Decision Point One
Savella  12.5 mg once daily on day 1; followed by 12.5 mg BID on day 2 and 3;  followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client comes into the office to without crutches but is limping a  bit. The client states that the pain is “more manageable since I started  taking that drug. I have been able to get around more on my own. The  pain is bad in the morning though and gets better throughout the day”.  On a pain scale of 1-10; the client states that his pain is currently a  4. When asked what pain level would be tolerable on a daily basis, the  client states, “I would rather have no pain but don’t think that is  possible. I could live with a pain level of 3.”. When questioned  further, the PMHNP asks what makes the pain on a scale of 1-10 different  when comparing a level of 9 to his current level of 4?”. The client  states that since using this drug, I can get to a point on most days  where I do not need the crutches. ” The client is also asked what would  need to happen to get his pain from a current level of 4 to an  acceptable level of 3. He states, “If I could get to the point everyday  where I do not need the crutches for most of my day, I would be happy.”
•  Client states that he has noticed that he frequently (over the  past 2 weeks) gets bouts of sweating for no apparent reason. He also  states that his sleep has “not been so good as of lately.” He does  complain of nausea today
•  Client’s blood pressure and pulse are recorded as 147/92 and 110  respectively. He also admits to experiencing butterflies in his chest.   The client denies suicidal/homicidal ideation and is still future  oriented

Decision Point Two
 Continue with current medication but lower dose to 25 mg twice a day  
RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client comes to office today with use  of crutches. He states that his current pain is a 7 out of 10. “I do not  feel as good as I did last month.”
• Client states that he is sleeping at night but woken frequently from pain down his right leg and into his foot
• Client’s blood pressure and heart rate recorded today are 124/85 and 87 respectively. He denies any heart palpitations today
• Client denies suicidal/homicidal ideation but he is discouraged about the recent slip in his pain management and looks sad

Decision Point Three
 Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME 

Guidance to Student
The client has a complex neuropathic  pain syndrome that may never respond to pain medication. Once that is  understood, the next task is to explain to the client that pain level  expectations need to realistic in nature and understand that he will  always have some level of pain on a daily basis. The key is to manage it  in a manner that allows him to continue his activities of daily living  with as little discomfort as possible. Next, it is important to explain  that medications are never the final answer but a part of a complex  regimen that includes physical therapy, possible chiropractic care, heat  and massage therapy, and medications. Savella is a SNRI that also  possesses NMDA antagonist activity which helps in producing analgesia at  the site of nerve endings. It is specifically marketed for fibromyalgia  and has a place in therapy for this gentleman. Tramadol is never a good  option along with other opioid type analgesics. Agonists at the Mu  receptors does not provide adequate pain control in these types of  neuropathic pain syndromes and therefore is never a good idea. It also  has addictive properties which can lead to secondary drug abuse.  Reductions in Savella can help control side effects but at a cost of  uncontrolled pain. It is always a good idea to start with dose  reductions during parts of the day that pain is most under control. The  addition of Celexa with Savella needs to be done cautiously. Both  medications inhibit the reuptake of serotonin and can, therefore, lead  to serotonin toxicity or serotonin syndrome.