A 37-year-old man is brought to the emergency department by ambulance 20 minutes after he was hit by a motor vehicle while crossing the street. At the scene of the accident, he was awake, alert, and in considerable distress. On initial assessment, temperature is 36.7 C (98 F), blood pressure is 154/88 mm Hg, pulse is 108/min, and respirations are 31/min. There is an open fracture of the right femur. Chest radiograph shows several fractured ribs. Medical history is significant for opioid use disorder. The patient has undergone a drug rehabilitation program and successfully tapered off all opioids 2 years ago. He is given acetaminophen and ketorolac but continues to rate his pain as 6-7 on a scale of 0-10. Which of the following is the most appropriate next step in management of this patient's acute pain?

Question

A 37-year-old man is brought to the emergency department by ambulance 20 minutes after he was hit by a motor vehicle while crossing the street.  At the scene of the accident, he was awake, alert, and in considerable distress.  On initial assessment, temperature is 36.7 C (98 F), blood pressure is 154/88 mm Hg, pulse is 108/min, and respirations are 31/min.  There is an open fracture of the right femur.  Chest radiograph shows several fractured ribs.  Medical history is significant for opioid use disorder.  The patient has undergone a drug rehabilitation program and successfully tapered off all opioids 2 years ago.  He is given acetaminophen and ketorolac but continues to rate his pain as 6-7 on a scale of 0-10.  Which of the following is the most appropriate next step in management of this patient's acute pain?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c044_885b_8f63_d9ed09b1503d_MD0005_00 This patient with opioid use disorder (OUD) is notable for having maintained abstinence after tapering off opioid agonists (in contrast to most patients with OUD who require long-term medication-assisted treatment). Acute pain management in such patients is challenging because they are particularly vulnerable to relapse, which can be life threatening and triggered by a single dose of opioids. Therefore, they must be warned about the risk of relapse with opioid treatment. Although severe pain (eg, open fracture) may limit the time available to formalize an opioid treatment agreement, every pain-management decision must be made with patient collaboration due to this risk. If the patient desires to completely avoid opioids due to fear of relapse, this decision must be respected, and every attempt must be made to ensure the patient does not feel abandoned. In addition to nonopioid analgesics (eg, ketorolac), a multimodal pain strategy including adjuvant medications (eg, ketamine) and regional anesthesia (eg, peripheral nerve blockade) should be attempted, even if it is less effective for severe pain. If the patient chooses opioid therapy, the partial opioid agonist buprenorphine can be useful for mild to moderate pain because it limits opioid-induced euphoria, which may reduce relapse risk. However, full opioid agonists are usually needed for more severe pain. Pain specialist consultation can be helpful if available. When opioid therapy is used in patients with OUD, it should be followed by a relapse-prevention strategy, including reengagement with opioid treatment programs if necessary. (Choices A and B) Abstinent patients with OUD lose all opioid tolerance within weeks to months of cessation. Patients who choose opioid therapy after discussion of the risks should be treated with the same doses as opioid-naïve patients. (Choice D) Letting the patient experience pain would violate the principle of beneficence; this decision can only be made by the patient. Also, fear of unrelieved pain can jeopardize the patient-physician relationship and even increase the risk of relapse. (Choice E) Gabapentin, indicated for postherpetic neuralgia and frequently used for neuropathic pain, can be helpful as an adjuvant for acute pain; however, it is unlikely to provide adequate relief as monotherapy for severe pain. Educational objective: Due to the life-threatening risk of relapse, the use of opioids in abstinent patients with opioid use disorder requires a clear discussion of the risks, even in the setting of severe pain. If the patient chooses nonopioid management, a multimodal strategy including nonopioid analgesics, adjuvant medications, and regional anesthesia should be attempted. References: Acute pain management in patients with drug dependence syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/29392226)

A 37-Year-Old Man Is Brought to the Emergency Department by Ambulance