What's the next step for a homeless female with abdominal pain, on Trulicity (dulaglutide) and LTG (lamotrigine), with a history of seizures, type 2 diabetes, hyperlipidemia, hypothyroidism, major depressive disorder, anxiety, and daily alcohol use?

Management of Recurrent Abdominal Pain in a Homeless Patient with Multiple Comorbidities

The next step for this 48-year-old homeless female with severe unremitting abdominal pain should be a comprehensive pain management approach with neuromodulators, specifically starting with a low-dose tricyclic antidepressant such as nortriptyline or amitriptyline, while addressing her alcohol use disorder and optimizing her current medication regimen.

Assessment of Current Situation

This patient presents with a complex clinical picture:

• Severe, unremitting abdominal pain despite normal imaging (MRCP, CTAP)
• EGD showing only mild gastritis
• Multiple comorbidities: seizures (on lamotrigine), T2DM (on dulaglutide), hyperlipidemia, hypothyroidism, major depressive disorder, anxiety
• Daily alcohol consumption
• Homelessness (social determinant affecting care)

Pain Management Strategy

First-line Approach

1. Neuromodulator therapy:

   • Start with a low-dose tricyclic antidepressant (TCA) such as nortriptyline 10-25mg at bedtime, gradually titrating up as needed 1
   • TCAs have demonstrated efficacy for abdominal pain in disorders of gut-brain interaction
   • Alternative options include SNRIs (duloxetine) or gabapentinoids (pregabalin, gabapentin) if TCAs are not tolerated 1

2. Non-opioid analgesics:

   • Consider antispasmodics (hyoscyamine, dicyclomine) for cramping pain 1
   • Peppermint oil capsules may help with pain and bloating 1
   • Avoid NSAIDs due to gastritis and alcohol use 1
   • Avoid opioids which can worsen GI symptoms and lead to dependency 1

Addressing Alcohol Use

1. Alcohol cessation counseling:
   • Daily alcohol use is likely contributing to gastritis and pain
   • Interestingly, the patient's dulaglutide (GLP-1 receptor agonist) may help reduce alcohol consumption 2
   • Consider referral to addiction services for structured support

Medication Optimization

1. Review current medications:
   • Evaluate lamotrigine dosage - can occasionally cause psychiatric symptoms including anxiety that might exacerbate pain perception 3, 4
   • Ensure dulaglutide dosing is optimized for T2DM management 5
   • Review antidepressant therapy for MDD - some antidepressants have significant GI side effects 6

Non-pharmacological Interventions

1. Brain-gut behavioral therapies:

   • Cognitive behavioral therapy has strong evidence for pain reduction in functional GI disorders 1
   • Consider referral for gut-directed hypnotherapy or mindfulness-based stress reduction 1

2. Dietary modifications:

   • Low FODMAP diet trial if symptoms suggest IBS component 1
   • Regular meal pattern despite homeless situation (connect with local resources)

Social Support Interventions

1. Housing assistance referral:

   • Homelessness complicates medication adherence and follow-up
   • Connect with social worker to explore temporary housing options

2. Care coordination:

   • Establish regular follow-up despite housing instability
   • Consider patient assistance programs for medications

Follow-up Plan

1. Schedule follow-up within 2-4 weeks to assess:
   • Response to neuromodulator therapy
   • Progress with alcohol reduction
   • Medication adherence and side effects
   • Housing situation

Common Pitfalls to Avoid

• Pursuing additional imaging without clear indications
• Starting opioid therapy for chronic abdominal pain
• Focusing solely on pain without addressing alcohol use
• Overlooking the impact of homelessness on treatment adherence
• Failing to consider medication interactions among her multiple prescriptions

By implementing this comprehensive approach that addresses pain management, substance use, and social determinants of health, we can help improve this patient's quality of life while avoiding unnecessary testing and potentially harmful treatments like opioids.