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.
- What is your presumptive diagnosis of this patient and what evidence supports your diagnosis?
- 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?
- 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.
- Provide a specific plan of care for the patient: specific medications, doses, important educational points, and important monitoring points.
- What non-pharmacological advice would you offer this patient?