Dr. Overman Substance Abuse Case Studies

SOCIAL HISTORY: Patient admits alcohol ingestion nightly and on weekends. Denies tobacco use and illicit drug us. He is married.

The patient is a 34 year old black male. The patient reports he is single with 3 daughter ages 3, 11, and 13. The 3 year old live with him. He reports currently live with his mother and brother. The patient reports he has 14 years of education however has not received his degree. The patient reports being on probation for Injury to a child for the next two years. The patient is scheduled to be complete his probation in September 2016. The patient reports Cannabis is primary substances and his last use July 20, 2015. He stated on that day he smoked about 5 joint. The patient also report that he tried Xanax . The patient denies any issues with HI/SI. Patient also reports he is taking his medication as prescribed. The patient appear to be in the pre-contemplation stage of change. The patient next scheduled individual session with the counselor is on Thursday, July 30, 2015 at

Mr. Gillespie is a 21 year old male who presented to the ED after an intentional overdose on 20 600mg of Gabapentin. Per documentation from ED staff Mr. Gillespie reported he became angry at his grandmother tonight and tried to "prove a point." Mr. Gillespe reported to staff threatened to overdose on his on pills, however dumped them in the toilet. He expressed after making threats to overdose on his prescribed Celexa did not phase his grandmother, he proceeded to take her Gabapentin. Per documentation Mr. Gillespe has been living with grandmother for 2 weeks and before that was living with his mother in Cary. At the time of the assessment Mr. Gillespie was calm and cooperative. He denies current suicidal ideation, homicidal ideation, and symptoms of psychosis. He appears guarded during the assessment. He reports tonight his grandmother and he got into an argument over him getting a job. He reports his grandmother informed him he has to be out by Friday. Mr. Gillespe denies history of self harm. He

is a nurse practicing in Missouri that has, already, previously been placed on probation for testing positive for heroin. She has recently had a relapse in her recovery and is fighting to get her license back so she can practice nursing. The state board has already given her one chance and she was practicing in Missouri. She has been sober for nearly 3 years and has taken suboxone the entire time of her sobriety to help with withdrawal. E.M. hates that she has a dependency on the suboxone and wanted very badly to wean herself off of it. She spoke with her physician about this matter and her physician strongly suggested that she not be taken completely off her prescription of suboxone. Her physician lowered her dose and she began taking a lower dose. After time passed, E.M. felt like she had things under control and she completely stopped taking her prescription. E.M. went under some stress at her job and ended up leaving the facility she was working at. She knew that one of her old co-workers had access to heroin and after running into him at a local store, she started abusing again. Beginning at the time of her first time being placed on probation E.M. has been required to provide urine samples at randomly selected intervals. During her time of remission, when she was abusing, she failed to call and leave urine samples. At this time, E.M. explained that she was focusing on bettering herself and working on her sobriety. I feel that E.M. was very sincere and was accountable for her actions. She truthfully took responsibility for her wrongful actions. E.M. stated that she now realizes that her heroin addiction is a lifelong addiction that will always be knocking at her door and she cannot stop taking suboxone. The board questioned her and wanted to make sure she did not have plans of going against her physician’s orders again. E.M. was in tears almost the entire time she was explaining her actions to the members of the board and I feel like they were true

Pt is a 14 y/o African American male presented to NNBHC with his mother with a dx of ADHD, ODD, PTSD and Depressive D/O. Pt states that he had an episode of enuresis last night when he had a nightmare about killing his family. Pt states that when he woke up he began to have intrusive thoughts of wanting to kill his family and himself so he wouldn’t have to go jail. Pt states that recently he have been blamed for everything in the home that is missing, or goes wrong. Pt states that he has taken ownership over all the negative things in the home, so none of the his sibilings wont get in trouble. Pt states “I am pretending to be happy, this is not my family”. Pt states when he cam home from residential that his biological

Mr. Goins is a 52 year old male who presented to the ED via LEO following a 4 day binge on alcohol and requesting help with his dependence. Mr. Goins reports he moved to Asheboro recently and found work, however recently lost his job. He reported a history of alcohol use and depression. Dr. Keith requested an assessment on Mr. Goins.At the time of the assessment Mr. Goins denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He reports 5 days ago he became unemployed. Mr. Goins reports his fiance who is his primary support system left town to go to a doctor appointment in their home state of Georgia. He reports binge drinking for the past 4 days attempting to cope with his recent stressor. Mr. Goins reports calling his fiance last night an expressed to her he need help. He states, "I told her I felt at the time no reason to live." Further Mr. Goins stated, "I just had too much in me last night, I had about 14 of them airplane bottles." Mr. Goins denies a history of self harm. He does report a prior hospitalization for depression in Georgia. He also reports a history of attending substance abuse treatment, which was a positive experience for him.

Pt. has been in the AMS program for 2 years. Pt. has had no positive UDS results for two years. Pt. is on a dose of 150 of methadone and he is responding as expected to his prescribed medication. Pt. demonstrated responsible attitude by attending monthly AMS groups faithfully. Pt. has discontinued all illicit drugs use and now he has used financial income in a more self-sustaining manner. Pt is effectively addressing this area by making regular payments as scheduled. Demonstrates treatment maturity and appropriately participating in medical treatment services. Pt. was taught calming strategies, such as relaxation and breathing techniques as indicated by previous counselor documentation. Pt. was assigned to this writer caseload and counselor

Ms. Webster is a 28 year old female who presented to the ED via LEO under IVC by her mother for suicidal ideation and alcohol dependence. Ms. Webster denies allegations to nursing staff. Per documentation she appears intoxicated. Per documentation Ms. Webster states, "Going through withdrawals". Before assessment this clinician spoke with nursing staff about Ms. Webster, they reports she has been asking for Ativan since she has been placed in her room. They reports she informed them that she had not consumed any alcohol today. At the time of the assessment Ms. Webster is found sitting upright in her room. Ms. Webster reports she had a plan to hang herself. She states, " you know I have to say that to get into detox." Ms. Webster reports alcohol abuse as primary stressor contributing to her distress. She denies depressive symptoms. Ms. Webster states,

Mrs. Payne is a 48 year old female who presented to the ED via EMS following her visiting to Liberty, NC from Greensboro and going into the police department and reporting she was having suicidal thoughts to wreck her car. During Mrs. Payne being triage she informed ED staff of compliant as a plan to over dose on Oxycodone at home. She reports not being able to get to prescribed Geodon and Valium for the past 2 weeks.

Presenting Problem: Pt is 16 y/o female who is currently at Tuckers Pavilion Acute facility. 8/7/16 Kelly refused to take her medication, and was generally noncompliant to staff directions. She communicated AWOL intent; she also broke a lightbulb to make a number of superficial cuts to her arm, but refused to turn in the glass an dstated that she had flushed it down the toilet. She refused first aid and refused to cooperate with staff directions. She also communicated that she was going to do worse things to herself, Intercept contacted crisis stabilization which transitioned the child to Tuckers Psychiatric at 6am. 8/12/16, Pt was upset to find out she was not getting discharged from Tuckers. Require hydroxyzine 50mg at 1530 medication

Mr. Stevens is a 39 year old male who presented to the ED via LEO under IVC for alleged threatens towards others, recent delusions, and substance abuse issues. At the time of the assessment Mr. Stevens was calm and cooperative. He reports having a history of misuse of his medications. Mr. Stevens reports recently snoring prescribed medications and taking over the recommended amount. He states, "I have tripped out (referring to experiencing symptoms of psychosis) in the past taking my Adderall." Mr. Stevens reports for the past 6 months he has suspected his wife of having an affair with various people, however most recent his neighbor. Mr. Stevens reports he has stopped using his prescribed Adderall 4 months ago. He states, "Sometimes I would take em and get paranoid, my cousin put me on, and they would make me feel high." Mr. Stevens reports for the daily use of Adderall for the past 2 years. According to Mr. Stevens a Dr. Bill prescribed them to him after he told him he had a history of ADHD as a child. According to Mr. Steven for the

D-Met with the patient as she placed on HOLD due to recent concern of her overall well-being reported by Nurse Frank as he reported to this writer yesterday of his concerns that the patient's boyfriend is refusing her to increase on her methadone due to an agreement and the patient tends to appear emotional. Upon meeting with the patient, the patient immediately knew why she is meeting with her and started to get emotional. Denies feeling SI/HI. According to the patient, she had an agreement with her boyfriend of which she agreed to increase her dose up to 55mgs as her boyfriend will closely monitor her recovery. The patient does not feel unsafe around her boyfriend as she reported. This writer strongly advised the patient that she has rights to her own recovery process because it's her in the recovery and seeking treatment, at which the patient agreed. But says, "I am fine with my current

REPORTER: The reporter/ Social Services Director (Vernestine) called with concerns for the victim, Tanya. Tanya has had an aneurism, and she has paralysis. The reporter said the victim’s cognition is off, and she cannot perform her daily ADL’s, but she can talk. The reporter said Tanya has two small children, but her mother (Phyllis) may be keeping the children. The alleged perpetrator is Bryan Blakemore (Husband). On Yesterday (03/29/2016), the victim was discharged AMA (on medical advice). The reporter said when the victim is discharged AMA, they are not given any medications. The victim left with out any medications, but Bryan was given a list of all the victim’s medication. Bryan said he was going to see a doctor in Jackson, MS to have

His patient is young 21-year-old girl. She has three children from three different fathers. The first father impregnated her at the age of 16. He openly cheated on her and would beat her during his drunken rages. She left him and met her second child’s father. This man was an addict with a criminal history. He died in an accident while driving a stolen car. The father of her third told her to have his child or he would leave her. She lived with him and had his child. A week after giving birth he left her. She went to Dalrymple claiming to be depressed.

She reports that a lot of current medical condition stem from riding horses for 30 years and a lot of physical labor. The patient has 2 children-females. The patient does not get along with her oldest child due to conflicts with her patient's father and the patient was upset that her daughter sold one of her horses for profit. The patient does in fact get along with her youngest child, who is 25 years. The patient discussed the marital issues with her ex-husband. The patient was married for 18 years and divorced her husband in 2003 due to verbal, physical, mental, and fiancial abuse. The patient reports she is happy that she left her marriage; however, her husband had caused a lot fiancial issues in her life by fraudlant acts. The patient had attempted to go after her husband for the frauds he did by using the alimony and her name, but the patient reports she had a conflict with her attorney. Till this day, the action was