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Chronic pain

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Middle aged lady with chronic pain , treated for many years .GP referral for depression .pain relief is opioid and non opioids .She is on amitriptyline .Assess and manage/ Mechanism of amitriptyline in relief pain?

Any one can help please

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hi paul

i assume this pmp

would be done the same as all the rest.

why refer her now?

collateral from Gp

past psych hx, and medical hx and surgical hx

origins of chronic pain

differentials

depression, dysthymia organic incl anxiety etc and rem if her chronic pain is due to an accident possible PTSD? now explore treatment resistant depression, causes, meds, doses, maintaining factors, etc

review previous meds and diagnosis and compliance

social circumstances

detailed hx of pain and mood etc

and work down this line

amitrip is an analgesic antidepressant  used in pain clinics everywhere

can be combined with pain  killers

useful if sleep disturbed as its sedating

works it is assumed  via descending tracts from the brain via noradrenaline and serotonin systems to modulate signalling of pain in the spinal cord

now can u pad this answer up the correct way?

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Middle aged lady with chronic pain , treated for many years .GP referral for depression .pain relief is opioid and non opioids .She is on amitriptyline .Assess and manage/ Mechanism of amitriptyline in relief pain?

Any one can help  please

Well, this PMP can be tricky

1. 'Chronic pain Rx years with opioid, non-opioid and AMT'

- Referral: non-effective, patient's request, 2nd-opinion, co-morbid psy Sx

- Then Ddx would be quite 'over-inclusive'

A. Pain-related: organic (autoimmune, MS), chronic-fatique / fibromyalgia / neurathesia / somatoform pain / somatisation / hypochondriasis

B. Iatrogenic-related: opioid / pain-killer dependence

C. Co-morbid / undiagnosed psy Sx: As dutchie described

2. Need to note patient's initiative / wish / motivation to our clinic

3. Others' as a typical PMP does, but as point A/B's guide you consider

- keep liase with referrer (you may not need to take over and consider risk of doctor-shopping)

- Cautious with medication (advise only, communicate w/ referrer whether further revise / Ix needed. Treat only when indicated in terms of psychiatry)

- Continue follow-up at our clinic?

- Further Ix?

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Thanks Dutchei and Joy

Is quite common that Gps prescribe opiate base pain killer , like DF118 or Codeine and then usually patients abusing these tablets , then GP referring them to drug and alcohol sevices , more difficult to treat than heroin users as they do not consider this as their fault.

I am not about the main issue here , somatisation ,psychogenic pain, depression , personality , substance misuse , organic

Any one had this PMP before ,what is probs?

Thanks

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chronic pain is realistic

ive had patients from RTA with depression and chronic pain secondary to back injury and spasm

they have been on antidepressants, gabapentin, lamotrigine and amitript

sometimes its unfair to start saying its all psychogenic

id hold my ground on this type of pmp

esp if their MrI scans show evident of injury and neurologists are involved.i suppose the issues are

1. chronic depression tackle that

2. chronic pain

3. possible addiction to pain killers .. question.. possible refer to pain clinic?

4. investigate social factors and how her problem affects her level of functioning

5. need for additional supports? can she cope? Ot assessment etc

6. Risks

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