. https://www.therecoveryvillage.com/local-rehab-resources/florida/tampa/aa-na-meetings/ 

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




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