NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology

It is imperative to note that people experience pain differently, something that is caused by underlying factors such as ethnicity, age, and gender, to name a few. Psych mental health practitioners will encounter clients with complaints of pain. This pain negatively impacts their daily lifestyles. Furthermore, some of the pains that clients experience is different and unique due to individual factors like precipitating, intensity, and psychological factors, making it more challenging for practitioners to treat despite the existing pain medications and therapy. However, psych mental health practitioners must make a proper and accurate assessment and management of these pains.

This document analyzes a case scenario of a 43-year-old white male client experiencing right hip pain and, as a result, has a pair of crutches to help with ambulation. The client started having hip pains after a fall incident that occurred several years ago. The client has diagnoses of complex regional pain syndrome (CRPS), which neurologists also refers to as the reflex sympathetic dystrophy (RSD). The client’s family doctor thinks that his continued experience of pain is psychological as he is battling depression. The writer, as a practitioner, will assess the client’s pain, its source, and propose appropriate therapies that can be effective on him utilizing the decision tree. In addition, I will consider the legal and ethical implications attached to each of the proposed interventions.

Decision One

One of the components of the complex regional pain syndrome (CRPS) with my client is neuropathic pain. The mainstay therapies for this pain include antidepressants, tricyclic, carbamazepine, and gabapentin (Chung-Chieh Lo, Cavazos, and Burnett, 2017). After reading up the patient’s information, the practitioner decides to start the client on Milnacipran (Savella) 12.5 mg orally once daily on day one. On days two and three, the dosage would be 12.5 mg orally BID. The dosage on days four to seven would be 25 mg BID, followed by 50 mg BID after that. The reason for these decisions involves symptoms the client is displaying.

The client has diagnoses of CRPS relating to pain in the right hip joint. According to his family doctor, the client shows signs of depression, a factor that portrays the element of his pain is psychological. Savella is a serotonin and norepinephrine reuptake inhibitor (SNRI). The US Food and Drug Administration (FDA) government agency has approved Savella to treat fibromyalgia. Stahl (2014b) states that Savella is also useful in treating neuropathic pain or major depressive dis . The author states that the usual dosage for the medicine varies from 30-200 mg/day in 2 doses. From the findings by Stahl, the practitioner is sure that the decision to put the client on the Savella would help deal with the pain he was experiencing.

The other two options available include Amitriptyline 25 mg by mouth at night, then increase the dosage by 25mg weekly to a maximum dose of 200mg per day, or Neurontin 300mg by mouth at bedtime with weekly increases of 300 mg per day to a maximum of 2400 mg if needed. Although Amitriptyline is both a Tricyclic antidepressant (TCA) and an SNRI, the FDA approves it for treating depression; it can also be useful for treating fibromyalgia, chronic and nerve pains (Stahl 2014b). Amitriptyline has side effects of sedation and weight gain more than Savella’s. Neurontin has anticonvulsant properties and FDA approves gabapentin for the treatment of pain due to diabetic neuropathy and partial seizures, restless leg syndrome, (Stahl 2014b). According to Stahl (2014), one of the distinguishing factors of the Amitriptyline is that it is more effective when used as an adding agent than when administered alone.

It is important to remember that the goal of these treatment decisions is to help reduce the pain that the client is experiencing and eliminate his depressive state. Stabilizing his moods without there being future relapse would indicate that his depression has been dealt with. The client’s pain should decrease to a 5 out of 10 pain scale or lower. In any treatment intervention, the onset of the therapeutic actions of the medicine often delays, but there should be evidence of positive responses within 2-4 weeks into using it. Stahl (2014b) recommends that if this medication does not show its therapeutic response within 6-8 weeks, the practitioner should increase the dosage or change the medication altogether.

After weighing these options, the practitioner decisions on prescribing Savella to the client. The client returns in the next appointment ambulating without crutches but limping a little. The client reports decrease in pain, although the pain is more in the morning and subsides during the day. Client rates current pain 4/10. The client reports experiencing extended sweating spells that occur for no apparent reason has difficulty sleeping, reports nausea with his blood pressure and pulse readings is 147/92 and 110, respectively. He also states butterflies in his chest. From these symptoms, it is evident that though the client has a positive therapeutic response to his pain from Savella, the client is also experiencing the side effect of the medications that the practitioner needs to manage. Geisser et al. (2011), in their randomized control trials of the effectiveness of the Milnacipran monotherapy treatment, shows that 5% of the patients show visible side effects of the medication that include an increase in heart rate, nausea/vomiting, dry mouth, hyperhidrosis, hot flush, and constipation.

Decision Two

Though the client experience some side effects from the Savella, the practitioner decides to continue the client on the medication to reduce its side effect, the practitioner will lower the dose to 25 mg twice a day, a dosage that is still within the recommended dose limit. Reducing the dosage more will eliminate the side effect. The practitioner can achieve greater medication efficiency in controlling client pain if there is an increase in the dosage. However, this decision can be life-threatening should the client start developing cardiac complications. At this point, the risk versus the benefits of continuing with this medication comes into role.

The practitioner will decide this phase of the treatment after weighing the other options on the decision tree considering the risks versus negative. The available option the practitioner has in this treatment phase is discontinuing the Savella and starting the patient on Lyrica (pregabalin) 50 mg orally BID, or Zoloft (sertraline) 50 mg daily. The decision to eliminate Savella and starting the client on a new medication will not be the best approach as it is evident that the client has a positive therapeutic response to his pain from Savella, a chronic pain that the patient has been experiencing for years, with no affirmative relief from previous medications. The second available option is Zoloft, which is a selective serotonin reuptake inhibitor (SSRI). Zoloft treats depression and minor health dis s except for neuropathic/chronic pain and fibromyalgia (Stahl, 2014b). FDA approves Lyrica to treat fibromyalgia, neuropathic pain, and postherpetic neuralgia, but it has a sedating side effect. Therefore, the practitioner will not incorporate it into the treatment plan for the client that is prone to falls.

At this junction, the practitioner’s goal is to balance managing chronic pain, depression, and eliminating the side effects that the client is portraying when he takes Savella. This knowledge encourages the practitioner that the decision of sticking with Savella will help in the further improvement of the client’s condition. Expectations: client will improve more from his symptoms. Outcome: the client returns to the clinic 4 weeks after taking the second decision of continuing with lower dosage of Savella. The client ambulates with his crutches, reports not feeling well, pain rating being 7 out of 10, and lack of enough sleep, with blood pressure and heart rate readings of 124/85 and 87, respectively. There was clear evidence that the client was experiencing an increase in pain and a relief of Savella’s side effects. The provider will address the chronic pain he is experiencing.

Decision Three

The client did not show symptoms of adverse effects at 25 mg twice a day. The practitioner thought that making a compromise with the new dosage would help treat his chronic pain condition. However, the practitioner was ready to put him back on the 25 mg dosage if he showed the reoccurrence of these unwanted side effects during the next visit. For the first time in his treatment history, the patient reports that Savella has a positive impact and responded well in eliminating the pain he has been experiencing for years, making it impractical to drop it.

The practitioner is confident that the client will positively respond if the provider changes his Savella to 25 mg in the morning and 50 mg orally at bedtime. The expected goal/outcome of this decision is adequate pain management with minimal to no side effects of the medication.

Ethical Considerations:

The treatment plan that I have for my client is bound to be affected by ethics. Thus, I must make the necessary considerations. My first step is conducting a thorough discussion of the treatment plan with my client. These discussions with the client will point out the merits and demerits of prescribing, using and increasing the Savella. These conversations present to the practitioner the chance to empower the client as part of the decision-making process and provide all the necessary information as relates to the treatment intervention. These engagements give the client the chance to ask for any clarification as the need may arise during the treatment. The client is 43 years old means that the client is in an excellent position to make and give legal consent for his treatment. The practitioner will document all decisions in the patient’s chart.

The general principle in medical practice is the phase both the practitioner and the patient agree on when switching to an entirely new medication or augmenting the current treatment. This principle comes to play when the initial treatment intervention has no significant impact on relieving the patient’s symptoms. However, the practitioner can augment the initial treatment with a second treatment when the patient shows a partial response to the initial treatment (Stahl, 2013).

Vitiello (2012) states that in psychiatry, there tends to be a recurrence or persistence of dis s, and thus practitioners need to adopt long-term treatment interventions that raise concerns among practitioners regarding the persistence of their therapeutic effect. In this scenario, the client is suffering from complex neuropathic pain syndrome, a condition that might never lead to typical pain medication management (Laureate, 2016a). Making the patient understand this from the onset of the treatment is very important.

The next step is making the patient understand that his condition and its complexity means that there must always be a certain level of pain the client will always experience on daily basis. Establishing this fact at the initial onset of treatment and assuring client the practitioner will do the best within the practitioner’s capability will establish the foundation for trust and development of rapport between the practitioner and the client. Such information is inclined to ensuring that the patient is fully aware of the chosen treatment intervention for his condition, as against promising full recovery and not meeting up with the expectations.

Conclusion

In conclusion, the information in this document shows how debilitating it is when dealing with individuals with chronic pain, especially the one that has adverse effects on the patients’ daily activities. Practitioners are always required to prescribe medications using proper evidence. It is necessary to do the prescription so that it becomes easier for both the patients and practitioners to manage the pain without using the word “medication seekers.” In my case scenario, my patient was diagnosed with CRPS. From the evidence provided by CT scans, x-rays, and MRI tests done on the patient, it was evident that the 75% source of his pain was from the torn cartilage surrounding his hip joint. The Savella that the practitioner prescribed to him was effective in managing the chronic pain he felt in addition to reducing some of its side effects.

According to Laureate (2016a), physicians dealing with patients who are suffering from chronic pain need to be aware that the treatment plan that they undertake needs to allows patients to continue with their normal lives with some minimum of discomfort as possible. Laureate (2016a) continues to advise that the treatment intervention needs to incorporate not only pain medication but also chiropractic care, physical therapy, heat, and massage therapy as part of a complex regime when dealing with the condition.

References:

Chung-Chieh Lo, J., Cavazos, J., & Burnett, C. (2017). Management of complex regional pain yndrome. Baylor University Medical Center Proceedings, 30(3), 286-288.

Geisser, M. E., Palmer, R. H., Gendreau, R. M., Wang, Y., &Clauw, D. J. (2011). A Pooled Analysis of Two Randomized, Double-Blind, Placebo-Controlled Trials of Milnacipran Monotherapy in the Treatment of Fibromyalgia. Pain Practice, 11(2), 120-131. doi:10.1111/j.1533-2500.2010.00403.x

Laureate Education (2016a). Case study: A Caucasian man with hip pain [Interactive media file]. Baltimore, MD: Author

Lovatt, P. (2010). Pharmacology. Drug profile: tramadol for moderate to severe pain. Nurse Prescribing, 8(8), 388-391.

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

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

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

Press.

Vitiello, B. (2012). Principles in using psychotropic medication in children and adolescents.

IACAPAP e-textbook of child and adolescent mental health. Geneva, Switzerland: International Association for Child and Adolescent Psychiatry and Allied Professions. Retrieved from http://iacapap. org/wp-content/uploads/A.