Complex Regional Pain Disorder

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 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 Client returns to clinic in four weeks Client comes into the office to without crutches but is limping a bit. The client states that the pain is “more manageable since I started taking that drug. I have been able to get around more on my own. The pain is bad in the morning though and gets better throughout the day”. On a pain scale of 1-10; the client states that his pain is currently a 4. When asked what pain level would be tolerable on a daily basis, the client states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.”. When questioned further, you ask what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 4?”. The client states that since using this drug, I can get to a point on most days where I do not need the crutches. ” The client is also asked what would need to happen to get his pain from a current level of 4 to an acceptable level of 3. He states, “If I could get to the point everyday where I do not need the crutches for most of my day, I would be happy.” Client states that he has noticed that he frequently (over the past 2 weeks) gets bouts of sweating for no apparent reason. He also states that his sleep has “not been so good as of lately.” He does complain of nausea today Client’s blood pressure and pulse are recorded as 147/92 and 110 respectively. He also admits to experiencing butterflies in his chest. The client denies suicidal/homicidal ideation and is still future oriented Decision Point Two 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 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 Client returns to clinic in four weeks Client comes into the office to without crutches but is limping a bit. The client states that the pain is “more manageable since I started taking that drug. I have been able to get around more on my own. The pain is bad in the morning though and gets better throughout the day”. On a pain scale of 1-10; the client states that his pain is currently a 4. When asked what pain level would be tolerable on a daily basis, the client states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.”. When questioned further, you ask what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 4?”. The client states that since using this drug, I can get to a point on most days where I do not need the crutches. ” The client is also asked what would need to happen to get his pain from a current level of 4 to an acceptable level of 3. He states, “If I could get to the point everyday where I do not need the crutches for most of my day, I would be happy.” Client states that he has noticed that he frequently (over the past 2 weeks) gets bouts of sweating for no apparent reason. He also states that his sleep has “not been so good as of lately.” He does complain of nausea today Client’s blood pressure and pulse are recorded as 147/92 and 110 respectively. He also admits to experiencing butterflies in his chest. The client denies suicidal/homicidal ideation and is still future oriented Decision Point Two 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 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 Write a 1- to 2-page summary paper that addresses the following: • Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. • Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources. • What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources. • Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.

Write a 1- to 2-page summary paper that addresses the following:

Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.

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Complex Regional Pain Disorder
The case study involves a 43-year-old Caucasian man who reported hip pain that started 7 years after sustaining a fall at work. The client reported that he was also experiencing anxiety, sleeping disturbances, paresthesia, depression, and deterioration o physical function. The client was diagnosed with complex regional pain disorder (reflex sympathetic dystrophy).
The first treatment choice for this client was Savella 12.5 mg orally once daily and increase the dose appropriately, up to 50 mg BID thereafter. Savella was selected as it is effective in the treatment of fibromyalgia. Savella is an SNRI and has NMDA antagonist activity and hence acts as an analgesic at the nerve endings, relieving the pain (Tzadok & Ablin, 2020). This decision hoped that the client would report significant pain reduction and improved mood. It was expected that he would not experience side effects. The expected results were similar to the treatment outcomes since as expected, the client reported reduced pain. For example, he reported a reduced pain score, he had stopped using crutches, and did not report any depressive symptoms. However, he also reported that he was experiencing side effects like increased blood pressure, increased heart rate, nausea, sweating bouts, and butterflies in the chest. Savella was chosen over the other provided medications because it does not have numerous side effects when compared to Amitriptyline and Neurontin (Gupta et al., 2021). Amitriptyline and Neurontin have an affinity for cholinergic, adrenergic, and histaminergic receptors and thus they are associated with numerous side effects.
As a result, the second decision was for the client to continue with Savella but reduce the dose to 25 mg twice daily. This decision was selected because even if Savella is effective in reducing the pain score, the client reported side effects. Therefore, it was necessary to reduce the dose in order to minimize side effects (Polychroniou et al., 2018). Selection of this decision hoped that the client would report reduced pain score and also not experience side effects. However, the treatment outcomes were different from the expected outcomes. The treatment outcome for this decision was that the pain score increased, while the side effects reduced. The increased pain score is attributable to the reduced efficacy of the low dose (Kim et al., 2020). According to Ferreira et al (2021), the recommended dose for Savella in pain management is 2.5 mg/day for the first day, 25 mg/day on the 2nd and 3rd day, 50 mg/day on the 4th-7th day and after the 7th day 100 mg/day. Therefore, the reduced Savella dose was not fully effective in reducing the pain score.
Therefore, the third treatment decision was to maintain Savella but change the dose to 25 mg orally in the MORNING and 50 mg orally at BEDTIME. The decision was chosen in order to increase the efficacy of Savella. The efficacy of Savella has been shown to be dose-dependent (Toivo et al., 2019). Therefore, it is expected that with an increased dose, the client would manifest a reduced pain score, stop using crutches and also report improved functionality. Additionally, a higher dose was administered at bedtime to minimize the side effects daytime. With this decision, it is expected that the client will report reduced pain and improved mood. It is also expected that the client would tolerate the medication and not report significant side effects. The option of stopping Savella was not selected because sudden discountunation of Savella can lead to withdrawal symptoms (Colzato et al., 2021).

References
Colzato, L., Zhang, W., Walter, H., Beste, C., & Stock, A. K. (2021). An Oppositional Tolerance Account for Potential Cognitive Deficits Caused by the Discontinuation of Antidepressant Drugs. Pharmacopsychiatry.
Ferreira, G. E., McLachlan, A. J., Lin, C. W. C., Zadro, J. R., Abdel-Shaheed, C., O’Keeffe, M., & Maher, C. G. (2021). Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis. BMJ, 372.
Gupta, H., Girma, B., Jenkins, J. S., Kaufman, S. E., Lee, C. A., & Kaye, A. D. (2021). Milnacipran for the Treatment of Fibromyalgia. Health psychology research, 9(1), 25532. https://doi.org/10.52965/001c.25532
Kim, K. H., Seo, H. J., Abdi, S., & Huh, B. (2020). All about pain pharmacology: what pain physicians should know. The Korean journal of pain, 33(2), 108.
Polychroniou, P. E., Mayberg, H. S., Craighead, W. E., Rakofsky, J. J., Aponte Rivera, V., Haroon, E., & Dunlop, B. W. (2018). Temporal Profiles and Dose-Responsiveness of Side Effects with Escitalopram and Duloxetine in Treatment-Naïve Depressed Adults. Behavioral sciences (Basel, Switzerland), 8(7), 64. https://doi.org/10.3390/bs8070064
Toivo, T., Airaksinen, M., Dimitrow, M., Savela, E., Pelkonen, K., Kiuru, V., … & Puustinen, J. (2019). Enhanced coordination of care to reduce medication risks in older home care clients in primary care: a randomized controlled trial. BMC geriatrics, 19(1), 1-13.
Tzadok, R., & Ablin, J. N. (2020). Current and emerging pharmacotherapy for fibromyalgia. Pain Research and Management, 2020.