Assessing and Treating Clients With Pain

Introduction

In this paper, the management of a43-year-old man who was diagnosed with complex regional pain disorder is discussed. Three decisions will be made on the choice of medications to use, the expected outcomes of pharmacological therapy and the actual outcomes. An explanation of how ethical considerations are likely to impact treatment and communication with families and clients will also be provided.

Decision #1

Decision Selected

Start Amitriptyline 25 mg PO QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day. Assessing and Treating Clients With Pain

Reason for Selecting This Decision

Amitriptyline is a tricyclic antidepressant with proved efficacy in managing neuropathic pain. It is often used off label by practitioners to manage neuropathic pain. It functions by inhibiting the reuptake of neurotransmitter norepinephrine and serotonin from the brain to the spinal cord. Its effects of inhibition are much faster as compared to the antidepressive effects. Although it causes lightheadedness, drowsiness, and cardiac arrhythmias as potential side effects, this often happens in instances of high dosing. Therefore, for this patient prescribing amitriptyline for the beginning will be the best course of action (Murnion, 2018).

            It should be noted that the intensity of pain in patients with regional pain disorder is low as a result of CNS changes. These changes cause wrong levels of neurotransmitters in the brain making a patient be more sensitive to pain. Savella, an SNRI has similar effects on brain neurotransmitters. It acts on the nerve endings to promote the reuptake of neurotransmitters giving rise to analgesia effects leading to a good memory, reduced intensity and severity of pain and reduced fatigue. However, even in small dosages, it leads to palpitations and drowsiness, a major side effect that the client mentioned to dislike. Therefore, prescribing it could only result in high chances of non-adherence (Finnerup et al., 2015).

Neurontin, also called gabapentin, an anticonvulsant, could also be a good option since it is often used off label to relieve nerve pain by some clinicians. However, in high doses, Neurontin can lead to feeling drowsy and extreme somnolence (Murnion, 2018). Based on the client’s initial dislike for the side effect of drowsiness, it is obvious that prescribing it can only lead to non-compliance and poor health outcomes.

Expected Outcome

            It was anticipated that the patient’s severity and intensity of pain will reduce significantly to an approximate level of 3 on a scale of 1-10 and that he will be able to perform his activities of daily life with very little or minimal support (Finnerup et al., 2015).  It was also expected that his mood would improve and his affect would be stable.

Difference between Expected Outcome and Actual Outcome

            After four weeks, the client returned to the clinic walking with crutches. According to own assessment, his current level of pain as compared to what he previously experienced was a little bit manageable.  However, he had critically noted that in the morning hours, the intensity of the pain was worse but got better as the day progressed.  Based on the client’s assessment, the level of pain was 4 on a scale of 1-10 but he anticipated to have a level of 3. The half-life of amitriptyline is exactly 20 hours. This means that, depending on the dosing, only a small amount is left in the client’s system by morning. This explains why the intensity of pain used to worsen in the morning hours.

Decision #2

Decision Selected

            The client will continue with the current medication but the dosage will be increased to 125mg HS towards the goal dose of 200mg daily. The patient was also instructed to take the medications one hour earlier than usual and to call the office within 3 days to report about his functioning in the morning.Assessing and Treating Clients With Pain

Reason for Selecting his Decision

Based on the client’s progress, it is certain that the treatment goal of pain management and improved functional status was gradually being attained.  Besides, the client’s initial visit evidently revealed that the initial dosing and frequency of amitriptyline was affecting his functioning in the morning hours. It was, therefore, important to adjust the medication, dosing, and frequency to ensure that pain was controlled and that the client’s functionality throughout the day was improved (Murnion, 2018).

Reducing Elavil to 75mg during bedtime with weekly dosage titrations using Bio freeze could be an alternative option. However, the client could experience high levels of pain in the morning or throughout the day, since bio freeze only lasts for 2 hours before requiring re-application. Therefore, it cannot provide extended pain relief (Stanton-Hicks, 2018). Similarly, reducing Elavil 75 mg at bedtime and adding Neurontin 300 mg at bedtime is not in the patient’s best interest as it will only worsen the drowsiness experienced by the client during daytime to last the whole day (Gilron, Baron & Jensen, 2015).

Expected Outcome

            The frequency and dosing adjustment was meant to ensure that the patient’s pain level reduced to a level of around 4 and improve his functional status in the morning hours. In the management of neuropathic pain, higher doses have been associated with good pain control outcomes and vice versa.  Similarly, dosage reductions during the part of the day when pain is efficiently under control is a good strategy for achieving the goals of treatment (Finnerup et al., 2015).

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Difference between Expected Outcome and Actual Outcome

After four weeks, the client returned to the clinic. He appeared to be better than his previous visit, an indication that the change in time of administering the medication was helpful. He clearly mentioned that he was not as groggy in the morning hours and that he was able to officially start his day earlier than before. The client also mentioned that he has realized that he was gaining weight and he had gained 5 pounds since he started taking the drugs. At this point, the client was bothered much about the weight gain as compared to the pain since the latter had significantly reduced. A thorough assessment revealed that the client weighed 162 pounds, was 5’7″ tall and his pain level was 4 in a scale of 1-10.

Decision # 3

Decision Selected

            The current medication will be continued and the dosage will be increased to 125mg at HS towards the goal of 200mg daily. The patient should also be counseled on a healthy lifestyle before being referred to a life coach.

Reasons for Selecting This Decision

            Clearly, it was evident that the initial dosing and frequency of amitriptyline was working apart from the side effect of weight gain which the patient was concerned about and could adequately be addressed by a life coach through physical activity and nutrition. Reducing the dosage of amitriptyline could help to reduce the effect of weight gain. However, this decision couldn’t be in the patient’s best interest as it could increase the intensity and severity of pain (Finnerup et al., 2015). Assessing and Treating Clients With Pain

Reducing the dosage of Elavil to 100 mg a day and follow up in a month and continuing Elavil 125 mg a day and starting Qsymia 3.75 mg/23 mg tablet daily and titrating as required by package insert could not be good options. Reducing the dosage could have significant costs on the management of pain. On the other hand, qsymia causes palpitations and cardiac arrhythmias in higher dosages, which is a life-threatening adverse effect that could place the patient’s life at risk. Besides, according to the guidelines provided by the FDA, Qsymia can only be prescribed for patients who are obese (BMI more than 30 kg/m²). Based on the previous visit, the BMI for this client was 25.5 kg/m², meaning that he only meets the criteria of being overweight and not obese(Gilron, Baron & Jensen, 2015).

Expected Outcome

            Apart from good pain management outcomes and increased functionality, it was expected that the life coach would be able to assist the client to gradually reduce his weight using a more specific and meaningful approach. He would receive enough counseling on good exercise and dietary habits which when applied could ensure that treatment goals were achieved (Murnion, 2018).

Difference between Expected Outcome and Actual Outcome

            There was no significant difference between the expected and actual outcome. After four weeks, the client returned to the clinic walking without support. He was stable and jovial and seemed satisfied with his progress. He mentioned that apart from being able to achieve good levels of pain control, he noted that he had lost one pound. Since the weight loss was going to be gradual and couldn’t be 100% guaranteed, the client was advised to continue with counseling and seeing the life coach (Gilron, Baron & Jensen, 2015).

How Ethical Considerations Might Impact Treatment Plan and Communication with Clients

            For this client, ethical considerations of utmost significance are that of informed consent, autonomy, and beneficence. The patient clearly stated that he wouldn’t like drugs that would cause him to feel dizzy or drowsy. Therefore, when selecting the mediations to prescribe, the PMHNP should respect the client’s autonomy and should not force or coerce him to agree to a treatment that he is against (Millum, 2013).  This means that, before starting the patient on any medications, the PMHNP should be informed to the client of all the benefits and risks of a drug and obtain written consent. Besides, the choice of drugs that the PMHNP looks forward to prescribing should purpose to serve his best interest and have lesser side effects (Millum, 2013).

References

Finnerup, N. B., Attal, N., Haroutounian, S., McNicol, E., Baron, R., Dworkin, R. H., & Kamerman, P. R. (2015). Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. The Lancet Neurology, 14(2), 162-173.Assessing and Treating Clients With Pain

Gilron, I., Baron, R., & Jensen, T. (2015, April). Neuropathic pain: principles of diagnosis and treatment. In Mayo Clinic Proceedings (Vol. 90, No. 4, pp. 532-545). Elsevier.

Millum J. (2013). Introduction: Case Studies in the Ethics of Mental Health Research. J Nerv Ment Dis. 200(3), 230–235.

Murnion, B. P. (2018). Neuropathic pain: current definition and review of drug treatment. Australian Prescriber, 41(3), 60.

Stanton-Hicks, M. (2018). Complex regional pain syndrome. In Fundamentals of Pain Medicine (pp. 211-220). Springer, Cham.

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”

SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health.

She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

Diagnosis: Gambling disorder, alcohol use disorder

Decision One

Naltrexon Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weekse (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

RESULTS OF DECISION ONE

• Client returns to clinic in four weeks
• Perez said that she felt “wonderful” as she has not “touched a drop” to drink since receiving the injection
• Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)
• Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also have her concerned

Decision Point Two

Refer to a counselor to address gambling issues

RESULTS OF DECISION TWO

• Client returns to clinic in four weeks
• Client reports that the anxiety that she had been experiencing is gone
• Client reports that she has met with the counselor, but did not really like her. She did start going to a local meeting gamblers anonymous. She stated that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group

Decision Three

Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetings Assessing and Treating Clients With Pain

Guidance to Student
Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, four weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As you will learn in future courses, ruptures and the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA approved treatments for gambling addiction, and the mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the gamblers anonymous meetings, she should be encouraged to continue her participation with this group.

The PMHNP needs to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.

Reference resources for this assignment

Required Readings

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M., & Grady, M. (2012). Stahl’s illustrated substance use and impulsive disorder New York, NY: Cambridge University Press.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

For insomnia

For obsessive-compulsive disorder

• Citalopram
• clomipramine
• escitalopram
• fluoxetine
• fluvoxamine
• paroxetine
• sertraline
• venlafaxine
• vilazodone

For alcohol withdrawal

• chlordiazepoxide
• clonidine
• clorazepate
• diazepam
• lorazepam
• oxazepam

For bulimia nervosa and binge eating

• fluoxetine
• topiramate
• zonisamide

For alcohol abstinence

• acamprosate
• disulfiram

For alcohol dependence

• nalmefene
• naltrexone

For opioid dependence

• buprenorphine
• naltrexone

For nicotine addiction

• bupropion
• varenicline

Book Excerpt: Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders. Treatment Improvement Protocol Series, No. 32. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64350/

• Chapter 1, “Substance Use Among Adolescents”
• Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”
• Chapter 7, “Youths with Distinctive Treatment Needs”

University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control in adulthood, study finds. Retrieved from https://www.sciencedaily.com/releases/2016/01/160120201324.htm

Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375–381. doi:10.1111/j.1365-2125.2012.04457.x

.Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing, 42(4), 10–15. doi:10.3928/00989134-20160314-04

Salmon, J. M., & Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in older adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis, 8(1), 74–84. doi:10.1080/15504263.2012.648439

Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., & … Soares, J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry, 55(6), 1337–1341. doi:10.1016/j.comppsych.2014.04.018

Complex Regional Pain Disorder
White Male With Hip Pain

BACKGROUND

This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.”Assessing and Treating Clients With Pain

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SUBJECTIVE

The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”

The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”

He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”

During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.Assessing and Treating Clients With Pain

Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)

Complex Regional Pain Disorder
White Male With Hip Pain

Decision Point One

Start patient on Savella 12.5 mg once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID after Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning
• Client’s pain level is currently a 6 out of 10. The PMHNP questions the client on what would be an acceptable pain level. He states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.” He states that his pain level normally hovers around a 9 out of 10 on most days of the week before the amitriptyline was started. The PMHNP asks what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 6?” The client states, “I’m able to go to the bathroom or to the kitchen without using my crutches all the time. The achiness is less and my toes do not curl as often as they did before.” The client is also asked what would need to happen to get his pain from a current level of 6 to an acceptable level of 3. He states, “Well, that is kind of hard to answer. I guess I would like the achiness and throbbing in my right leg to not happen every day or at least not several times a day. I also could do without my toes curling in like they do. That really hurts.”
• Client denies suicidal/homicidal ideation and is still future oriented

Decision Point Two

Continue current medication and increase the dose to 125 mg at HS this week continuing towards the goal dose of 200 mg daily. The client will be instructed to take the medication one hour earlier than normal starting tonight and call the office in three days to report how his function is in the morning.

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• The change in administration time seemed to help. The client states he is not as groggy in the morning and is able to start his day sooner than before
• Client’s current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime.
• Client’s has noticed that he is putting on a little weight. When asked, the client states that he has gained 5 pounds since he started taking this medication. He currently weighs in at 162 pounds. He is 5’ 7”. He states that his right leg doesn’t bother him nearly as much as it used to and his toes have only “cramped up” twice in the past month. He states that he is able to get around his apartment without his crutches and that he has even started seeing someone he met at the grocery store. The weight gain seems to bother him a lot and he is asking if there is a way to avoid it

Decision Point Three

Continue current medication and increase the dose to 125 mg at HS this week continuing towards the goal dose of 200 mg daily and counsel patient about healthy lifestyle then refer him to a lifestyle couch.Assessing and Treating Clients With Pain

Guidance to Student

At this point, the client is almost at his goal pain control and increased functionality. Weight gain is a common side effect with amitriptyline and should be a counseling point at the initiation of therapy. He has a small weight gain of 5 pounds in 8 weeks. A reduction in dose may have an effect on the weight gain but at a considerable cost of pain to the client. This would not be in the best interest of the client at this point. Amitriptyline has a side effect of cardiac arrhythmias. He is not experiencing this at this point. The drug, qsymia contains a product called phentermine which has a history of causing cardiac arrhythmias at higher doses. This product is also only approved for a client with obesity defined as a BMI greater than 30 kg/m2. Your client’s BMI is currently 25.5 kg/m2. He does not meet the definition of obesity but is considered overweight. His best course of action would be to continue the same dose of Elavil, counsel him on good dietary and exercise habits and connect him with a life coach who will help him with this problem in a more meaningful way than a 10 minute counseling session will be able to accomplish.Assessing and Treating Clients With Pain