Complex Regional Pain Disorder
White Male With Hip Pain

White male on crutches

 

Decision Point One


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

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what you should do next:


Continue current medication and increase dose to 125 mg at BEDTIME this week continuing towards the goal dose of 200 mg daily. Instruct the client to take the medication an hour earlier than normal starting tonight and call the office in 3 days to report how his function is in the morning

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • The change in administration time seemed to help. The client states he is not as groggy in the morning and is able to start his day sooner than before
  • Client's current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime.
  • Client's has noticed that he is putting on a little weight. When asked, the client states that he has gained 5 pounds since he started taking this medication. He currently weighs in at 162 pounds. He is 5’ 7”. He states that his right leg doesn’t bother him nearly as much as it used to and his toes have only “cramped up” twice in the past month. He states that he is able to get around his apartment without his crutches and that he has even started seeing someone he met at the grocery store. The weight gain seems to bother him a lot and he is asking if there is a way to avoid it
Decision Point Three
Select what you should do next:


Continue with the Elavil at his current 125 mg a day dose and start Qsymia (phentermine and topiramate) 3.75 mg/23 mg tablet once daily and titrate as required by package insert
Guidance to Student

At this point, the client is almost at his goal pain control and increased functionality. Weight gain is a common side effect with amitriptyline and should be a counseling point at the initiation of therapy. He has a small weight gain of 5 pounds in 8 weeks. A reduction in dose may have an effect on the weight gain but at a considerable cost of pain to the client. This would not be in the best interest of the client at this point. Amitriptyline has a side effect of cardiac arrhythmias. He is not experiencing this at this point. The drug, qsymia contains a product called phentermine which has a history of causing cardiac arrhythmias at higher doses. This product is also only approved for a client with obesity defined as a BMI greater than 30 kg/m2. Your client’s BMI is currently 25.5 kg/m2. He does not meet the definition of obesity but is considered overweight. His best course of action would be to continue the same dose of Elavil, counsel him on good dietary and exercise habits and connect him with a life coach who will help him with this problem in a more meaningful way than a 10 minute counseling session will be able to accomplish.


Reduce the dose of Elavil to 100 mg a day and follow up in a month
Guidance to Student

At this point, the client is almost at his goal pain control and increased functionality. Weight gain is a common side effect with amitriptyline and should be a counseling point at the initiation of therapy. He has a small weight gain of 5 pounds in 8 weeks. A reduction in dose may have an effect on the weight gain but at a considerable cost of pain to the client. This would not be in the best interest of the client at this point. Amitriptyline has a side effect of cardiac arrhythmias. He is not experiencing this at this point. The drug, qsymia contains a product called phentermine which has a history of causing cardiac arrhythmias at higher doses. This product is also only approved for a client with obesity defined as a BMI greater than 30 kg/m2. Your client’s BMI is currently 25.5 kg/m2. He does not meet the definition of obesity but is considered overweight. His best course of action would be to continue the same dose of Elavil, counsel him on good dietary and exercise habits and connect him with a life coach who will help him with this problem in a more meaningful way than a 10 minute counseling session will be able to accomplish.


Continue the current dose of Elavil of 125 mg per day, refer the client to a life coach who can counsel him on good dietary habits and exercise
Guidance to Student

At this point, the client is almost at his goal pain control and increased functionality. Weight gain is a common side effect with amitriptyline and should be a counseling point at the initiation of therapy. He has a small weight gain of 5 pounds in 8 weeks. A reduction in dose may have an effect on the weight gain but at a considerable cost of pain to the client. This would not be in the best interest of the client at this point. Amitriptyline has a side effect of cardiac arrhythmias. He is not experiencing this at this point. The drug, qsymia contains a product called phentermine which has a history of causing cardiac arrhythmias at higher doses. This product is also only approved for a client with obesity defined as a BMI greater than 30 kg/m2. Your client’s BMI is currently 25.5 kg/m2. He does not meet the definition of obesity but is considered overweight. His best course of action would be to continue the same dose of Elavil, counsel him on good dietary and exercise habits and connect him with a life coach who will help him with this problem in a more meaningful way than a 10 minute counseling session will be able to accomplish.


Reduce the dose of Elavil to 75 mg at BEDTIME (dose has been titrated at weekly intervals by 25mg per week). Add on Biofreeze roll-on therapy to his right leg below the knee and into the foot and toes to be used as needed daily for muscle cramping

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client's current pain level is still a 6 out of 10. His grogginess has gone away but his pain level has not changed
  • Client's functionality has improved somewhat since your last visit. He is able to make it around his apartment without the crutches but still needs them when he ventures outside. He says that the Biofreeze does work but he is constantly applying it and it isn’t practical for a long term solution. He is asking if there is a long-acting form
Decision Point Three
Select what you should do next:


Continue same dose of Elavil. Continue the BioFreeze on an as-needed basis. Add on lidocaine patches applied to the areas of pain for 12 hours on and 12 hours off
Guidance to Student

At this stage of therapy, anyone of the above mentioned options could be appropriate therapy except for the addition of oxycodone. Opioid analgesics rarely will help with neuropathic-type pain which is what our client is experiencing. As the client continues with the oxycodone, it will continue to be in-effective. The in-effectiveness of opioids on neuropathic pain leads to dose escalation. Soon, the client is escalating the dose on his own and you risk induction of an addictive disorder in the client that will require treatment. BioFreeze is an interesting product. It is menthol. I have copied the mechanism of action from their website:

1. Menthol Counter-irritant Effect: The counter-irritant theory suggests that menthol stimulates cutaneous sensory receptors. This blocks pain signals from reaching the brain via the “Gate Control” theory (Melzak & Wall 1965).

2. Cryotherapy through Evaporation: Evaporation of alcohol and menthol reduce skin temperature, which stimulates thermosensitive cold receptors in the skin known as “TRP-M8” receptors. These specific receptors have been shown to play a role in pain control through the body’s glutamate (Proudfoot et al. 2006) or opioid system (Galaeotti et al. 2002).

This is a great topical product that can offer immediate relief from pain and does not have addictive properties. It should, however, not be relied on for the sole purpose of extended pain relief as the menthol lasts for about 2 hours and then requires re-application. Lidocaine patches are another option for a topical analgesia but is long acting. Remember, lidocaine, in higher doses can also cause cardiac dysrhythmias and should be limited to no more than (3) patches applied at one time. Although it is a topical product, about 3% of lidocaine becomes available systemically due to absorption. Lidocaine in continuous use results in a tolerance to the effects of the medication and, therefore, requires a 12 hour drug free period.


Increase the amitriptyline Elavil to 100 mg at bedtime BEDTIME but instruct patientclient to take it an hour earlier. Discontinue the BioFreeze. Add- on oxycodone 5 mg po Q6H prnorally every 6 hours as needed for Ssevere breakthrough pain
Guidance to Student

At this stage of therapy, anyone of the above mentioned options could be appropriate therapy except for the addition of oxycodone. Opioid analgesics rarely will help with neuropathic-type pain which is what our client is experiencing. As the client continues with the oxycodone, it will continue to be in-effective. The in-effectiveness of opioids on neuropathic pain leads to dose escalation. Soon, the client is escalating the dose on his own and you risk induction of an addictive disorder in the client that will require treatment. BioFreeze is an interesting product. It is menthol. I have copied the mechanism of action from their website:

1. Menthol Counter-irritant Effect: The counter-irritant theory suggests that menthol stimulates cutaneous sensory receptors. This blocks pain signals from reaching the brain via the “Gate Control” theory (Melzak & Wall 1965).

2. Cryotherapy through Evaporation: Evaporation of alcohol and menthol reduce skin temperature, which stimulates thermosensitive cold receptors in the skin known as “TRP-M8” receptors. These specific receptors have been shown to play a role in pain control through the body’s glutamate (Proudfoot et al. 2006) or opioid system (Galaeotti et al. 2002).

This is a great topical product that can offer immediate relief from pain and does not have addictive properties. It should, however, not be relied on for the sole purpose of extended pain relief as the menthol lasts for about 2 hours and then requires re-application. Lidocaine patches are another option for a topical analgesia but is long acting. Remember, lidocaine, in higher doses can also cause cardiac dysrhythmias and should be limited to no more than (3) patches applied at one time. Although it is a topical product, about 3% of lidocaine becomes available systemically due to absorption. Lidocaine in continuous use results in a tolerance to the effects of the medication and, therefore, requires a 12 hour drug free period.


Discontinue the Elavil and start client on Savella (milnacipran) as recommended by the manufacturer
Guidance to Student

At this stage of therapy, anyone of the above mentioned options could be appropriate therapy except for the addition of oxycodone. Opioid analgesics rarely will help with neuropathic-type pain which is what our client is experiencing. As the client continues with the oxycodone, it will continue to be in-effective. The in-effectiveness of opioids on neuropathic pain leads to dose escalation. Soon, the client is escalating the dose on his own and you risk induction of an addictive disorder in the client that will require treatment. BioFreeze is an interesting product. It is menthol. I have copied the mechanism of action from their website:

1. Menthol Counter-irritant Effect: The counter-irritant theory suggests that menthol stimulates cutaneous sensory receptors. This blocks pain signals from reaching the brain via the “Gate Control” theory (Melzak & Wall 1965).

2. Cryotherapy through Evaporation: Evaporation of alcohol and menthol reduce skin temperature, which stimulates thermosensitive cold receptors in the skin known as “TRP-M8” receptors. These specific receptors have been shown to play a role in pain control through the body’s glutamate (Proudfoot et al. 2006) or opioid system (Galaeotti et al. 2002).

This is a great topical product that can offer immediate relief from pain and does not have addictive properties. It should, however, not be relied on for the sole purpose of extended pain relief as the menthol lasts for about 2 hours and then requires re-application. Lidocaine patches are another option for a topical analgesia but is long acting. Remember, lidocaine, in higher doses can also cause cardiac dysrhythmias and should be limited to no more than (3) patches applied at one time. Although it is a topical product, about 3% of lidocaine becomes available systemically due to absorption. Lidocaine in continuous use results in a tolerance to the effects of the medication and, therefore, requires a 12 hour drug free period.


: Reduce dose of amitriptyline Elavil to 75 mg po orally at BEDTIME and add- on Neurontin (gabapentin) 300 mg po orally at BEDTIME. Schedule a Ffollow-up phone call in 1 week to assess pain control

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client returns with his crutches. He states that he is still groggy in the morning but now is having trouble staying awake throughout the day. His current pain level is 7 out of 10. He states that his right leg is “killing” him, and he still is dealing with the cramping in his right foot
  • Client blames all of this on you because “you changed my medication and added the Neurontin which doesn’t help at all”
Decision Point Three
Select what you should do next:


Increase the Neurontin to 300 mg orally three times a day and increase the amitriptyline to 100 mg orally at BEDTIME
Guidance to Student

Clients in pain want immediate help. Sometimes they get lost in the syndrome and forget that you are trying to help and will blame you for any back steps. Don’t take it personal. It is not the client taking but rather the disease state taking its’ toll on their ability to think rationally. A dose increase with the Neurontin will only worsen the daytime drowsiness, especially if he was only taking it at bedtime and will now take it throughout the day. Referring clients who have pain syndromes to a clinic that specializes in pain is never a bad option and sometimes is the best option. If you do make this referral, then you will need to bridge therapy until the clinic is able to see the client. The amitriptyline seemed to work. Continuing with this medication is a good option. Early morning drowsiness of grogginess can usually be alleviated with a change in administration time. An hour or two earlier usually will give the results you are looking for and should be tried first before a medication change.


Refer the client to a pain specialist since he does not perceive any benefit from what you are doing
Guidance to Student

Clients in pain want immediate help. Sometimes they get lost in the syndrome and forget that you are trying to help and will blame you for any back steps. Don’t take it personal. It is not the client taking but rather the disease state taking its’ toll on their ability to think rationally. A dose increase with the Neurontin will only worsen the daytime drowsiness, especially if he was only taking it at bedtime and will now take it throughout the day. Referring clients who have pain syndromes to a clinic that specializes in pain is never a bad option and sometimes is the best option. If you do make this referral, then you will need to bridge therapy until the clinic is able to see the client. The amitriptyline seemed to work. Continuing with this medication is a good option. Early morning drowsiness of grogginess can usually be alleviated with a change in administration time. An hour or two earlier usually will give the results you are looking for and should be tried first before a medication change.


Discontinue the Neurontin. Increase the Elavil to 100 mg at BEDTIME but instruct the client to take it an hour earlier and call the office in 3 days to assess his pain and ability to stay awake during the day
Guidance to Student

Clients in pain want immediate help. Sometimes they get lost in the syndrome and forget that you are trying to help and will blame you for any back steps. Don’t take it personal. It is not the client taking but rather the disease state taking its’ toll on their ability to think rationally. A dose increase with the Neurontin will only worsen the daytime drowsiness, especially if he was only taking it at bedtime and will now take it throughout the day. Referring clients who have pain syndromes to a clinic that specializes in pain is never a bad option and sometimes is the best option. If you do make this referral, then you will need to bridge therapy until the clinic is able to see the client. The amitriptyline seemed to work. Continuing with this medication is a good option. Early morning drowsiness of grogginess can usually be alleviated with a change in administration time. An hour or two earlier usually will give the results you are looking for and should be tried first before a medication change.