Question

Chronic Pain: GK is a 40-year-old female who was referred to you from her PCP for a mental health evaluation. The PCP feels the need to increase the dose of hydrocodone based upon the patient’s poor response to existing treatment. GK complains of “pain all over her body.” She describes the pain as muscular pain with a feeling of spasm or tightening. She has had this pain for over a year. Her PCP has treated her with both NSAIDs and opioids with minimal impact on pain. GK also complains of not sleeping well, having no energy and difficulty concentrating and completing work which she thinks is related to her poor sleep. Her past medical history includes: HTN diagnosed at age 38; hyperlipidemia diagnosed at age 38; depression diagnosed at age 35. She was adopted so little is known about her biological family history. She works as a secretary in a school office and is married with two children who are 11 and 9 years old. She smokes one pack of cigarettes per day and drinks only occasionally (a glass of wine at social gatherings). Her medication history includes:

• Lipitor 40mg QHS
• Amlodipine 5mg QD
• Sertraline 50mg QD
• Celebrex 200mg QD (discontinued b/c of lack of effectiveness/cost)
• Meloxicam 15mg QD
• Hydrocodone 5mg/325mg Q8 hours as needed for severe pain

She has no known allergies. Her labs are all within normal limits. Physical exam is normal with the exception of pain at 13 of the 18 tender point sites on digital palpitation. She also appears tired and older than her stated age.

1. What is your presumptive diagnosis of this patient and what evidence supports your diagnosis?
2. Are there any medications on this patient’s medication list that can be contributing to the patient’s chief complaint? If so, what course of action should be taken?
3. Assuming you rule out medication-related causes of the patient’s pain, identify two different therapeutic options that might provide benefit for this patient and explain how each will work.
4. Provide a specific plan of care for the patient: specific medications, doses, important educational points, and important monitoring points.
5. What non-pharmacological advice would you offer this patient?

Answer 1

A.It may be fibromyalgia. Because,the patient complaints that pain all over the body,mainly muscle pain and tightening.Patients with fibromyalgia experience pain over necks,shoulders which make patient unable to sleep.Here GK has same complaint of lack of sleep.She is having painful "tender points".Fibromyalgia associated pain may not relieve with medications.

B.Hydrocodone is an opioid analgesic.Use of opioid analgesics in patients of fibromyalgia is less effective than using non opioids.FM guidelines discourage the use of opioids in treatment.Long term use of opioid also contributes to tolerance and became less effective.It is better to avoid opiod analgesic,in this case,hydrocodone.It is more effective is to include muscle relaxants,antidepressants,NSAIDs to treat pain

C.1.HYDROTHERAPY:Using of hot water to relieve pain at tender sites.This will relieve the tightening of muscles thus relieve pain.

2.ACUPUNCTURE :It is the process of inserting needles to specific sites in the body to relieve pain.

D.Specific medications

• Pain relievers such as acetaminophen,ibuprofen are helpful.
• This patient has history of depression,so antidepressants are needed,Duloxetine may reduce the pain associated with fibromyalgia
• Sometimes,fibromyalgia pain can be relieved by antiseizure medications such as Pregabalin.
• Muscle relaxants

  Client education

• It is important to keep patient tension or stress free.Stress management is important.Instruct the patient to follow a regular pattern of sleep and wake cycle.
• Follow regular exercise and rest period,don't be too strained.
• Follow balanced diet,include more fruits and vegetables in the diet.
• Instruct to follow non therapeutic measures such as hydrotherapy,massage,acupuncture etc.

Monitoring

• Assess the level of pain and check whether the response of medications to the pain.If good results is seen,taper the doses gradually.
• Assess the aggravating factors of pain,if any.
• Check for medicine compliance.Make sure that tolerance will not be developed in the patients.
• Check for the effectiveness of home remedies and other non therapeutic measures.

E.There are home remedies or non pharmacological interventions available for this patient.They are:

• therapeutic massage :massaging of tender points have effect on pain which looses the muscle tightening thereby reducing the pain.
• Moist heat application:Moist heat application at the tender site can relieve the pain.it is advised to do twice a day.Also follow a hot bath twice a day
• Follow regular mild exercise,not too intense, may aggravate pain. Adequate rest and activities should be balanced.
• stress management is key :Increased stress level may aggravate pain.Stress management includes relaxation exercises,breathing exercise,yoga and meditations.Involving in social relationships,maintain good friends will also enable you to cope up with stress
• Follow a regular pattern for day,especially;sleep-wake cycles,follow good-balanced diet etc.