DECISION TREE FOR NEUROLOGICAL AND MUSCULOSKELETAL :Complex Regional Pain Disorder

Running head: Assessing and Treating Clients with Pain

Assessing and Treating Clients with Pain

NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology

1

Managing care for patients with Pain 2

Introduction

Complex regional pain syndrome (CRPS) is a chronic neuropathic pain that can occur

weeks to months after a bone injury (type I) or nerve injury (type II). The pathophysiology of

CRPS is attributable to the idea that when and an incident occurs, the brain and sympathetic

nervous system releases norepinephrine that causes vasoconstriction which leads to vessel spasm

and thus leads to pain and inflammation (Tajerian & Clark, 2016). The pain continues in the

same loop which causes chronic pain in the patient. Symptoms of CRPS include; burning pain

sensation, skin changes (redness, increase temperature, sweating, and edema) and decreased

range of motion (Goh, Chidambaram & Ma, 2017). Also, the patient can present with

psychological distress and can develop anger and mental illnesses such as depression. Diagnosis

of CRPS includes identifying clinical criteria and allodynia which is pain from stimuli that do

not typically cause pain and hyperalgesia where the patient has increased pain to a painful

stimulus. A sympathetic nerve block can be utilized as a diagnostic test as well as treatment for

CRPS. Other therapies for CRPS include the use of antidepressants, opioid analgesics and

physical therapy (Tajerian & Clark, 2016).

Summary of patient case

The patient is a 43-year-old white male who 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 a 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.” The patient reports that his pain began

about seven 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 four years ago, it was discovered that the cartilage surrounding his right hip

Managing care for patients with Pain 3

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 time. Since then, he reported the development of a

strange constellation of symptoms including cooling of the extremity (measured by

electromyogram).

The patient also reports that he experiences severe cramping of the extremity. He states

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.”

The patient 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 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

Managing care for patients with Pain 4

releasing. The client states “if there is anything you can do to help me with this pain, I would

appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he

states that he uses “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 do anything for

the pain.

The patient 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

spirit and content of the 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 (SI/HI) and is future-oriented. The patient is

diagnosed with Complex regional pain disorder (reflex sympathetic dystrophy). The purpose of

this paper is to present and discuss treatment options at three various levels in the management

of the patient’s pain symptoms. Also, the essay will include ethical considerations and practical

communication skills when caring for patients with pain disorders.

Decision 1

To begin treatment, the Psychiatric mental health nurse practitioner (PMHNP) can start

the patient on Savella 12.5mg orally once daily on day 1; followed by 12.5mg BID on day 2 and

3; followed by 25mg BID on days 4-7; followed by 50mg BID after that. The second option is to

begin Amitriptyline 25mg PO QHS and titrate upward weekly by 25mg to a maximum dose of

200mg per day. The third option is to start Neurontin 300mg PO at bedtime with weekly

increases of 300mg per day to a max 2400mg if needed. The PMHNP decides to start the patient

on Amitriptyline 25mg PO QHS and titrate upward weekly by 25mg to a maximum dose of

200mg per day. As a Tricyclic antidepressant, Amitriptyline is often used as first line treatment

Managing care for patients with Pain 5

for patients with chronic and neuropathic pain due to its norepinephrine and serotonin inhibition

which increases the amount of these neurotransmitters and therefore increases nociceptive

inhibition (Stahl, 2014).

Although Milnacipran (Savella) is effective in treating cases of fibromyalgia, research

shows no significant change in neuropathic pain control with this medication and side effects

especially at higher doses can cause bouts of sweating, and nausea and feeling of anxiety (Derry,

Phillips, Moore & Wiffen, 2015). Also, the PMHNP would not choose to start the patient on

Neurontin at this time for high chances of daytime drowsiness, sleepiness and decrease motor

function especially (Stahl, 2013) which may not be especially beneficial for this patient who

does not have much physical support and uses crutches for ambulation. The goal of treatment is

to attain a pain level at a 3-5/10 after initial treatment and minimize the use of crutches by 25%

in activities of daily living.

The patient returns to clinic in four weeks still using crutches. He states that the pain has

improved, but he is a bit tired in the morning. Client's pain level is currently a 6 out of 10. The

PMHNP questions the client on what an acceptable pain level would be. 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 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 would probably 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 as they

Managing care for patients with Pain 6

do. That hurts.” Client denies SI/HI, and he is still future-oriented. The outcome is as expected

because although Elavil is effective in controlling neuropathic pain, the onset is delayed, and the

patient was started on minimum dose with ample room to titrate the mediation until a therapeutic

effect is seen.

Decision 2

Based on the outcomes form the first treatment option, the PMHNP can continue the

medication and increase the dose to 125mg QHS this week maintaining towards the goal dose of

200mg daily. Also, instruct the client to take the pill an hour earlier than normal starting tonight

and call the office on three days to report how his function is in the morning. The second choice

will be to reduce the dose of Elavil to 75mg at Bedtime and add on Biofreeze roll-on therapy to

his right leg below the knee and into the foot and toes to be used as needed daily for muscle

cramping. The third option is to reduce the dose of amitriptyline to 75mg PO at bedtime and add

on Neurontin 300mg PO at night then schedule a follow-up call in 1 week to assess the patient’s

pain control. The PMHNP decides to continue the medication and increase the dose to 125mg

QHS this week maintaining towards the goal dose of 200mg daily. Also, the PMHNP will

instruct the client to take the medication an hour earlier than normal starting tonight and call the

office on three days to report how his function is in the morning.

Elavil has a strong serotoninergic action for which is it frequently prescribed for nerve

damage/neuropathic pain (Moore, Derry, Aldington, Cole & Wiffen, 2015) and this patient

appears to have some control of his pain while on this medication thus titrating up the dose can

be beneficial for him. Although Neurontin functions to reduce neurotransmitters release such as

glutamate and thus beneficial for neuropathic pain, this medication can increase drowsiness

especially during the day time (Stahl, 2014). Moreover, the Elavil appears to be helping the pain

control; thus, it would not be recommended to decrease the dose instead. Thirdly, Biofreeze

Managing care for patients with Pain 7

which contains menthol that works by desensitizing nociceptors which can help with muscle

cramping and pain but this regime requires frequent application thus is not a suitable for a long-

term solution for this patient with chronic pain (Studies from J.V, 2018). The goal at this point is

for the patient’s pain level to be tolerable at 3 or less and a decrease by 60% or more of the use

of crutches and alleviate achiness/throbbing in right leg and curling of toes by the next

appointment.

The patient returns to the clinic in four weeks stating the change in administration time

seemed to help. The client also says he is not as tired in the morning and can start his day sooner

than before. He reports his current pain level is a 4 out of 10 with the current treatment. The

patient 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 can 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.

With the increased dose in Elavil, the outcome is as expected since the patient is reporting lesser

pain rating, improving in physical and social status (antidepressant property of Elavil) and a

decrease in previous negative muscle symptoms. Also, small- moderate weight gain can be

anticipated with patients when on Elavil (Stahl, 2013).

Decision 3

At this level in treatment, the PMHNP can continue with the Elavil at his current 125mg

a day dose and start Qysmia 3.75mg/23mg tablet oral once and titrate as required by package

insert. Another choice is to reduce the dose of Elavil to 100mg a day and follow up in a month.

The third choice is to continue the current treatment of Elavil of 125mg per day and refer the

Managing care for patients with Pain 8

patient to a life coach who can counsel him on good dietary habits and exercise. The PMHNP

decides to move forward with the third choice. Elavil has shown positive therapeutic effects in

the patient; thus, it is recommended to continue to treatment while addressing his weight gain

concern. Adding Qsymia to his therapy is not needed because this is a medication utilized

primarily for weight loss in combination with other medicines such as Topiramate (Sweeting,

Tabet, Caterson & Markovic, 2014).

Moreover, weight gain is not an acceptable adverse effect that requires the need for add-

on therapy, and the patient’s BMI is currently 25.5 kg/m2 which is not considered overweight

(Centers for Disease Control and Prevention, 2017). A reduction in the Elavil dose may have an

effect on the weight gain but at a significant cost of pain to the client. Decreasing the

prescription would not be in the best interest of the patient at this time. The goal is for pain level

to be tolerable at 3 or less, decrease by 80% or more of the use of crutches and 1 to no

occurrence of achiness/throbbing in the right leg and curling of toes by the next appointment.

The outcome is as expected because the patient has attained a therapeutic dosage of Elavil with

almost solid control of his pain. The patient appears to be improving physically and mentally

thus including a life coach for weight gain concerns can promote even more improvement in

care as the PMHNP continue to follow the patient and address concerns as they arise.

Conclusion with Ethical considerations and Communication

Complex regional pain syndrome (CRPS) is a chronic neuropathic pain that can occur

post nerve or bone injury. CRPS is caused by a loop cycle that occurs after an injury and leads to

symptoms such as intense pain sensations, skin changes (redness, increase temperature,

sweating, and edema) and decreased muscle action (Goh, Chidambaram & Ma, 2017). Diagnosis

of CRPS includes a clinical presentation, sympathetic nerve block, and the presence of allodynia

Managing care for patients with Pain 9

and hyperalgesia. Treatment for CRPS can be challenging and can include the use of

antidepressants, opioid analgesics and physical therapy (Tajerian & Clark, 2016).

Ethical considerations while treating patients with pain disorders can arise from the

subjective nature of the disease. Pain is what the patient report it is (Stahl, 2014) and dilemmas

can occur when the provider is unsure if a patient is “medication seeking” for opioids or higher

potency medications or if the patient is indeed in as much pain as they state. Nonetheless, it is

vital to have an open and honest clinical assessment/communication with the patient to ensure

that as the PMHNP you are identifying critical components of the patient's pain and addressing

them appropriately. Referring a patient to a pain specialist can also be beneficial in cases where

the current regime for pain control is beyond the scope of the PMHNP.

.

Managing care for patients with Pain

10 References

Centers for Disease Control and Prevention. (2017). Overweight & obesity. Adult Body Mass

Index (BMI). Retrieved from https://www.cdc.gov/obesity/adult/defining.html

Derry S, Phillips T, Moore RA, Wiffen PJ. (2015). Milnacipran for neuropathic pain in adults.

Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD011789. DOI:

10.1002/14651858.CD011789.

Goh, E. L., Chidambaram, S., & Ma, D. (2017). Complex regional pain syndrome: a recent

update. Burns & trauma, 5, 2. doi:10.1186/s41038-016-0066-4

Moore RA, Derry S, Aldington D, Cole P, Wiffen PJ. (2015). Amitriptyline for neuropathic

pain in adults. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.:

CD008242. DOI: 10.1002/14651858.CD008242.pub3.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical

applications (4th ed.). New York, NY: Cambridge University Press.

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

Studies from J.V. Pergolizzi and Co-Researchers in the Area of Opioids Reported (The role and

mechanism of action of menthol in topical analgesic products). (2018). Clinical Trials

Week. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?

direct=true&db=edsgea&AN=edsgcl.532158755&site=eds-live&scope=site

Sweeting AN, Tabet E, Caterson ID, & Markovic TP. (2014). Management of obesity and

cardiometabolic risk – role of phentermine/extended release topiramate. Diabetes,

Metabolic Syndrome and Obesity : Targets and Therapy, (default), 35. Retrieved from

https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?

direct=true&db=edsdoj&AN=edsdoj.56e0dd14d9f45b49aa2b9cff1739cda&site=eds-

live&scope=site

Managing care for patients with Pain

11 Tajerian, M., & Clark, J. D. (2016). New Concepts in Complex Regional Pain Syndrome. Hand

clinics, 32(1), 41–49. doi:10.1016/j.hcl.2015.08.003