Psychopharmacologic Approaches to Treatment of Psychopathology

  // Complex Regional Pain Disorder

Complex Regional Pain Disorder White Male With Hip Pain

 

Decision Point One Neurontin (gabapentin) 300 mg orally at BEDTIME with weekly increases of 300 mg per day to a max of 2,400 mg if needed

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client returns to the office today and seems to be in agony. He states that the Neurontin did not help him at all. He also states that he is foggy in the morning. His current pain level is a 9 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.” The client is also asked what would need to happen to get his pain from a current level of 9 to an acceptable level of 3. He states, “I guess I would like this 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.”
• Clientis denies suicidal/homicidal ideation and is still future oriented. He does seem to be discouraged throughout the interview about his current pain

Decision Point Two

Select what the PMHNP should do next:

Discontinue Neurontin. Start Zoloft (sertraline) 50 mg orally daily and titrate at weekly intervals to a dose of 200 mg

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client returns today with a current pain level of 5 out of 10. He appears anxious, which is a new presentation. He states that he feels “amped up” and he cannot seem to control it
• Client also states that he hasn’t been able to get an erection in over a week and thinks his pain may be causing erectile dysfunction.
• Although client's pain is “more manageable than it has been before”, he thinks it may have gotten the best of him. His new problems really have him discouraged

Decision Point Three

Select what the PMHNP should do next:

Reduce Zoloft to 100 mg per day. Give the client a short course (2 weeks) of Ativan to help with his anxiety

Guidance to Student

Anxiety is a transient effect of SSRI and SNRI therapy and should be anticipated. Counseling the client is key in continuing the therapeutic alliance you have with the client. Short course benzodiazepines will usually be sufficient to bridge this time period. Erectile dysfunction is a side effect of all SSRI’s and should be a counseling point for men. It happens in roughly 10% of men using SSRI’s. A dose reduction in Zoloft will certainly help with the side effects but will most likely result in increased pain. A change in therapy is always an option at this point but will normally not reduce the anxiety or erectile dysfunction experienced and will still require short course benzodiazepine therapy and appropriate counseling. It would be most prudent, in this case, to add-on Wellbutrin XL 150 mg po QAM to help with the side effect of erectile dysfunction. Although we have told you throughout this course that the addition of a medication to treat a side effect is not good therapy, this is one of those cases where it is recommended, especially when the client is experiencing relief from a regimen that took time to achieve. Wellbutrin is a DNRI and does not overlap in SSRI therapy (maybe a little in the DRI of Zoloft).

Start Over

Discontinue Zoloft and start Prozac (fluoxetine) 40 mg orally per day. Give the client a short course (2 weeks) of Ativan to help with his anxiety

Guidance to Student

Anxiety is a transient effect of SSRI and SNRI therapy and should be anticipated. Counseling the client is key in continuing the therapeutic alliance you have with the client. Short course benzodiazepines will usually be sufficient to bridge this time period. Erectile dysfunction is a side effect of all SSRI’s and should be a counseling point for men. It happens in roughly 10% of men using SSRI’s. A dose reduction in Zoloft will certainly help with the side effects but will most likely result in increased pain. A change in therapy is always an option at this point but will normally not reduce the anxiety or erectile dysfunction experienced and will still require short course benzodiazepine therapy and appropriate counseling. It would be most prudent, in this case, to add-on Wellbutrin XL 150 mg po QAM to help with the side effect of erectile dysfunction. Although we have told you throughout this course that the addition of a medication to treat a side effect is not good therapy, this is one of those cases where it is recommended, especially when the client is experiencing relief from a regimen that took time to achieve. Wellbutrin is a DNRI and does not overlap in SSRI therapy (maybe a little in the DRI of Zoloft).

Start Over

Add on Wellbutrin (bupropion) XL 150 mg orally in the MORNING. Give the client a short course (2 weeks) of Ativan to help with his anxiety

Guidance to Student

Anxiety is a transient effect of SSRI and SNRI therapy and should be anticipated. Counseling the client is key in continuing the therapeutic alliance you have with the client. Short course benzodiazepines will usually be sufficient to bridge this time period. Erectile dysfunction is a side effect of all SSRI’s and should be a counseling point for men. It happens in roughly 10% of men using SSRI’s. A dose reduction in Zoloft will certainly help with the side effects but will most likely result in increased pain. A change in therapy is always an option at this point but will normally not reduce the anxiety or erectile dysfunction experienced and will still require short course benzodiazepine therapy and appropriate counseling. It would be most prudent, in this case, to add-on Wellbutrin XL 150 mg po QAM to help with the side effect of erectile dysfunction. Although we have told you throughout this course that the addition of a medication to treat a side effect is not good therapy, this is one of those cases where it is recommended, especially when the client is experiencing relief from a regimen that took time to achieve. Wellbutrin is a DNRI and does not overlap in SSRI therapy (maybe a little in the DRI of Zoloft).

Start Over

Continue with Neurontin but double the current dose (600 mg PO orally 4 times a day)

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client returns to the clinic with complaints of significant daytime drowsiness. He can barely keep his eyes open in the clinic today
• Client's current pain level is a 4 out of 10. He says, between nods, that his pain has been significantly more manageable over the past month but he cannot seem to stay awake so his function has decreased overall. The appointment is a wash do to his current condition

Decision Point Three

Select what the PMHNP should do next:

Reduce Neurontin dose to 1,500 mg daily in divided doses and add -on Celexa (citalopram) 20 mg daily increasing to 40 mg daily after 1 week

Guidance to Student

Neurontin can have significant drowsiness and somnolence at higher doses. He was experiencing daytime drowsiness when his dose was 300 mg at bedtime. An increase in dose will only intensify this effect. The best way discontinue most medications with effects on the CNS is through dose de-escalation strategies. This helps avoid “withdrawal” symptoms. Both options that offer dose reductions and discontinuation/starting a new therapy or add-on therapy are great strategies to help reduce adverse side effects and further reduce pain. The addition of a stimulant is never good practice. Adderall is a schedule II and has significant addictive (both physical and psychological dependence) properties. This is one of those cases where the addition of a medication to control side effects is not in the best interest of the client.

Start Over

Continue with same dose of Neurontin. Add-on Adderall (amphetamine and dextroamphetamine) XR 5 mg orally in the MORNING

Guidance to Student

Neurontin can have significant drowsiness and somnolence at higher doses. He was experiencing daytime drowsiness when his dose was 300 mg at bedtime. An increase in dose will only intensify this effect. The best way discontinue most medications with effects on the CNS is through dose de-escalation strategies. This helps avoid “withdrawal” symptoms. Both options that offer dose reductions and discontinuation/starting a new therapy or add-on therapy are great strategies to help reduce adverse side effects and further reduce pain. The addition of a stimulant is never good practice. Adderall is a schedule II and has significant addictive (both physical and psychological dependence) properties. This is one of those cases where the addition of a medication to control side effects is not in the best interest of the client.

Start Over

Reduce Neurontin dose by 300 mg weekly until discontinued. Begin Celexa 20 mg orally in the MORNING and titrate up to a max of 40 mg daily after 1 week

Guidance to Student

Neurontin can have significant drowsiness and somnolence at higher doses. He was experiencing daytime drowsiness when his dose was 300 mg at bedtime. An increase in dose will only intensify this effect. The best way discontinue most medications with effects on the CNS is through dose de-escalation strategies. This helps avoid “withdrawal” symptoms. Both options that offer dose reductions and discontinuation/starting a new therapy or add-on therapy are great strategies to help reduce adverse side effects and further reduce pain. The addition of a stimulant is never good practice. Adderall is a schedule II and has significant addictive (both physical and psychological dependence) properties. This is one of those cases where the addition of a medication to control side effects is not in the best interest of the client.

Start Over

Increase the Neurontin dose to 900 mg orally TID and add on Celexa 20 mg orally daily. Increase dose to a max of 40 mg daily

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client returns today even groggier than the last time but his pain is under better control with a current pain level of 5 out of 10
• Client is complaining of problems getting an erection but states “at least I am not in as much pain. I wish I wasn’t so tired all the time.” The lancinating pain down his right leg is less frequent and not as intense or of the same duration as it was on his last appointment. He doesn’t know if there is anything you can give him to wake him up. If it wasn’t for the grogginess, he thinks he could live with this pain level

Decision Point Three

Select what the PMHNP should do next:

Add on Nuvigil (armodafinil) 150 mg orally in the MORNING

Guidance to Student

The addition of a stimulant (Nuvigil) is never a good option in clients when the drowsiness is the result of a medication side effect. Only in select cases is this a good treatment modality. Since the Neurotin is the most likely cause of the grogginess/drowsiness, a reduction in dose is a good option to help with this side effect. Although Neurontin is markets for neuropathic pain, many clients will tell you that it doesn’t “seem” to work. The expectation of pain management must be laid out before treatment begins and that expectation must be a focus on reduction as opposed to elimination with an increase in daily function. When changing from one therapy to another within the same class (such as Celexa to Prozac), you can discontinue one medication and substitute with another at a higher than normal starting dose. This is an additional switching strategy as compared to a cross-taper (decrease dose of one medication as doses of the new medication are escalated). A valuable less at the close of this case is that sometimes there are no good options, just better versions of bad options. In any event, the one therapy that would not be considered a good therapeutic decision would be the addition of a stimulant to treat the side effect. The other two options could be equally efficacious depending on the client (interclient variability) and could therefore be good choices in this scenario.

Start Over

Reduce dose of Neurontin to 300 mg at bedtime over the next 3 weeks through dose de-escalation strategies. Change the Celexa 40 mg to Prozac (fluoxetine) 40 mg orally daily and escalate dose as needed for pain control by 20 mg once every 3 weeks to a max of 80 mg daily

Guidance to Student

The addition of a stimulant (Nuvigil) is never a good option in clients when the drowsiness is the result of a medication side effect. Only in select cases is this a good treatment modality. Since the Neurotin is the most likely cause of the grogginess/drowsiness, a reduction in dose is a good option to help with this side effect. Although Neurontin is markets for neuropathic pain, many clients will tell you that it doesn’t “seem” to work. The expectation of pain management must be laid out before treatment begins and that expectation must be a focus on reduction as opposed to elimination with an increase in daily function. When changing from one therapy to another within the same class (such as Celexa to Prozac), you can discontinue one medication and substitute with another at a higher than normal starting dose. This is an additional switching strategy as compared to a cross-taper (decrease dose of one medication as doses of the new medication are escalated). A valuable less at the close of this case is that sometimes there are no good options, just better versions of bad options. In any event, the one therapy that would not be considered a good therapeutic decision would be the addition of a stimulant to treat the side effect. The other two options could be equally efficacious depending on the client (interclient variability) and could therefore be good choices in this scenario.

Start Over

Discontinue the Celexa. Continue the Neurontin but reduce daily dose by 600 mg (reduce morning and afternoon dose to 600 mg and continue bedtime dose of 900 mg)

Guidance to Student

The addition of a stimulant (Nuvigil) is never a good option in clients when the drowsiness is the result of a medication side effect. Only in select cases is this a good treatment modality. Since the Neurotin is the most likely cause of the grogginess/drowsiness, a reduction in dose is a good option to help with this side effect. Although Neurontin is markets for neuropathic pain, many clients will tell you that it doesn’t “seem” to work. The expectation of pain management must be laid out before treatment begins and that expectation must be a focus on reduction as opposed to elimination with an increase in daily function. When changing from one therapy to another within the same class (such as Celexa to Prozac), you can discontinue one medication and substitute with another at a higher than normal starting dose. This is an additional switching strategy as compared to a cross-taper (decrease dose of one medication as doses of the new medication are escalated). A valuable less at the close of this case is that sometimes there are no good options, just better versions of bad options. In any event, the one therapy that would not be considered a good therapeutic decision would be the addition of a stimulant to treat the side effect. The other two options could be equally efficacious depending on the client (interclient variability) and could therefore be good choices in this scenario.

Start Over