From the Guidelines
I strongly recommend continuing the patient's home medications (Robaxin, gabapentin, Seroquel, mirtazapine, and MS Contin) while she is hospitalized, with careful evaluation and monitoring, as medication continuity is crucial for managing her chronic conditions and preventing withdrawal, as supported by the CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1.
When considering the management of the patient's chronic pain, it is essential to weigh the benefits and risks of continuing her home medications. The patient's history of substance abuse, depression, and suicidal ideation makes it critical to avoid abrupt discontinuation of psychiatric medications or opioids, which could precipitate withdrawal or worsen her mental health 1.
The patient's current presentation of left leg pain, slurred speech, and dysarthria requires urgent evaluation to rule out stroke or other neurological conditions before attributing them to medication effects. Some of these medications, particularly MS Contin (morphine) and Seroquel (quetiapine), can cause sedation and potentially worsen speech issues 1.
A thorough medication reconciliation with the caregiver is necessary to confirm exactly what she takes at home. The CDC guideline recommends that clinicians should determine with patients how functional benefit will be evaluated and establish treatment goals, which can include improvement in function, pain, and quality of life 1.
Given the potential risks and benefits, it is crucial to continue the patient's home medications while closely monitoring her condition and adjusting the medications as needed to balance the management of her chronic pain and psychiatric conditions with her acute presentation. The guideline also emphasizes the importance of patient education and discussion before starting opioid therapy, including reviewing available low-cost options for pain management, being explicit and realistic about expected benefits, and advising patients about serious adverse effects of opioids 1.
In terms of specific medications, gabapentin, which the patient is currently taking, has been shown to be effective in the treatment of neuropathic pain, with a study published in the Mayo Clinic Proceedings in 2010 recommending it as a first-line treatment for neuropathic pain 2. Additionally, a study published in the Annual Review of Medicine in 2018 found that gabapentin and pregabalin are considered first-line anticonvulsants for the treatment of neuropathic pain other than trigeminal neuralgia 3.
Overall, continuing the patient's home medications while carefully evaluating and monitoring her condition is the most appropriate course of action, given the potential benefits and risks of these medications.
From the FDA Drug Label
Call your healthcare provider or get emergency medical help right away if you or your family member have any of the following symptoms, especially if they are new, worse, or worry you: • attempts to commit suicide • acting aggressive, being angry or violent • new or worse depression • panic attacks • new or worse irritability • an extreme increase in activity or talking (mania) • acting on dangerous impulses • thoughts about suicide or dying • new or worse anxiety • feeling very agitated or restless • trouble sleeping • other unusual changes in behavior or mood
Do not start or stop any other medicines during treatment with mirtazapine tablets without talking to your healthcare provider first. Stopping mirtazapine tablets suddenly may cause you to have serious side effects.
The patient is taking mirtazapine and has a history of depression and substance abuse. Given the patient's history and current symptoms, including anxiety, it is crucial to exercise caution when considering continuing their home medications.
- The patient's medication regimen should be carefully evaluated by their healthcare provider, Dr. Yeung, to ensure that it is safe and effective for their current condition.
- The patient's anxiety and other symptoms should be closely monitored, and any changes to their medication regimen should be made under the guidance of their healthcare provider.
- It is essential to consider the potential risks and benefits of continuing the patient's current medications, including mirtazapine, and to weigh these against the potential risks of stopping or changing their medications.
- The patient's healthcare provider should be consulted before making any changes to their medication regimen, and the patient should be closely monitored for any signs of adverse reactions or worsening symptoms 4.
From the Research
Medication Review
The patient is currently taking several medications, including:
- Robaxin
- Gabapentin
- Seroquel (quetiapine)
- Mirtazepine
- MS Contin
Considerations for Continuing Medications
Given the patient's history of substance abuse, it is essential to carefully consider the potential risks and benefits of continuing certain medications.
- The use of quetiapine (Seroquel) has been associated with a risk of abuse, particularly in individuals with a prior history of substance abuse 5.
- However, quetiapine may also be beneficial in treating substance use disorders, as well as other psychiatric conditions such as bipolar disorder and schizophrenia 5.
Next Steps
The caregiver will be contacted to remove any medications the patient is not currently taking from the list.
- The patient's medication record was updated just before shift change due to anxiety over not taking her home medications.
- It is crucial to weigh the potential benefits of continuing the patient's current medications against the risks, particularly given her history of substance abuse.