Assignment: Assessing and Treating Clients With Pain

Pain can greatly influence an individual’s quality of life, as uncontrolled pain negatively impacts mood, concentration, and the overall physical and mental well-being of clients. Although pain can often be controlled with medications, the process of assessing and treating clients can be challenging because pain is such a subjective experience. Only the person experiencing the pain truly knows the intensity of the pain and whether there is a need for medication therapies. Sometimes, beliefs about pain and treatments for pain can have an adverse effect on the provider-client relationship. For this Assignment, as you examine the interactive case study consider how you might assess and treat clients presenting with pain.
Learning Objectives
Students will:

Assess client factors and history to develop personalized therapy plans for clients with pain
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for pain
Evaluate efficacy of treatment plans for clients presenting for pain therapy
Analyze ethical and legal implications related to prescribing therapy for clients with pain

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Note: All Stahl resources can be accessed through this link provided.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 10, “Chronic Pain and Its Treatment”

Stahl, S. M., & Ball, S. (2009a). Stahl’s illustrated chronic pain and fibromyalgia. New York, NY: Cambridge University Press.

To access the following chapter, click on the Illustrated Guides tab and then the Chronic Pain and Fibromyalgia tab.

Chapter 5, “Pain Drugs”

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

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

For insomnia

amitriptyline
amoxapine
carbamazepine
clomipramine
clonidine (adjunct)
desipramine
dothiepin
doxepin
duloxetine
gabapentin
imipramine
lamotrigine

levetiracetam
lofepramine
maprotiline
memantine
milnacipran
nortriptyline
pregabalin
tiagabine
topiramate
trimipramine
valproate (divalproex)
zonisamide

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

National Institute of Neurological Disorders and Stroke. (2019). Chronic pain information page: What research is being done? Retrieved from https://www.ninds.nih.gov/Disorders/All-Disorders/Chronic-Pain-Information-Page

Required Media

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

Note: This case study will serve as the foundation for this week’s Assignment.

To prepare for this Assignment:

Review this week’s Learning Resources. Consider how to assess and treat clients requiring therapy for pain and sleep/wake disorders.

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.

At each decision point stop to complete the following:

Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
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.

Submission and Grading Information

Complex Regional Pain Disorder
White Male With Hip Pain
White male on crutches

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. 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. 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.

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 50 mg BID thereafter
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day
Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed

——
Free essay Sample
Psychopharmacologic Approaches to Treatment of Psychopathology

Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date

Psychopharmacologic Approaches to Treatment of Psychopathology
Introduction
Regional pain disorder can traumatize patients for years if they do not receive the right treatment. Providers should make a careful analysis and prescribe effective medication to manage the pain. One of the best decisions is to prescribe Savella which is effective in chronic pain management (Hollander et al., 2020). Providers should also educate patients to enhance compliance and trust. Clinicians should also observe ethical guidelines to enhance the quality of treatment. The prescription of Savella requires a careful analysis of patient outcomes to promote recovery and suppress side effects.
Decision #1
The first decision is to prescribe 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.
Rationale
The rationale for making the decision and disregarding the other two options is to alter how the brain detects pain. According to the assessment, the patient is suffering from regional pain disorder. The condition causes patients to experience a low pain threshold in the brain as a result of the changes in the central nervous system and how it responds to pain (Staal et al., 2019). Consequently, patients of regional pain disorder are highly sensitive to pain due to the alterations in the neurotransmitter levels. Savella is an effective medication since it will interfere with the neurotransmitters thus reducing the sensitivity to pain. One of the effects of the drug is to inhibit serotonin and norepinephrine reuptake (Stahl, 2013). The drug is also responsible for triggering an analgesic effect on the nerve endings that are responsible for detecting pain. The general impact leads to relieving pain, enhance memory and reduce the level of fatigue (Stahl, 2013). Savella is thus an effective and compatible disease with the condition of the patient.
One of the major considerations while prescribing Savella to the patient is to provide information about the drug. For example, the patient should avoid taking other drugs or alcohol while on treatment (Stahl, 2013). Drug interaction may cause negative outcomes such as fainting, dizziness or death. It is also essential to stick to the treatment plan to avoid adverse effects.
Decision #1 also involves discarding other available options such as Amitriptyline. The drug is a common antidepressant that is mostly used in the management of pain. Amitriptyline triggers side effects such as drowsiness (Chevreau et al., 2017). The drug is not effective since the patient indicated that he was taking another drug that caused drowsiness. The patient indicated he did not take the drug consistently as a result of the side effects (Chevreau et al., 2017). Prescribing the drug may thus lead to non-compliance issues which can affect the treatment of pain.
Neurontin, an anticonvulsant as well as an antiepileptic, is also another common drug for treatment and management of pain. One of the side effects of the drug is drowsiness and dizziness which can also trigger non-compliance (Goh et al., 2017). In some cases, the drug can cause tremors and viral infections. Therefore, it is essential to select an option that will be friendly to a patient.
Projected Outcomes
The projected outcome after four weeks is that the severity of pain will decrease to 3 points on a scale of 1 to 10. A significant reduction in the severity of the pain should enhance the movement of the patient with minimal support. He should also go back to work even if it is of minimal participation. Savella should also generate a stable effect that will improve the mood of a patient (Birklein et al., 2018). During treatment, it is expected that the patient may experience side effects such as increased heart palpitations, reduced quality of sleep and bouts of sweating.
Actual vs. Projected Outcomes
While the patient reports to the clinic after four weeks, he is walking, with minimal limping, without crutches as compared to the initial visit to the clinic. According to the patient, the pain had abated significantly enabling him to walk and work without using crutches. This is according to the expectations after prescribing the medication. The patient reports that, however, the pain is severe in the morning hours compared to the evening. According to the patient, the pain is at level 4 on a scale of 1 to 10 compared to the expected level 3. He also indicated that in some instances his sleep was disrupted by intense pain.
Savella also causes a common side effect which includes bouts of sweating which can disrupt the quality of sleep (Birklein et al., 2018). According to the patient, the sweating has reduced quality of sleep. Savella increases heart palpitations which are responsible for disrupting sleep and triggering bouts of sweating. The blood pressure of the patient was 147/92mmhg while the pulse rate was 110 beats/ min. No suicidal or homicidal thoughts were reported. The side effects of the drug were expected, but they will be managed as the treatment progresses.
Decision #2
The decision #2 is inspired by the outcomes of the first decision and the side effects. The patient reported significant improvement which should be maintained in the next four weeks. One of the decisions could involve reducing the dosage to relieve the patient of the increasing heart palpitations, sweating and improve the quality of sleep (Birklein et al., 2018). However, reducing the drug instantly could lead to a relapse of the pain-causing more discomfort to the patient.
Therefore, the best decision is to increase the drug at bedtime to lower the chances of waking up due to intense pain at night while reducing the dosage in the morning. Savella 25mg orally in the morning and 50mg orally at bedtime is the best option for this decision to boost positive outcomes and manage the negative outcomes (Hollander et al., 2020). Research shows that the management of pain requires a critical adjustment of drugs since the pain may occur at different times causing a diverse impact on patients.
Changing the drug is not healthy since the current prescription is already generating the desired results. According to evidence-based practice, changing the drug can lead to side effects that can undermine the recovery process (Hollander et al., 2020). The current prescription will involve balancing between treatment and suppressing the negative outcome.
Projected Outcomes
The results of decision #2 include suppressing the pain further and allowing the patient to work and walk without any assistance. Another expectation is that the patient should experience a reduction in the heart palpitations. He should also experience a better quality of sleep and a reduction in the sweating episodes (Staal et al., 2019). For example, the patient should not complain of waking up at night due to pain since bedtime medication is high. A decrease in the side effects is essential especially in improving the quality of life of a person (Staal et al., 2019).
Actual vs. Projected Outcomes
The patient reports back to the clinic after four weeks. He is still walking without crutches which is a significant milestone in the treatment of pain. He also reports that he can participate in his workplace with minimal assistance. According to the patient, the severity of the pain is still at level 4 out of 10. The same outcome was experienced four weeks ago. It is easy to understand the results since the dosing changed to manage the side effects. Evidence-based practice demonstrates that reducing the dosage can interfere with the management of pain (Chevreau et al., 2017). A provider should thus strike a critical balance between managing pain and suppressing the side effects. Additionally, the patient reported that he did not wake up at night due to pain (Chevreau et al., 2017). His quality of sleep had improved but his heart palpitations and heart rate were still evident. He also reports that episodes of sweating had reduced. Another outcome is that the patient did not experience a difference in the severity of pain in the morning and evening. He also denied suicidal or homicidal ideation.
Decision #3
Decision #3 involved continuing with the current medication and dosing since it is generating significant positive progress. One of the major expected outcomes was to help the patient to walk and work without using crutches. The decision involves prescribing Savella 25mg orally in the morning and 50mg at bedtime.
During the prescription, it is essential to educate the patient that the treatment is trying to balance between side effects and treatment. The patient should also know that the drug is one of the best options available and that other drugs cause worse side effects (Goh et al., 2017). However, upon recovery, the side effects will abate naturally. It is not advisable to introduce a new drug at this stage since it can comprise treatment (Goh et al., 2017). The provider should also caution a patient against buying medication to treat side effects. However, the provider will take a precaution of examining the heart rate and pulse rate of a patient regularly (Goh et al., 2017). The purpose of regular checkups is to ensure he is within the normal limits.

Projected Outcomes
The patient should report back to the clinic after four weeks. The results include the ability to work and walk with minimal or no support. It is expected that the patient will rate the severity of pain at 3 out of 10. A reduction in the level of pain should allow the pain to participate in daily activities without struggling (Birklein et al., 2018). It is also expected the patient will indicate they had quality sleep since they did not have to wake up in the middle of the night due to pain (Birklein et al., 2018). Another projected outcome is that the heart rate and the palpitations will have normalized without severe bouts of sweating.
The expectations should also involve educating a patient on what they should expect. One of the expected outcomes is that the pain may remain at 3 out of 10 without further subsidizing. Neuropathic pain syndrome may trigger some pain in the long-term (Birklein et al., 2018). However, the patient will participate in his workplace and walk without any support.
Actual vs. Projected Outcomes
The patient reports back to the clinic after four weeks. He reports that the pain had reduced to 3 out of 10 which is manageable. His blood pressure is at 120/84mmhg while the pulse rate is 86 beats per minute. He also reports no suicidal or homicidal ideation. The results and the projected outcomes have great similarities thus showing the treatment was effective. During the assessment, it is essential to alert him that other forms of therapy are necessary to manage the pain in the long-term (Hollander et al., 2020). For example, he needs heat and physical therapy and chiropractic.
Ethical Issues Affecting Treatment
Ethical issues affect treatment by ensuring that providers comply with various requirements to provide high-quality treatment (Stahl, 2013). One of the ethical issues is to educate the patient about the treatment to receive informed consent from them (Hollander et al., 2020). A provider should also ensure that all decisions are patient-centered with no intention to harm them. For example, the medication with the least side effects should be selected. Patient autonomy is also necessary to observe (Staal et al., 2019). Ethical requirements state that patients should not be forced or coerced. A clinician should also educate a patient and assess their condition to their safety.
Conclusion
Treatment and management of regional pain disorder require careful analysis and assessment. One of the best medications is Savella at various doses depending on the patient outcomes. Providers should also make decisions depending on the outcomes to improve positive results and minimize side effects. It is essential to educate a patient that they require other forms of treatment to manage the condition in the long-term. Ethical issues also affect communication and treatment. The purpose is to provide treatment to patients to ensure they carry out activities with minimal pain and support.

References
Birklein, F., Ajit, S. K., Goebel, A., Perez, R. S., & Sommer, C. (2018). Complex regional pain syndrome phenotypic characteristics and potential biomarkers. Nature Reviews Neurology, 14(5), 272. https://doi.org/10.1038/nrneurol.2018.20
Chevreau, M., Romand, X., Gaudin, P., Juvin, R., & Baillet, A. (2017). Bisphosphonates for treatment of Complex Regional Pain Syndrome type 1: a systematic literature review and meta-analysis of randomized controlled trials versus placebo. Joint Bone Spine, 84(4), 393-399. https://doi.org/10.1016/j.jbspin.2017.03.009
Goh, E. L., Chidambaram, S., & Ma, D. (2017). Complex regional pain syndrome: a recent update. Burns & Trauma, 5(1). https://doi.org/10.1186/s41038-016-0066-4
Hollander, M., de Jong, J., Onghena, P., & Vlaeyen, J. W. (2020). Generalization of exposure in vivo in Complex Regional Pain Syndrome type I. Behaviour Research and Therapy, 124, 103511. https://doi.org/10.1016/j.brat.2019.103511
Staal, J. B., Klomp, F. P., & Nijhuis-van der Sanden, M. W. (2019). Pain exposure to physical therapy in complex regional pain syndrome: promising enough to warrant further investigation. Canadian Journal of Anesthesia, 66(1), 115. https://doi.org/10.1007/s12630-018-1174-3
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

~~~For this or similar assignment papers~~~