Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder

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.”

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. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. 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. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. 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 Essay – Complex Regional Pain Disorder.
Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)
Decision Point One
Select what the PMHNP should do:

Savella 12.5 mg orally 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
Savella 12.5 mg orally 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 thereafter

50 mg BID thereafter

Amitriptyline 25 mg po QHS and titrate upward weekly by 25
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day

mg to a max dose of 200 mg per day

Neurontin 300 mg po BEDTIME with weekly increases of 300
Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed

mg per day to a max of 2400 mg if needed

The Assignment
Examine Case Study: A Caucasian Man With Hip Pain. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.
At each decision point stop to complete the following:
• Decision #1
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.
• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Below is a simple paper for reference, the needs an introduction and a conclusion.

Assessing and Treating Clients with Anxiety Disorder
Introduction
Anxiety disorders refer to a syndrome of mental disorders typified by substantial feelings of fear and anxiety. The anxiety and fears may cause physical symptoms like shakiness and rapid heart rate. Various forms of anxiety disorders include panic disorder, social anxiety disorder, agoraphobia, generalized anxiety disorder, among other disorders (Locke et al, 2015). The focus of this assignment is on a 46-year-old male who presented with symptoms of anxiety disorder that included shortness of breath, chest tightness as well as a feeling of impending doom. Lab results and EKG in the ER were normal which ruled out myocardial infarction. (HAM-A) scale yielded a score of 26 and a diagnosis of generalized anxiety disorder (GAD) was made. Following the diagnosis, three decisions will be made about the treatment regimen for the client. After making each decision, a rationale supported by clinical evidence and patient data will be provided. Moreover, after making each decision, factors likely to impact the pharmacokinetic and pharmacodynamic processes for the client will be considered when making decisions. Finally, ethical considerations likely to impact the client’s treatment plan will be discussed. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.
Decision # 1
The first decision for this client would be to start Zoloft 50 mg orally daily. This decision was made because Zoloft is selective serotonin reuptake inhibitors (SSRIs) and SSRIs are the recommended first-line treatments for anxiety disorders. SSRIs work by increasing the amount of serotonin within the brain; serotonin is a brain chemical that is very important for mood regulation (Locher et al, 2017). Accordingly, SSRIs such as Zoloft work by hindering serotonin reuptake in the brain and therefore increases the level of serotonin in the brain; availability of serotonin thus helps in regulating moods and hence improves anxiety symptoms. In addition, evidence shows that Zoloft is effective in improving anxiety symptoms manifest in GAD; this is because anxiety depletes serotonin in the brain and this is addressed by an SSRI such as Zoloft which replaces the depleted serotonin in the brain (Patel et al, 2018).
Imipramine (Tofranil) at 25 mg BID and Buspirone (Buspar) 10 mg orally twice daily choices were not selected because evidence shows that SSRIs as the first-line medications in the treatment of anxiety disorders. Both Imipramine and Buspirone takes about 2 – 4 weeks before making any improvement on the symptoms. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. Moreover, these two medications are not well tolerated as Zoloft and also have numerous side effects when compared to Zoloft.
By selecting the decision to begin Zoloft 50 mg orally daily, it was expected that symptoms of generalized anxiety disorder manifested by the client would gradually clear away. It was also expected that the HAM-A score for the client would significantly reduce indicating an improvement of the anxiety symptoms. This is because evidence shows that Zoloft as an SSRI is effective in the treatment of GAD symptoms (Patel et al, 2018). In addition, it was hoped that the client would have minimal side effects and tolerate the medication because evidence shows that SSRIs have minimal side effects are well tolerated (Clevenger et al, 2018)
There was no significant difference between the actual outcome of the decision and the expected results because when the client came for review the anxiety symptoms had significantly reduced and manifested by the client not having symptoms such as shortness of breath or chest tightness. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. Moreover, the client reported that he had stopped worrying about his job and also the HAM-A score dropped from 28 to 18 which shows that the client was responding to treatment, although partially.
Decision # 2
The chosen second decision is to increase the client’s Zoloft dose to 75 mg orally daily. This decision was selected because the client’s HAM-A score dropped from 28 to 18 which indicated a partial response to treatment which shows that the client is responding to the treatment. Therefore, the increase of the dose from 50 mg to 75mg will further increase the availability of serotonin within the brain and thus further improve the anxiety symptoms for the client. Evidence supports the gradual increase of the SSRIs dosage if the clients are not satisfactorily responsive to the treatment (Jakubovski et al, 2016). This decision was also based on the fact that the client seems to be tolerating Zoloft medication well and without any side effect.
The option to increase Zoloft to 100mg was not chosen because dosage increase and titration are supposed to be gradual to ensure the client continues to tolerate the medication well with minimal side effects. On the other hand, the option to have the client continue with the same dose and have him reassessed after four weeks was not selected because the client’s response is partial and therefore it is essential to increase the dosage to ensure complete response to the medication (Jakubovski et al, 2016).
By choosing this decision, the expectation was that the anxiety symptoms would continue reducing and this would be indicated by a significantly reduced HAM-A score. There was no noticeable difference between the actual decision and the expected decision because on coming to the clinic the client’s anxiety symptoms had further reduced as indicated by the further reduction of the HAM-A score. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.
Decision # 3
For the third decision, the decision will be to maintain the client on the current dose of Zoloft 75 mg orally daily. This decision was made because with the current regime the client is showing improvement of the anxiety symptoms as such as tightness in the chest, difficulty breathing or the feeling that something terrible is about to happen and also the HAM-A score indicated significant reduction with the current dose. This means that the client is responding to the current medication and dose adequately. In addition, with the current dose, the client is not experiencing any side effects and he is tolerating the medication very well. Evidence and clinical guidelines recommend titration of medications according to the response of the client; in this case, the client is responding very well and hence there is no need to titrate medication any further (Jakobsen et al, 2017).
The option to either augment the current treatment with Buspar or the option of increasing the current dose of Zoloft to 100mg was not chosen since the client is showing a satisfactory response to the current dose of Zoloft 75 mg.
By selecting this decision, the expectation is that the client will show a complete response to the treatment where the client will report complete clearance of the symptoms and the HAM-A score will significantly reduce.
Impact of Ethical Considerations on the Treatment Plan
For this client, the ethical considerations will encompass informed consent, confidentiality, and autonomy. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. First, it is essential to seek informed consent from the client to ensure that the client has full information about the recommended treatment before he consents to the treatment (Millum, 2013). Secondly, the confidentiality of the client should be respected. This means that any information and the client’s treatment regimen should not be disclosed to any other party without the consent of the client. Lastly, the client’s autonomy should be respected where the client should not be forced or coerced to have any treatment; he should decide to accept or refuse the treatment. Any decision the client makes about the treatment should be respected (Millum, 2013).

Conclusion
The selected first decision is to begin Zoloft 50 mg orally daily. The rationale for selecting this decision is because SSRIs such as Zoloft are the first treatment choice for anxiety disorders and evidence shows that the medication is effective in treating anxiety symptoms. There was significant improvement with this decision. The second decision was to increase the dose to the Zoloft dose to 75 mg orally daily. This decision was made because the client was showing partial response as indicated by the HAM-A score and hence increasing the dose would facilitate a satisfactory response. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. The third decision is to maintain the current dose because the client is showing a satisfactory response to the treatment as indicated by the reduced HAM-A score and reduced symptoms as per the subjective data. Finally, the ethical considerations that should be considered include autonomy, confidentiality, and informed consent.

References
Clevenger S, Devvrat M, Dang J, Vanle B & William I. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Ther Adv Psychopharmacology. 8(1): 49–58.
Jakubovski E, Anjali V, Freemantle N, Taylr M & Bloch M. (2016). Systematic Review and Meta-Analysis: Dose-Response Relationship of Selective-Serotonin Reuptake Inhibitors in Major Depressive Disorder. Am J Psychiatry. 173(2): 174–183.
Jakobsen J, Kumar K, Timm A, Gluud C, Ebert E et al. (2017). Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis. BMC Psychiatry. 17(58).
Locke A, Faafp M, Krist N & Shultz C. (2015). Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. Am Fam Physician. 1;91(9),617-624. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.
Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I. & Kossowsky, J. (2017).
Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry. 74(10), 1011–1020.
Millum J. (2013). Introduction: Case Studies in the Ethics of Mental Health Research. J Nerv Ment Dis. 200(3), 230–235.
Patel D, Feucht C, Brown K & Ramsay J. (2018). Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners. Transl Pediatr. 7(1): 23–35. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Introduction

Complex regional pain syndrome is a debilitating condition that affects the limbs and is likely to be induced by trauma or surgery. Apart from complicating the entire recovery process, it tends to impair the psychosocial and functional well-being of an individual. It’s characterized by vasomotor abnormalities, hyperalgesia, , and allodynia. The pain that a patient experiences is often disproportionate to the degree of tissue injury that occurs and may persist beyond the anticipated period required for tissue healing (Stanton-Hicks, 2018). Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. The major goals of therapy are: to ensure pain relief, to restore functioning and psychologically stabilize a patient.

Many drugs are often used in pain management to improve functional status. However, mental health practitioners should ensure that the choice of drugs promotes compliance and have fewer side effects. This paper discusses the management of a 43-year-old who presented with complex regional pain disorder. In his management, three decisions are to be made regarding the most effective medications, expected outcomes, , and actual outcomes. A description of the ethical issues when engaging clients with complex regional pain disorder and their families will also be provided.

Decision #1

Decision Selected

Start Savella 12.5 mg orally 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 thereafter

Reasons for Selecting This Decision

Patients with regional pain disorder have a low pain threshold which may be caused by changes in the central nervous system. These changes cause a patient to be more sensitive to pain due to wrong neurotransmitter levels in the brain. As selective norepinephrine and serotonin reuptake inhibitor (SNRI) that has an equal effect on both neurotransmitters, Savella is an NMDA antagonist that works on nerve endings to produce analgesic effects (Stanton-Hicks, 2018). It promotes the reuptake of the neurotransmitters in the brain thus easing the pain, reducing fatigue and promoting memory. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Amitriptyline, a tricyclic antidepressant that has proven to be effective in the management of neuropathic pain off label could also be a good option (Benzon, Liu & Buvanendran, 2016). However, it has a side effect of drowsiness and dizziness that the client initially stated clearly that he didn’t like. Therefore, prescribing this medication for a start might only trigger non-compliance.

Neurontin, also referred to as gabapentin, is an anti-epileptic / anticonvulsant, is used in for nerve pain relief. Therefore, it could also be a good option for the management of this patient. However, it also has the side effects of drowsiness and in high doses, results in extreme somnolence and drowsiness (Finnerup, et al., 2015). Since the patient expressed his dislike for the side effect of feeling sleepy from the start, prescribing it would only lead to non-compliance. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Expected Outcome

By starting the patient on Savella, it was expected that his pain will significantly reduce to 3 on a scale of 1-10 and be able to walk without support. It was also expected that he would resume to a normal work routine and be able to perform activities of daily life will very minimal or no assistance (Stanton-Hicks, 2018). His mood would be happy or joyous and he would have a stable effect.

Difference between Expected outcome and Actual Outcome

The client returned to the clinic after four weeks walking without crutches but minimally limping. He reported that the main was more manageable and he was able to walk around with no assistance. However, he noted that the pain was worse during the morning hours and got better as the day progressed. On a scale of 1-10, his pain was reportedly 4 but admitted that he could be able to live and tolerate a level of 3. The client also noted that he occasionally experienced bouts of sweating that he couldn’t explain with some sleep disturbance. An assessment revealed that he had a blood pressure of 147/92mmhg and a pulse of 110 beats/ min. He was still future-oriented and denied homicidal/suicidal ideation. One of the major side effects of Savella is heart palpitations (Finnerup, et al., 2015). It is for this reason that the patient experienced bouts of sweating, sleep disturbance and had a high blood pressure. Reducing the dosage can help to minimize this side effect.

Decision #2

Decision Selected

Continue With the Current medication but reduce the dosage to 25 mg twice daily

Reasons for Selecting This Decision

During the first visit, the client reported that he experienced unexplained symptoms of bouts of sweats, sleep disturbance and he had a high blood pressure. These symptoms were the resultant side effects of Savella. According to Stanton-Hicks (2018), by reducing the dosage of Savella, its side effects are also minimized resulting in more improved health outcomes. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Expected Outcome

By reducing the dosage of Savella, it was expected that the patient’spatient’s pain level will also be minimized, he will still be able to perform most activities of daily life with very minimal support and that his social, professional and physical functioning will also improve (Benzon, Liu & Buvanendran, 2016). Above all, the dosage reduction aimed to ensure that the side effects weren’t adverse and that he would live a near normal life.

Difference between Expected outcome and Actual Outcome

After four weeks, the patient returned to the clinic walking with crutches. He stated that the pain was 7 out of 10 and admitted that he didn’t feel good as compared to the previous month. He frequently woke up at night due to pain on his right leg and foot. He, however,, however, denied homicidal and suicidal ideation. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. His blood pressure was 124/85 and pulse rate was 87 beats/ min. He looked sad and discouraged by the slip in the management of his pain. The decision to lower the dosage of Savella in managing the client’s initial side effects to the dug inspired this difference at the cost of uncontrolled pain (Murnion, 2018).

Decision #3

Decision Selected

Change Savella to 25 mg orally in the morning and 50 mg orally at bedtime

Reasons for Selecting This Decision

During the client’s first visit to the clinic, he clearly stated that the medication Savella was effective for his pain management but the pain worsened early morning and improved as the day progressed. As supported by Finnerup, et al., (2015), starting with dose reductions during parts of the day when pain is mostly under control is a good idea that can still contribute to the achievement of therapeutic goals.

Expected Outcome

It was expected that the patient’s pain will effectively be managed to a level of 3 on a scale of 1-10. He will also be able to walk and perform most of his activities of daily life with minimal or no support. As supported by Stanton-Hicks (2018), the patient would no longer experience sleep disturbance and that his affect and mood will gradually be stable. With regards to the drugs side effects, it was expected that the patient’s blood pressure and pulse rate will gradually normalize and that he will no longer experience palpitations or unexplained bouts of sweating.

Difference between Expected outcome and Actual Outcome

The client returned to the clinic after four weeks walking without crutches. He reported his pain level to be 4 on a scale of 1-10 and expressed how he was grateful but would love it to reduce to 3 since it’s the best level that he could easily manage. His blood pressure was 120/84mmhg and pulse rate 86beats/min. He denied suicidal/homicidal ideation and was still future-oriented. At this point, it will be necessary to explain to the client that he has a neuropathic pain syndrome which probably may never respond to pain medications. Therefore, it would be practical to collaboratively set realistic expectations and make the patient understand that he will frequently experience some pain level daily (Benzon, Liu & Buvanendran, 2016). What matters most is to manage it in such a manner that permits him to effectively perform activities of daily life. The patient should also be educated that medications are not a final solution but a part of a complex regimen of chiropractic care, physical therapy, massage and heat therapy (Murnion, 2018).

How Ethical Considerations Might Impact Treatment plan and Communication With Clients

The most significant ethical consideration for this client is that of informed consent, autonomy, beneficence, and non-maleficence. Before changing any treatments, it is important to seek informed consent just to ensure that he is fully aware of what he is consenting to, possible dangers and outcomes involved (Millum, 2013). Secondly, any treatment options considered should only be for the patient’s best interest/benefit and have fewer side effects. This will guarantee that all treatment options cause no harm. Lastly, the client’s autonomy should also be respected such that, he shouldn’t be forced or coerced to agree to a treatment modality that his conscience is against (Millum, 2013). Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Conclusion

The management of regional pain disorder in adults requires a careful and thorough assessment of a patients needs which will help to decide the best medications to use as part of a broader regimen of heat and massage therapy, chiropractic care and physical therapy. Savella, an SNRI was the best medication choice for the management of this patient’s pain. It has minimal side effects with the major side effect being heart palpitations which can be managed with dosage reduction. Although in patients with regional pain disorder dose reduction comes with the cost of uncontrolled pain, string reductions during the parts of a day when pain is mostly under control helphelp to achieve the desired therapeutic goals as it was in this case.

References

Benzon, H. T., Liu, S. S., & Buvanendran, A. (2016). Evolving definitions and pharmacologic management of complex regional pain syndrome.

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 Essay – Complex Regional Pain Disorder.

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. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.