Decisions
As a result of the prolonged chronic pain experienced by the patient, he has decided to see a different doctor from his family doctor. His pain has lasted for seven years. The clinician needs to make the right decision in order to help relieve the patient’s pain. The pain began when the client fell on his right side while at work. An earlier scan showed that he had a tear of ligaments at his hip. He was advised against surgery with the doctors arguing that he was young and the tissues would just grow back with time. He has therefore had to live with the pain all these years. It is important to note that the patient experiences severe pain and periodical leg crumpling. The pain has made the client reliant on pain medication as well as losing out on his social life. Therefore, his treatment will follow a methodical procedure made up of a number of decisions.
Decision 1
My first decision would be to start Savella 12.5mg administered orally once on day one followed by 12.5mg BID on day two and three. Savella is a drug used to treat pain that affects muscles and tissues. Excessive pain causes a change in the nervous system by altering the levels of neurotransmitters. Neurotransmission refers to the process where neurotransmitters are released by one neuron and bind to the receptors of another neuron. Stahl (2013) explains that neurotransmission can be anatomical, electrical or chemical. Neurons are the cells that enable communication within the brain, hence when they malfunction; there is a general behavioral change. This severe pain experienced by the patient could be as a result of malfunctioning neurons, which are also the neurotransmitters. The medicine works by restoring the balance of neurotransmitters in the brain. (Savella Oral, n.d). The primary mode of administration is orally with food if the patient has nausea or without food (Stahl, 2014). In making this decision, I left out two possible drugs, amitriptyline and Neurontin.
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Amitriptyline is more of an antidepressant and is used mainly to treat mental and mood disorders like depression and anxiety. Even though amitriptyline can also regulate neurotransmitters within the brain, this medication does not take effect immediately, hence not an effective pain reliever (Amitriptyline Oral, n.d). the main reason amitriptyline is not commonly used is because of the side effect of patient having suicidal thoughts and behavior. Other side effects include confusion, dizziness, and constipation. Neurontin on the other hand is a drug used to control seizures. Sometimes it is used as pain medication to relieve nerve pain. However, in this case I wouldn’t prescribe it because it needs frequent dosing regimen because of its short half-life. It also has severe side effects like dizziness, drowsiness, and blurred vision, and sometimes weight gain (Neurontin Oral, n.d). Therefore, the best option for medication in this case would be Savella.
The most expected outcome for this decision was a reduction in the level of pain experienced by the client. From the narration of the patient above, he seems to be experiencing too much pain. Chronic pain has been classified as one of the main reasons why adults seek medication (Dahlhamer et al, 2018). The client has also stated that he is unable to work like he used to, hence he cannot fend for his family, making his fiancé abandon him. Pain is never about just the hurting. Pain interferes with the physical and emotional well-being of an individual. It also affects one’s social life (Squibb, 2018). With this treatment regimen, the client is expected to be able to manage his pain in a way that he can be able to work and afford his basic needs. Currently, the pain originating from his hips is making it impossible for him to work (U.S Department, 2018).
Decision 2
The second decision would be to continue with administration of Savella, with a slight increase in the dosage for a few days. I would administer 25mg BID orally on days four to seven. The main reason for the slight increase in the dosage is to reduce the side effects (McCargerg, 2008). Some of the known side effects of the drug are nausea, constipation, and dizziness. It is therefore advisable to start off on a lower dose and gradually increase the dosage so that the side effects are not severe.
The client reports a reduction in the level of pain felt. He is responding to the medication and is starting to become active. He experiences some slight side effects like nausea, but it is manageable. The nausea experienced on the first two days subsided because he started taking the drugs with food. The patient appreciates this medication because he finally gets a relief from his pain without having to take so many drugs like a junkie. In the third decision, the clinician will have to consider whether to continue use of Savella, discontinue, or introduce a new drug.
Decision 3
The third decision would be to continue with Savella, but increase the dosage further. The clinician will administer 50mg BID from day eight onwards. The client will continue with this dosage for a period of months until there is no more pain, then gradually stop. The patient has shown a positive response to this medication and it is just in order to continue and not introduce any new drugs.
Ethical Considerations
The first ethical consideration by the clinician should be identifying and evaluating the client’s problem. The patient may be having fibromyalgia. This is a syndrome of extensive prolonged pain that is accompanied with sleep disorders and depressed moods. It is believed that this condition could be due to a malfunction of the mechanisms responsible for processing pain (Stahl & Ball, 2009a). The neurotransmitters responsible for mood control could be inhibited from performing their normal functions, hence fibromyalgia sets in (Salaffi, 2009). Once the clinician understands the client’s problem, only then can he give the right prescription. The clinician must also understand all drug options available; how they work and their side effects.
Chronic pain is common, hard to manage, and very costly in terms of medical care (Feliu-Soler et al, 2018). It is important that as the clinician tries to find the best drug for the patient, they consider something that is cost effective. The clinician owes the client all the information on drug use, how the drugs work, possible side effects, cost implications, and success rates. The health professional has an ethical obligation of reducing prescription errors which are quite common in medical care. The patient needs to receive proper medical care without being overburdened.
The clinician must also understand the social and cultural background of the client, in this case a Caucasian. He needs to know what beliefs and myths, if any, that relate to drug use and medication. With this kind of information, the physician should talk to the client and rule out any myths that may interfere with his medication and recovery process. The clinician will also advice the client appropriately in regards to drug use. All avenues need to be exploited if the patient is to recover fully.
References
Amitriptyline Oral : Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. (n.d.). Retrieved July 10, 2019, from https://www.webmd.com/drugs/2/drug-8611/amitriptyline-oral/details
Dahlhamer, J., Lucas, J., Zelaya, C., et al. (2018). Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults-United States, 2016| MMWR. Retrieved July 10, 2019, from https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm
Feliu-Soler, A., Montesinos, F., Gutierrez-Martinez, O., Scott, W., McCracken, L. M., & Luciano, J. V. (2018, October 02). Current status of acceptance and commitment therapy for chronic pain: A narrative review. Retrieved July 10, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174685/
McCarberg, B. H., Nicholson, B. D., Todd, K. H., Palmer, T., & Penles, L. (2008). The impact of pain on quality of life and the unmet needs of pain management: Results from pain sufferers and physicians participating in an internet survey. Retrieved July 10, from https://www.ncbi.nlm.nih.gov/pubmed/18645331
Neurontin Oral : Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. (n.d.). Retrieved July 10, 2019, from https://www.webmd.com/drugs/2/drug-9845-8217/neurontin-oral/gabapentin-oral/details
Salaffi, F., Sarzi-Puttini, P., Girolimetti, R., Atzeni, F., Gasparini, S., Grassi, W. (2009). Health-related quality of life in fibromyalgia patients: a comparison with rheumatoid arthritis patients and the general population using the SF-36 health survey. Clinical and Experimental Rheumatology, 56(5), 67-74.
Savella Oral : Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. (n.d.). Retrieved July 10, 2019, from https://www.webmd.com/drugs/2/drug-152224/savella-oral/details
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4 th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. & Ball, S. (2009a). Stahl’s illustrated chronic pain and fibromyalgia. New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The Prescriber’s guide (5 th ed.). New York, NY: Cambridge University Press.
Squibb, B. (2018, February 26). Understanding the effect of pain and how the human body responds. Retrieved July 10, 2019, from https://www.nursingtimes.net/clinical-archive/pain-management/understanding-the-effect-of-pain-and-how-the-human-body-responds/7023422.article#
U.S Department of Health and Human Services, National Institutes of Health (2018). Prevalence and profile of High Impact Chronic Pain. Retrieved from https://nccih.nih.gov/research/results/spotlight/Prevalence-Profile-High-Impact-Chronic-Pain
