Case Study: A Caucasian Man with Hip Pain
NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology
Case Study: A Caucasian Man with Hip Pain
“The patient is 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.” 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. 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.” (Laureate Education, 2016a).
My first decision was to start this patient on Amitriptyline 25mg po QHS and titrate upward weekly by 25g to a max dose of 200mg per day (Laureate Education, 2016a). This is a serotonin and norepinephrine/noradrenaline reuptake inhibitor that can be prescribed for neuropathic pain/chronic pain, fibromyalgia and for a wide variety of pain syndromes (Stahl, 2013). It boosts neurotransmitters serotonin and norepinephrine/noradrenaline and presumably desensitizes both serotonin 1A receptors and beta adrenergic receptors (Stahl, 2013). I did not choose Savella because it is a selective serotonin-norepinephrine reuptake inhibitor (SNRI), similar to some drugs used for the treatment of depression and other psychiatric disorders (Wolters Kluwer Clinical Drug Information, 2018b). It is also used for fibromyalgia but I did not feel it was appropriate to start this patient on a medication for psychiatric disorders when he has chronic pain in his hip. I did not choose Neurontin because it is commonly prescribed for neuropathic pain and posttherpetic neuralgia (Stahl, 2013). I did not think it would be an appropriate medication or effectively treat his pain. With this decision I was hoping to have a decrease in his pain.
When he returns in four weeks he is still using his crutches but states his pain has improved and he is groggy in the morning (Laureate Education, 2016a). He reports his pain level is 6 out of 10 and states his acceptable pain level would be a 3(Laureate Education, 2016a). He reports he is able to go the bathroom or to the kitchen without using his crutches all the time and the achiness is less and his toes to not curl as often as they did before (Laureate Education, 2016a). His level prior to starting the medication was 9 out of 10 so there was a slight decrease in his pain but he is still experiencing his toes curling (Laureate Education, 2016a).
My second decision was to continue the current medication and increase dose to 125mg at bedtime this week continuing towards the goal dose of 200mg daily (Laureate Education, 2016a). I would instruct him 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 (Laureate Education, 2016a). I did not want to reduce the dose at bedtime and add Biofreeze roll-on because he did have a decrease of symptoms with his current dose and the Biofreeze is a temporary fix. I also chose not to reduce the dose and augment with Neurontin because it does not appear his pain is neurological and he did have a response to his current dose. By changing the medication time but continuing the increase in dose I was hoping for a decrease in his grogginess in the morning and a further decrease in his pain.
When he returns in four weeks the change in administration times seemed to help and he is not as groggy in the morning (Laureate Education, 2016a). He reports his current pain level is 4 out of 10 and he is taking 125mg at bedtime (Laureate Education, 2016a). He has noticed he has gained 5 pounds since he started taking the medication (Laureate Education, 2016a). He states his right leg doesn’t bother him as much as it used to and his toes have only cramped up twice in the past month (Laureate Education, 2016a). He is able to get around his apartment without his crutches but he is asking if there is a way to avoid the weight gain (Laureate Education, 2016a). A common side effect of amitriptyline is weight gain (Wolters Kluwer Clinical Drug Information, 2018a). The only difference between my decision and what I was hoping for was this patient’s 5lb weight gain.
My third decision was to continue the current dose of Elavil of 125mg per day and refer the patient to a life coach who can counsel him on good dietary habits and exercise (Laureate Education, 2016a). According to Laureate Education (2016a), the client is almost at his goal pain control and increased functionality and weight gain is a common side effect and should be a counseling point at the initiation of therapy. Reducing the dose may have an effect on the weight gain but it would be at a cost of pain to the client (Laureate Education, 2016a). I chose not to start this patient on Qysmia because it contains a product that has a history of causing cardiac arrhythmias and Amitriptyline has a side effect of cardiac arrhythmias (Laureate Education, 2016a). The best course of action would be to continue the same dose and counsel him on good dietary and exercise habits and connect him with a life coach (Laureate Education, 2016a). With this decision I was hoping for a therapeutic pain control and helping him to control the weight gain by referring him to a life coach.
When this patient presented it was important to listen to his concerns because other providers believed he was medication seeking. It was important to research each medication prior to prescribing it. I felt the best medication for this patient’s pain was the amitriptyline. Although at first he felt groggy, the administration time change helped with that feeling. He did experience weight gain, but that is a common symptom of this medication. It was important to listen to his concern and refer him to the life coach. I did not want to decrease the dosage of the medication because he was having a response and decrease in his pain.
Laureate Education (2016a). Case Study: A Caucasian man with hip pain [Interactive media
file]. Baltimore, MD: Author https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/07/mm/complex_regional_pain_disorder/2.html
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical
applications (4th ed.). New York, NY: Cambridge University Press.
Wolters Kluwer Clinical Drug Information (2018a). Amitriptyline.
Wolters Kluwer Clinical Drug Information (2018b). Milnacipran.
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