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Pain Case Study

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Ms. Kelly is a nondrinker, smokes five cigarettes per day and uses recreational grade cannabis for pain and sleep daily.

On admission, Ms. Kelly complained of low back pain ranging in intensity from 7 to 8, out of 10, on the pain scale where 0 is no pain and 10 is the worst imaginable pain. She subjectively describes this pain as throbbing, stabbing, burning and radiating along the posterior and anterior aspect of both upper legs, left worse than right. She has sharp, stabbing, burning pain in both her arms, particularly the left arm, and experiences intermittent tingling and numbness sensations in both her hands as well. She has pain in her neck and shoulder that she defines as tension-type pain. Factors that can aggravate the
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To treat symptoms of insomnia or anxiety, she has had trials of lorazepam, clonazepam and temazepam, and in 2016, quetiapine in doses of 25-50mg per day was prescribed.
In reviewing medications, Ms. Kelly mentioned that many of the drugs previously prescribed were either not effective in relieving the pain or caused her to feel unwell. While taking morphine, she frequently experienced stomach upset, nausea and constipation. In the past year, she decided on her own initiative to wean herself off morphine and she does not plan to resume taking opioids for her chronic pain problems.
Past trials of adjuvant pain medications may have failed to control the pain because of factors such as a sub-therapeutic dose or duration of the medication. We reviewed the role of duloxetine in the management of both neuropathic and nociceptive pain conditions and recommended a retrial of this SNRI, which she agreed was appropriate. A two-week trial of duloxetine, 30mg/day was initiated. Since she tolerated this well, her dose was increased to 60mg/day, which is the usual effective dose for both pain and mood.
During her admission, we also discussed trialing a course of oral cannabinoids as an alternative treatment as she does have chronic pain
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