Assessing and Treating a 43-Year-Old Caucasian with Reflex Sympathetic Dystrophy
Complex peripheral neuropathy disorder is a chronic pain syndrome usually on leg or arm that occurs as a result of stroke, heart attack, or self-injury. Complex neuropathic pain disorder also causes damage to the central and peripheral nervous system, which is composed of the spinal cord and brain, respectively. Hester’s study estimated that 20 % of the general population living with chronic pain disorder report insomnia related symptoms compared to 7.4 % of people living without chronic pain (Hester & Tang, 2008). Also, 90 % of people receiving treatment for chronic pain illness complain of sleep disorder. Studies on pharmaceutical drugs such as pregabalin, triazolam, and eszopiclone indicate improved sleep and chronic pain outcomes (Jank et al., 2017). Insomnia and mental disorders have a bidirectional relationship that necessitates concomitant treatment for both conditions to increase sustained response. Evidence on the treatment of co-morbid conditions suggests the likelihood of medication-induced insomnia. For instance, glucocorticoids, stimulants, opioids, diuretics, and antidepressants may precipitate insomnia(Krystal et., 2019).
Case Study
A 43-year-old white male initially presents to the initial appointment with hip pain and cramping of the right leg. The client complains of lack of sleep and low moods from time to time. He also mentions of previous assessment by a neurologist who diagnosed him with reflex sympathetic dystrophy. The client also referred to his family doctor’s suggestion to seek a further assessment from a psychiatrist. He also indicates previous use of hydrocodone medication, which he used sparingly owing to side effects of drowsiness and constipation. A mental evaluation by a psychiatric mental health nurse shows no sign of depression or suicide ideation. The mental health nurse diagnosed the client with complex neuropathic pain disorder. This paper aims to assess the case study, choose the appropriate selection of medications using research, and discuss ethical considerations.
Decision Point One
The selection includes Savella 12.5 oral once daily on day 1, followed by 12.5 mg B/D on days 2 and 3 followed by 25mg B/D on the day, followed by 25mg B/D on days 4-7, which is followed by 50mg B/D.As a mental health care practitioner treating the client with Savella 12.5 mg is the first choice at decision point one. Milnacipran (Savella) is a selective norepinephrine serotonin reuptake inhibitor. Savella has diminished affinity for cholinergic, adrenergic, and histaminergic receptors hence exhibits limited adverse effects in comparison with tricyclic antidepressants(English et al., 2010). The psychiatric health practitioner should administer Savella because of the first-line medication for neuropathic pain disorder. In comparison with other approved SNRIs such as duloxetine and venlafaxine, Savella exhibits fewer side effects with low plasma protein binding of 13%, allowing easy diffusion and distribution in the drug. Malciparan is also cost-effective and widely available (English et al., 2010). The results for decision one showed an expected treatment outcome expected with the administration of Savella. The client reported a significant reduction in pain to level four on a scale of 1-10, and therefore his level of ambulation improved. The palpitations, high blood pressure, and nausea are expected with the use of Savella hence similar symptoms of the drug side effects on the client (English et al., 2010).
Amitriptyline is a tricyclic antidepressant utilized for treating adult depression, insomnia, anxiety, and chronic pain disorder (Moore et al., 2015). It exhibits considerable adverse effects such as headache, dizziness, and constipation and hence not used as first-line treatment of depression. Amitriptyline is administered orally with an initial dose of 25mg /day with increments of 25mg for every 3-5 days and a maximum dose of 150 to 300mg based on efficacy and tolerance schedule (Moore et al., 2015). It is preferable to adjust the amitriptyline dosage at bedtime when the patient is stable. Also, to prevent relapse and withdrawal symptoms, it is preferable to continue dosage for three months (Moore et al., 2015). Amitriptyline should treat chronic pain mediated centrally and mood disorders in the client. The expected outcomes for treating the client with amitriptyline were similar to those of the client when he reported improved pain outcomes with nausea and insomnia.
Neurontin(Gabapentin) is an orally administered drug used in the treatment of chronic neuropathy disorder and also functions to release decreased amounts of serotonin, noradrenaline and dopamine (Rose & Kam,2002). Neurontin exhibits few side effects. The common side effects for neurotin include dizziness, drowsiness, and fatigue. In adults gabapentin is taken at bedtime with doses of 300mg on day one, followed by 300mg two times on day two, followed by 300mg three times on day three. The recommended dose for treating neuropathy pain syndrome is 300mg three times daily (Rose & Kam,2002). The mental health nurse administered neurotin to reduce chronic pain at the client’s hip. The client responded well with a start dose of 300mg at bedtime and reported a significant reduction of chronic pain. The expected treatment outcome of neurotin was similar to the symptoms described by the client hence improved pain and ambulation outcomes.
Decision Point 2
The present selection includes the continuation of savella at 25mg, starting with pregabalin at 50mg B/D and also starting with Zoloft at 50mg B/D. The use of 25mg of Savella instead of 50mg is appropriate because it reduces the cause of the adverse effects by prolonged use of SSNRIs and also to prevent relapse and withdrawal symptoms occasioned with the cessation of medication (English et al., 2010). Pharmaceutical companies recommend the withdrawal of SSNRIs after 14 days to prevent serotonin syndrome (English et al., 2010). The psychiatric health practitioner withdrew Savella when the client complained of palpitations and also when the blood pressure and pulse rate increased to 147/92 and 100, respectively.
Pregabalin is an analgesic drug that relieves pain by blocks voltage-gated calcium channels. Pregabalin is the first-line medication for the alleviation of neuropathy pain disorders (Verma et al., 2014). Pregabalin has high tolerability, cost-effective, and three times more potent than gabapentin (Verma et al., 2014). Also, pregabalin exhibits fewer adverse effects that occur in less than ten percent of populations experiencing chronic neuropathic pain disorder. Some of the side effects include dizziness, headache, and dry mouth. At the decision point, two pregabalin alleviates pain and improves the adherence of medication in case the client exhibits resistance to medication tolerance (Verma et al., 2014). The client’s report differed with the expectation of PMHN because of elevated pain levels. However, the client could still manage the pain after taking amitriptyline hence indicating effective synergistic interactions with pregabalin.
Sertraline is the first-line treatment for severe depression. The use of sertraline at decision point two is to increase the dopaminergic activity, which elevates the mood of the client (Lewis et al., 2019). Sertraline is classified as the newer class SSRIs that exhibit high tolerance compared to other TCA drugs. Sertraline also augments pregabalin since it quickly diffused and widely distributed (Lewis et al., 2019). At decision two, the mental health practitioner utilized sertraline to enhance the client’s mood outcomes of the patient. The results of decision two were similar to the expected outcome, whereby the client exhibited no signs of suicide ideation or mood disorder.
Decision Point 3
The present selections include the continuation of Savella at an increased dosage of 125mg at bedtime one hour earlier than before. The metal health practitioner increased the dosage for Savella extended release of the drug to relieve chronic pain at manageable levels for the patient to achieve ambulation. Also, the high dosage of the drug at night helps to prevent the effects of drowsiness during the day. The second selection includes reduced dosage levels for Elavil (Amitriptyline) at 75mg at bedtime to be titrated according to up to a maximum of 200mg according to the patient’s tolerability. The mental health practitioner also utilized the bio freeze roll on his right leg. The mental nurse also added Neurontin at 300mg dosage.
The purpose of reducing amitriptyline is to minimize the adverse effects and resistance to medication tolerance. The use of the bio freeze is to reduce the numbness of the leg due to centrally mediated neuropathy. The aim of utilizing Neurontin is to provide extended-release to increase the tolerability of the drug and bioavailability at night. The results of the patients differed with the expected treatment outcome. The client complained of increased pain levels and aching right leg. The difference in the expected outcomes and the results of the client is because of different drug interactions.Savella functions through inhibiting the uptake of serotonin and norepinephrine while amitriptyline functions by utilizing TCA pathway. Neurontin also functions to release small amounts of norepinephrine and serotonin which counteracts the uptake inhibition of Savella at the serotonergic noradrenergic pathway
Summary with Ethical Considerations
Complex neuropathy pain syndrome is a centrally mediated chronic pain that affects the body’s extremities, such as arms and legs. The majority of the population affected by chronic pain also claim to experience a lack of sleep. Some of the pharmaceutical drugs useful in mediating pain relief and sleep disorders include malciparan,pregabalin, eszopiclone, and gabapentin. Studies indicate the likelihood of induced insomnia as a result of treating underlying other underlying conditions. Additionally,psychiatric disorders are directly related to insomnia, and as such, treating both conditions can help reduce centrally mediated chronic pain, which is psychological.
The psychiatric facility attended 43 years caucasian old white man with a history of chronic hip pain. Pharmaceutical companies and healthcare should adhere to ethical principles, which include the protection of consumer rights through beneficence and maleficence (Gutheil, 2012). Beneficence refers to maximizing benefits while lowering risks associated with the prescription of medications, while maleficence is preventing harm to consumers through the reduction of adverse effects. Clinicians and doctors should also discuss with patients on possible drug interactions, which could pose harm to them. For instance, people with cardiac problems may risk acquiring serotonin syndrome arrhythmia. Also, drugs should be cost-effective for patients to prevent non-adherence of medications. Additionally, pharmaceutical companies should give full disclosure of drug safety and efficacy data to increase trust between drug consumers and doctors.
References
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Jank, R., Gallee, A., Boeckle, M., Fiegl, S., & Pieh, C. (2017). Chronic pain and sleep disorders in primary care. Pain research and treatment, 2017.
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry, 18(3), 337-352.
English, C., Rey, J. A., & Rufin, C. (2010). Milnacipran (Savella), a treatment option for fibromyalgia. Pharmacy and Therapeutics, 35(5), 261.
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).
Rose, M. A., & Kam, P. C. A. (2002). Gabapentin: pharmacology and its use in pain management. Anaesthesia, 57(5), 451-462.
Verma, V., Singh, N., & Singh Jaggi, A. (2014). Pregabalin in neuropathic pain: evidence and possible mechanisms. Current Neuropharmacology, 12(1), 44-56.
Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., & Gilbody, S. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomized trial. The Lancet Psychiatry, 6(11), 903-914.
Gutheil, T. G. (2012). Reflections on ethical issues in psychopharmacology: an American perspective. International journal of law and psychiatry, 35(5-6), 387-391.