Complex Regional Pain Disorder
White Male With Hip Pain

White male on crutches

 

Decision Point One


Savella 12.5 mg 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

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what you should do next:


Continue with current medication but lower dose to 25 mg twice a day

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client comes to office today with use of crutches. He states that his current pain is a 7 out of 10. “I do not feel as good as I did last month.”
  • Client states that he is sleeping at night but woken frequently from pain down his right leg and into his foot
  • Client's blood pressure and heart rate recorded today are 124/85 and 87 respectively. He denies any heart palpitations today
  • Client denies suicidal/homicidal ideation but he is discouraged about the recent slip in his pain management and looks sad
Decision Point Three
Select what you should do next:


Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME
Guidance to Student

The client has a complex neuropathic pain syndrome that may never respond to pain medication. Once that is understood, the next task is to explain to the client that pain level expectations need to be realistic in nature and understand that he will always have some level of pain on a daily basis. The key is to manage it in a manner that allows him to continue his activities of daily living with as little discomfort as possible. Next, it is important to explain that medications are never the final answer but a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is a SNRI that also possesses NMDA antagonist activity which helps in producing analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in therapy for this gentleman. Tramadol is never a good option along with other opioid type analgesics. Agonists at the Mu receptors does not provide adequate pain control in these types of neuropathic pain syndromes and therefore is never a good idea. It also has addictive properties which can lead to secondary drug abuse. Reductions in Savella can help control side effects but at a cost of uncontrolled pain. It is always a good idea to start with dose reductions during parts of the day that pain is most under control. The addition of Celexa with Savella needs to be done cautiously. Both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome.


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Discontinue Savella and start tramadol 50 mg orally every 6 hours. Client may increase to 100 mg orally every 6 hours if pain is not adequately controlled
Guidance to Student

The client has a complex neuropathic pain syndrome that may never respond to pain medication. Once that is understood, the next task is to explain to the client that pain level expectations need to be realistic in nature and understand that he will always have some level of pain on a daily basis. The key is to manage it in a manner that allows him to continue his activities of daily living with as little discomfort as possible. Next, it is important to explain that medications are never the final answer but a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is a SNRI that also possesses NMDA antagonist activity which helps in producing analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in therapy for this gentleman. Tramadol is never a good option along with other opioid type analgesics. Agonists at the Mu receptors does not provide adequate pain control in these types of neuropathic pain syndromes and therefore is never a good idea. It also has addictive properties which can lead to secondary drug abuse. Reductions in Savella can help control side effects but at a cost of uncontrolled pain. It is always a good idea to start with dose reductions during parts of the day that pain is most under control. The addition of Celexa with Savella needs to be done cautiously. Both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome.


Reduce Savella to 12.5 mg orally BID and start Celexa (citalopram) 10 mg orally daily
Guidance to Student

The client has a complex neuropathic pain syndrome that may never respond to pain medication. Once that is understood, the next task is to explain to the client that pain level expectations need to be realistic in nature and understand that he will always have some level of pain on a daily basis. The key is to manage it in a manner that allows him to continue his activities of daily living with as little discomfort as possible. Next, it is important to explain that medications are never the final answer but a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is a SNRI that also possesses NMDA antagonist activity which helps in producing analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in therapy for this gentleman. Tramadol is never a good option along with other opioid type analgesics. Agonists at the Mu receptors does not provide adequate pain control in these types of neuropathic pain syndromes and therefore is never a good idea. It also has addictive properties which can lead to secondary drug abuse. Reductions in Savella can help control side effects but at a cost of uncontrolled pain. It is always a good idea to start with dose reductions during parts of the day that pain is most under control. The addition of Celexa with Savella needs to be done cautiously. Both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome.


Discontinue Savella and start Lyrica (pregabalin) 50 mg orally BID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client returns today with his assistive devices in place. He is discouraged. The Lyrica doesn’t seem to be working and he ran out of medication 7 days ago. The pharmacy would not refill it early
  • Client's pain level is currently a 9 out of 10 and he can barely sit in the chair. His right leg is throbbing with electrical-like feeling down to his toes
  • Client's recorded blood pressure is 135/90 and heart rate is 105 beats per minute. Current respiratory rate is 22 breaths/minute
  • Client is very discouraged and says he doesn’t know if he has any fight left in him at this point
Decision Point Three
Select what you should do next:


Discontinue Lyrica. Start Elavil (amitriptyline) 25 mg orally at BEDTIME and increase at weekly intervals by 25 mg to a max of 200 mg. Submit an e-prescription to his pharmacy for a quantity of 60 of the 25 mg tabs and provide a written dose escalation scale for him to follow. Ask him to make a follow-up phone call to the office in 7 days
Guidance to Student

From the above description provided, it sounds as if the client may be experiencing some depressive symptomatology. In cases of depression, we worry about suicide ideation. You should evaluate this with the client. With this in mind, amitriptyline in overdoses can cause fatal cardiac arrhythmias and should never be dispensed in quantities larger than a 7-day supply to clients in this state. Some would argue that the class (TCA) should not be used at all in this client (even attempting to be cautious and dispensing 7 days at a time could result in the client stock-piling the pills for a fatal overdose).

Although not all SSRIs are FDA approved or indicated for treatment of neuropathic pain, they do have a role to play due to their activity within the central nervous system and the their effects on the serotonergic pathway. Since this client is clearly showing signs of dependence (he used a 30 day supply of medication in 21 days) and possible abuse; continuation of Lyrica, a DEA schedule V medication, would not be in the best interest of the client and should, therefore, be discontinued immediately.


Discontinue Lyrica and start Zoloft (sertraline) 100 mg orally at BEDTIME
Guidance to Student

From the above description provided, it sounds as if the client may be experiencing some depressive symptomatology. In cases of depression, we worry about suicide ideation. You should evaluate this with the client. With this in mind, amitriptyline in overdoses can cause fatal cardiac arrhythmias and should never be dispensed in quantities larger than a 7-day supply to clients in this state. Some would argue that the class (TCA) should not be used at all in this client (even attempting to be cautious and dispensing 7 days at a time could result in the client stock-piling the pills for a fatal overdose).

Although not all SSRIs are FDA approved or indicated for treatment of neuropathic pain, they do have a role to play due to their activity within the central nervous system and the their effects on the serotonergic pathway. Since this client is clearly showing signs of dependence (he used a 30 day supply of medication in 21 days) and possible abuse; continuation of Lyrica, a DEA schedule V medication, would not be in the best interest of the client and should, therefore, be discontinued immediately.


Increase the Lyrica to 100 mg orally TID
Guidance to Student

From the above description provided, it sounds as if the client may be experiencing some depressive symptomatology. In cases of depression, we worry about suicide ideation. You should evaluate this with the client. With this in mind, amitriptyline in overdoses can cause fatal cardiac arrhythmias and should never be dispensed in quantities larger than a 7-day supply to clients in this state. Some would argue that the class (TCA) should not be used at all in this client (even attempting to be cautious and dispensing 7 days at a time could result in the client stock-piling the pills for a fatal overdose).

Although not all SSRIs are FDA approved or indicated for treatment of neuropathic pain, they do have a role to play due to their activity within the central nervous system and the their effects on the serotonergic pathway. Since this client is clearly showing signs of dependence (he used a 30 day supply of medication in 21 days) and possible abuse; continuation of Lyrica, a DEA schedule V medication, would not be in the best interest of the client and should, therefore, be discontinued immediately.


Discontinue Savella and start Zoloft (sertraline) 50 mg daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client returns to the office with his assistive devices. His pain level today is a 7 out of 10. His pain is normally 9 to 10 out of 10. This therapy has provided some pain relief but not as much as he would like. He tells you his expectation is for a pain level of 3 out of 10 or lower. You have explained to him that “no pain” is not an attainable expectation
  • Client agrees to start physical therapy concurrently with medication. He tells you that as long as his pain is being managed he will comply
  • Client did notice that when he takes his Zoloft, his anxiety would amp up when he started taking it so he has been using it sporadically throughout the month. He brought his prescription bottle to the office and you count 12 tablets left in the bottle
  • Client's blood pressure is currently 118/74 and heart rate is 76 beats/minute. Respiratory rate is 17 breaths/minute. His right leg continues to have electrical-like pain running into his toes but he states that it is less severe than the last time you saw him
  • Client also tells you that he has not been able to get an erection in over a week and it is bothersome
Decision Point Three
Select what you should do next:


Counsel client on the anxiety inducing effects of SSRI’s and their transient nature. Encourage him to continue taking the Zoloft at 50 mg po QDAY
Guidance to Student

Anxiety induction is one of the most bothersome side effects of an SSRI in the initiation phases of therapy. Some clients, without proper counseling, will stop taking the medication because they perceive it as getting worse. Difficulty acquiring and maintaining an erection is another side effect with SSRI therapy that can be bothersome to male clients. Unfortunately, this side effect is not transient such as the anxiety. The usual course of action will include counseling and the addition of another medication (such as Wellbutrin) to help manage the sexual side effect. Another option is to discontinue the Zoloft and start a new medication but SSRI’s work well for neuropathic pain. In this situation, the addition of another medication to help manage this particular side effect would be prudent. Increasing the dose alone will do nothing to address the side effects and will only lead to non-compliance and a fractured therapeutic alliance with the client.


Increase the dose to 100 mg po qday and counsel client on the anxiety caused by SSRI’s and their transient effects. Encourage compliance with the medication daily as prescribed
Guidance to Student

Anxiety induction is one of the most bothersome side effects of an SSRI in the initiation phases of therapy. Some clients, without proper counseling, will stop taking the medication because they perceive it as getting worse. Difficulty acquiring and maintaining an erection is another side effect with SSRI therapy that can be bothersome to male clients. Unfortunately, this side effect is not transient such as the anxiety. The usual course of action will include counseling and the addition of another medication (such as Wellbutrin) to help manage the sexual side effect. Another option is to discontinue the Zoloft and start a new medication but SSRI’s work well for neuropathic pain. In this situation, the addition of another medication to help manage this particular side effect would be prudent. Increasing the dose alone will do nothing to address the side effects and will only lead to non-compliance and a fractured therapeutic alliance with the client.


Increase dose of Zoloft to 100 mg PO QDAY. Add-on Wellbutrin XL 150 mg po QAM. Counsel client on anxiety inducing effects of SSRI’s and how they are transient in nature. Encourage compliance with the drug regimen
Guidance to Student

Anxiety induction is one of the most bothersome side effects of an SSRI in the initiation phases of therapy. Some clients, without proper counseling, will stop taking the medication because they perceive it as getting worse. Difficulty acquiring and maintaining an erection is another side effect with SSRI therapy that can be bothersome to male clients. Unfortunately, this side effect is not transient such as the anxiety. The usual course of action will include counseling and the addition of another medication (such as Wellbutrin) to help manage the sexual side effect. Another option is to discontinue the Zoloft and start a new medication but SSRI’s work well for neuropathic pain. In this situation, the addition of another medication to help manage this particular side effect would be prudent. Increasing the dose alone will do nothing to address the side effects and will only lead to non-compliance and a fractured therapeutic alliance with the client.