Assessing and Treating Adults with Complex Regional Pain Disorder
Assessing and Treating Adults with Complex Regional Pain Disorder
Pain Disorder Complex regional pain disorder occurs in patients with a history of inherited complex neurological disease that is either subclinical or part of phenotypic characteristics. Complex neuropathy is also a chronic neurological disease that affects the limb characterized by motor, autonomic, and sensory impairment resulting from trauma or induced surgery. The management of patients suffering from neuropathy requires a recovery process that involves anaesthetists, orthopaedic surgeons, rehabilitation physicians, and rheumatologists. Peripheral neuropathy affects more than twenty million Americans with the identification of a hundred types of neuropathy disease. According to Baltenberger, neuropathy has a variety of etiologies with treatment regiments consisting of serotonin and norepinephrine (Baltenberger et al., 2015). This paper aims to review drug response and management case study, utilize the appropriate selection criteria, and discuss ethical implications for the research.
Case Study
A white male presents to the initial appointment with hip pain and complex regional pain disorder. Complex neuropathic pain disorder treatment includes the use of anti-inflammatory drugs consisting of antidepressants, analgesics, corticosteroids, and anesthetics. Also, the use of bisphosphonates and opioids has shown improved status for complex pain disorder. However, the long term use of opioids creates toxicity and tolerance and hence forms the third-line treatment for neurological pain disorders (Tran et al., 2010). The recent introduction of NaSSA, SNaRI, and NaSSA has reduced pain significantly for patients suffering from complex regional pain disorder.
Decision Point one
The options include Amitriptyline 25 mg initial dose at bedtime with effective dose of 150mg. Titrate upwards between (50-150 mg) when appropriate according to patient drug tolerance. Amitriptyline is an FDA approved drug for treating neuropathic pain and depression associated with drug resistance (Stahl, 2017). The first choice for a MHNP treating client would be Amitriptyline 25mg orally at bedtime because it is a recommended first treatment for neuropathic pain (Moore et al., 2015). Its mode of actions includes blocking the reuptake of serotonin and norepinephrine (Stahl, 2017). Therefore this drug is appropriate for treating the client. However, several studies indicate limited efficacy of Amitriptyline in neuropathic pain management (Moore et al., 2015). Additionally, Amitriptyline exhibits notable adverse effects such as constipation, sedative effect and cardiac arrhythmias in cases of drug overdose (Stahl, 2017). Amitriptyline is also known to cause withdrawal symptoms and as such tapering with gradual reduction may help to drug withdrawal. Therefore PMHNP should consider the adverse effects caused by the drug before prescribing medication. Also the mental health nurse should consider the adverse effects on drug adherence when prescribing medication to avoid withdraw symptoms in the patient.
The other available option is Gabapentin initial dose XL 300mg once daily with titration increments of 600mg when appropriate (Stahl, 2017). Gabapentin is an FDA approved drug initially used for treating epileptic patients has also proven to mediate neuropathic pain outcomes (Narain & Adcock, 2018). Gabapentin produces analgesic effects through high-affinity binding at the VGCC channels within the central and peripheral nervous system. The pharmacodynamics of Gabapentin includes modulation of calcium ion influx which inhibits nerve signal transmission to the brain. This medication is an appropriate prescription for the patient. However, several studies indicate limited efficacy of the drug for neuropathic pain treatment (Narain & Adcock, 2018). Additionally, reports indicate abuse of Gabapentin and are also associated with psychedelic and sedative effects. Therefore MHNPs should consider the adverse effects this drugs when deciding the treatment of neuropathic pain in psychiatric patients (Narain & Adcock, 2018).
The selection includes Savella 12.5mg per oral for day one, 12.5 mg for B/D on days two and three, 25mg B/D on days 4-7, and then followed by 50mg B/D. As a psychiatric health practitioner treating a client with Savella is the initial choice for decision point one. The adult dose is usually 50mg per oral two times in a day based on tolerability and efficacy schedule. Savella is a SSNRI and therefore blocks the reabsorption of norepinephrine and serotonin (Derry et al., 2012).
In this case, maintaining the initial required dosage for five days helps in evaluating the first response to treatment with Savella. The hip pain reduced significantly when the male patient-administered Savella. However, the male patient developed some bouts of swelling on his leg and also complained of nausea, lack of sleep and palpitations on his chest after two weeks of medication (Tran et al., 2010). The mental health doctor also observed high blood pressure and pulse rate. According to English and other authors, the adverse effects for Savella include palpitations, vomiting, increased heart rate and hypertension (English et al., 2010).
Decision Point 2
The reduction of the dosage after 25mg twice a day in the second week is to lower the symptoms associated with taking Savella. Since the patient needs to perform his daily activities without hindrance, it is only plausible to minimize the side effects while managing the pain at significant levels. While the blood pressure for the male patient reduces the pain significantly increase over time due to low drug, the client also does not experience palpitations and suicide ideation due to low drug dosage (Derry et al., 2012). However, due to the severe pain, the patient suffers psychologically.
Decision Point 3
The drug dosage decreases significantly to 25mg per oral, which is taken in the morning while 50mg administered at night. Lowering drug dosage in the day addresses the adverse effects caused by the drug. However, increasing the dosage at night lowers the pain on the patient’s hip hence reducing the adverse psychological effects of pain on the patient. A high dosage of Savella can lead to serotonin syndrome. Therefore manufacturers recommend drug withdrawal after 14 days (English et al., 2010).
Ethical considerations
The science of manufacturing drugs should be ethically commitment to its consumers. For instance, the efficacy of serotonin has always been questionable in that pharmaceutical companies might be deceiving the consumers on the safe use of SSRIs (Gutheil, 2012). The abuse of trust between the patients the doctors is implicit on dispensing the right information concerning safe use and prescription of drugs. Therefore pharmaceutical industries have the obligation for full disclosure of efficacy and safety data for the range of medicines available in the market. Physicians should also consider the no-harm principle and beneficence, whereby the benefits of a drug should outweigh the risks.
References
Baltenberger, E. P., Buterbaugh, W. M., Martin, B. S., & Thomas, C. J. (2015). Review of antidepressants in the treatment of neuropathic pain. Mental Health Clinician, 5(3), 123-133.
Derry, S., Gill, D., Phillips, T., & Moore, R. A. (2012). Milnacipran for neuropathic pain and fibromyalgia in adults. Cochrane Database of Systematic Reviews, (3).
English, C., Rey, J. A., & Rufin, C. (2010). Milnacipran (Savella), a treatment option for fibromyalgia. Pharmacy and Therapeutics, 35(5), 261.
Gutheil, T. G. (2012). Reflections on ethical issues in psychopharmacology: an American perspective. International journal of law and psychiatry, 35(5-6), 387-391.
Kamp, J., Van Velzen, M., Olofsen, E., Boon, M., Dahan, A., & Niesters, M. (2019). Pharmacokinetic and pharmacodynamic considerations for NMDA-receptor antagonist ketamine in the treatment of chronic neuropathic pain: an update of the most recent literature. Expert opinion on drug metabolism & toxicology, 15(12), 1033-1041.
Moore, R. A., Derry, S., Aldington, D., Cole, P., & Wiffen, P. J. (2015). Amitriptyline for neuropathic pain in adults. Cochrane Database of Systematic Reviews, (7).
Narain, T., & Adcock, L. (2018). Gabapentin for Adults with Neuropathic Pain: A Review of the Clinical Effectiveness.
Stahl, S. M. (2017). Essential Psychopharmacology Online. Retrieved October 7, 2019, from
Tran, D. Q., Duong, S., Bertini, P., & Finlayson, R. J. (2010). Treatment of complex regional pain syndrome: a review of the evidence. Canadian Journal of Anesthesia/Journal canadien d’anesthésie, 57(2), 149-166.