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neurological and musculoskeletal 6

Case Study: Complex Regional Pain Disorder (White Male with Hip Pain)

NUR6521 Advanced Pharmacology

Case Study: Complex Regional Pain Disorder (White Male with Hip Pain)

Introduction – Case Review

A 43-year-old male presents at clinic assisted with ambulation by a set of crutches with chief complaint of pain. Upon clinical interview, patient states that he was sent in for psychiatric evaluation by his primary care physician due to his pain. Patient states that physician feels that his continued pain “is all in his head”. He continues in stating that his primary care physician feels that he is complaining of pain in an effort to gain continued supply of narcotics in an effort to “get high”. Patient states that his pain is from a fall that occurred seven years prior while at work. He states that at that time he fell and landed on his right hip. Patient also states that at times he feels “down in the dumps” when he thinks about how his life turned out, yet at the same time emphatically denies that he suffers from any form of depression (Laureate Education, 2019).

Decision One

Upon review of the details provided surrounding the patient’s complaint, condition, and history I selected to start Amitriptyline 25mg po QHS and titrate upward weekly by 25mg until reaching a max dosage of 200mg per day (Laureate Education, 2019). Amitriptyline is classified as a reuptake inhibitor of both serotonin and norepinephrine. This allows for the blockage of reuptake of both serotonin and norepinephrine which can often be prescribed for controlling chronic pain, fibromyalgia, and a wide variety of pain disorders according to www.drugs.com (2020). Based on the choices provided in the decision tree exercise this appears to be the most logical choice. Information on why this conclusion was made will be provided in the following paragraph.

Elavil desensitizes both Serotonin 1A, and beta-adrenergic receptors and enhances serotonin and noradrenaline receptors (Moore et al, 2017). Savella, commonly known as Milnacipran Hydrochloride was not chosen treatment plan as it is “selective” serotonin and norepinephrine reuptake inhibitor which acts like other psychiatric drugs when used as a treatment for depression related conditions. This drug is also used at high rates when treating fibromyalgia in adult patients. Personally, upon my assessment of patient I do not feel this is the most appropriate starting point when focusing on therapeutic intervention for patients who may have psychiatric disorders because of the chronic pain complaints presented by the patient related to the previous hip injury (English, Rey, & Rufin, 2010). The choice of using Neurontin, also known as Gabapentin, is not appropriate as this is an anticonvulsant drug used to treat seizures and neuropathic pain (Lyons, 2018).

Patient Update

Upon the patient’s return four weeks after beginning treatment with Amitriptyline, he continued to use the crutches. Improvement in his movement was visible, however he still presented in an agitated state. That patient self-reported his pain level at a 6 out of 10, and he stated that he could only tolerate a pain level of 3 or less (Laureate Education, 2019). He reports that he can get to kitchen and restroom without crutches but further he needs assistance. Prior to the start of this medication he reported pain level of 9 out of 10. He does acknowledge a decrease in pain levels but expressed concern about his toes curling which causes significant pain (Laureate Education, 2019).

Decision Two

Based on the patient’s current state I decided to continue with Amitriptyline 125mg at bedtime, and to continue towards a regular 200mg target dose. Patient was also provided instruction to take the drug approximately an hour earlier than usual tonight, and report to the clinic for a recheck in three days. This adjustment was advised to see if there was significant mood change with medication timing. I eliminated the choices not to reduce the dose and/or augment with the use of Neurontin as the client acknowledged that there was help with the presence of chronic pain and demonstrated effective response to the current plan. Therefore, the best choice was to increase the initial dose and change the time at which medication is taken. I expect that upon recheck the patient will feel decreased pain and decrease tiredness and levels of irritability in the morning hours.

Patient Update

Patient reported to the clinic within the next four weeks and reports that taking the medication earlier in the evening has reduced the tiredness that he feels in the morning. He reports his pain now being a 4 out of 10. Patient is concerned however over recent weight gain (Laureate Education, 2019). He reports and it is noted that since beginning the Amitriptyline medication at dose of 125mg he shows a five-pound weight increase. Patient does acknowledge that his right leg is bothering him less, and that he has only noticed issues with his toes “curling” twice over the past month. He does report that he is now able to get around his apartment without the crutches. His main concern is the weight gain and asks for assistance with this issue. Weight gain is listed as one of the possible side effects of Amitriptyline (Drugs.com, 2020).

Decision Three

Upon review of the patients current status, I decided in decision three to continue with the use of Amitriptyline at the 125mg dose per day, and refer the patient to begin to work with a life coach to focus on better dietary habits, increased exercise and physical activity that would be well tolerated with his condition (Laureate Education, 2019). Through the use of the prescribed medications the patient has been able to control his chronic pain and through the use of life coach he should be able to find ways in which to make changes that will allow for better lifestyle habits and control the impact of the drug on his weight. Decreasing the dosage at this point while it may allow him to drop the extra weight would be a setback involving the pain which had significant control over his ability to lead a productive life.

I did not choose to start the patient on Qsymia with the same dose of Amitriptyline as the Qsymia is associated with increased chance of cardiac arrhythmias which can lead to increased cardiac risks and complications (Laureate Education, 2019). While Amitriptyline does have the possibility of cardiac impacts on patients, the risk is low, and patient has not experienced any of these issues. The best choice is therefore to continue the treatment plan as is and begin to focus on lifestyle changes to address weight gain.

Conclusion

When assessing the concerns of the patient, one of the most important components is to listen to the concerns of the patient, and to not dismiss his concerns regarding the reported pain. Chronic pain can be debilitating, and yet it is often disregarded as a condition in the patient’s head. One should then consider the patients concerns, risk factors, as well as side effects of medications and look at what will treat the condition but pose the least in negative impacts. Remembering to adjust involving dosage time can help to ensure that the patient also receives the maximum benefits from the mediations. Minor side effects can be addressed in many cases through lifestyle changes.

References

Amitriptyline (Elavil) Uses, Dosage, and Side Effects – Drugs.com (2020). Retrieved July 21, 2020, from https://drugs.com/amitriptyline.html

English, C., Rey, J.A., & Rufin, C. (2010). Milnacipran (Savella), a treatment option for Fibromyalgia, Pharmacy and Therapeutics, 35(5), 261.

Laureate Education (2019). Complex Regional Pain Disorder [Interactive Media File]. Baltimore, MD: Author Retrieved: July 21, 2020, from http: cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_07/2.html

Lyons, S. (2018) Overview on Pregabalin and Gabapentin. Drugnet Ireland, 11-12

Moore, R.A., Kalso, E.A., Derry, S., Tolle, T.R., Finnerup, N.B., Attal, N., & Wiffen, P.J. (2017). Antidepressant drugs for neuropathic pain-an-overview of Cochrane Reviews. The Cochrane database of systematic reviews (1).

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