The decision at this point was to start the patient on the minimum required dosage of amitriptyline based on pertinent findings from the patient’s history and neurological examination, which implied a diagnosis of complex regional pain syndrome with a differential diagnosis of depression. Amitriptyline is a tricyclic antidepressant medication and by and large, antidepressants have widely been used over the last several years for the treatment of pain disorders such as post-herpetic neuralgia, neuropathic pain, and fibromyalgia. Its mechanism of action in treating such pain disorders remains unclear, although it is known to exert its antidepressant effects by inhibiting the reuptake of serotonin and norepinephrine in the neurons (Moore, Derry, Aldington, Cole & Wiffen, 2015). Specifically, in this particular case of complex regional pain syndrome, amitriptyline reduces the associated autonomic and motor symptoms (Moore et al., 2015). Further, chronic pain conditions are associated with psychological symptoms such as depression, which also explains why amitriptyline would be the most effective drug in managing her condition based on its potent antidepressant effects.
The expectation from the decision of starting the patient on Amitriptyline 25 mg PO QHS to be titrated upwards weekly by 25 mg to a max dose of 200 mg per day was to relieve the patient from the chronic pain that he had been experiencing. This is because Amitriptyline is a safe drug that has proven to be effective in the treatment of complex regional pain syndrome (Moore et al., 2015). An additional expectation was that by starting with the low dose of amitriptyline and slowly titrating upwards, the therapeutic effect of alleviating the hip pain would be achieved with little or no associated side effects (Crane, 2019).
When the client reported to the clinic for follow up after four weeks, he reported that the pain has reduced from 9/10 to 6/10 as expected even though he was still ambulating using crutches. This was anticipated since it takes quite a while even as long as 30 days for the therapeutic effects of amitriptyline to be realized. However, the client reported that he often felt a bit groggy in the morning which was the least of the expectation. Amitriptyline is well known to cause anticholinergic and antihistaminic side effects such as sedation, constipation, blurred vision, and dry mouth which can explain why the client had been feeling groggy in the morning (Moore et al., 2015). Furthermore, even though the minimum dosage had been instituted, the dosing schedule of the drug seemed to lessen the brain functioning of the patient more so the morning dose which further explains this complaint.
The decision at this point was to continue amitriptyline and increase the dose to 125 mg daily to be taken at bedtime and further advance towards the ultimate goal dose of 200 mg daily. The expectation from this decision was that the pain experienced by the patient would further reduce. This is based on the fact that amitriptyline is an effective pharmacological agent in the management of off-label chronic pain conditions such as complex regional pain syndrome and fibromyalgia (Thour & Marwaha, 2020). Based on the previous complaint of grogginess by the patient during the last visit, additional expectation was that the dose adjustment that had been instituted would stop this side effect or at least reduce it. Nevertheless, with the accompanying increase in the daily dose to 125mg, I speculated that there would be other dose-related side effects that the patient would report.
There was not much difference between the expected outcomes and what was reported by the patient. When the client returned to the clinic after four weeks, he reported that the pain had reduced to about a 4/10, and he no longer experienced morning grogginess. Additionally, he reported that he did not feel inclined to use his crutches always and that he had added significant weight since the commencement of amitriptyline therapy. This dose-related side effect can be explained by the antihistamine side effects of amitriptyline since the dosage had been increased to 125 mg.
At this point, the decision was to continue with the current daily dose of Elavil of 125 mg and refer the client to a life coach who would counsel him on appropriate dietary habits and exercise. The expectation from this decision was that the clients’ hip pain would further reduce from the reported 4/10 to the extent that he could ambulate without crutches. Further expectation was that his weight gain would be well-controlled using the diet and exercise approach and that no other dose-related side effects would be reported (Thour & Marwaha, 2020). The outcome was as expected because the patient attained a therapeutic dosage of Elavil with almost solid control of his pain.
How Ethical Considerations Impact Treatment Plans and Communication
The practice and study of medicine pose numerous ethical challenges. Especially so, the management of patients poses some difficult ethical questions. Some of these questions range from the need for pain medications, the role of pain in affecting the quality of life of patients, and the role of healthcare professionals in alleviating pain in such patients. This, therefore, requires that healthcare professionals are vast in their knowledge of pain and its management since they have a moral obligation in alleviating pain and suffering. Pain is subjective and unrelieved pain can compromise a person’s autonomy. On the other hand, pain relief can potentially protect a person’s integrity and promote dignity (Carvalho et al., 2018). Such ethical considerations ensure that healthcare professionals are able to determine the impact of pain on the quality of life of patients and further guide the next treatment plan. Further, such ethical considerations also allow the healthcare professional to have open communication and discussion with the patient to ensure that critical components of the patient’s pain are identified in order to address them appropriately.