A 35-year-old woman is hospitalized following a high-speed motor vehicle collision in which she was an unrestrained passenger. She sustained multiple deep lacerations on her extremities, rib contusions, and a complex humerus fracture requiring surgical fixation. Over the next 2 days, the patient's pain is treated with oral morphine every 6 hours and nonsteroidal anti-inflammatory drugs (NSAIDs) every 4 hours. Her pain is controlled with this regimen but recurs if the interval between morphine doses is extended to 8 hours. The patient is otherwise medically stable for discharge. She is concerned about continuing to use narcotics at home to treat her pain because her cousin had a history of opioid use disorder and passed away several years earlier due to an overdose. Which of the following actions by the physician is most appropriate?

Question

A 35-year-old woman is hospitalized following a high-speed motor vehicle collision in which she was an unrestrained passenger.  She sustained multiple deep lacerations on her extremities, rib contusions, and a complex humerus fracture requiring surgical fixation.  Over the next 2 days, the patient's pain is treated with oral morphine every 6 hours and nonsteroidal anti-inflammatory drugs (NSAIDs) every 4 hours.  Her pain is controlled with this regimen but recurs if the interval between morphine doses is extended to 8 hours.  The patient is otherwise medically stable for discharge.  She is concerned about continuing to use narcotics at home to treat her pain because her cousin had a history of opioid use disorder and passed away several years earlier due to an overdose.  Which of the following actions by the physician is most appropriate?

Quizplus · Accepted Answer

11ec160b_3c57_5434_9249_fba7ebf92428_MD0001_00 Harm from opioid use (eg, overdose, addiction) represents a major patient safety concern and is the leading cause of injury-related death in young adults. Physicians should prescribe opioids only when indicated and minimize dose and duration of therapy. This patient's acute, post-traumatic pain, which is uncontrolled with NSAIDS alone (eg, she experiences breakthrough pain), is an appropriate indication for opioid therapy. Most patients with traumatic or postoperative pain have significant improvement within the first 3-5 days and may be prescribed a limited quantity of opioid medication with low risk of addiction. When prescribing opioids, physicians should apply the following strategies to promote safety and minimize potential harms: In addition, patients should receive close outpatient follow-up for pain reassessment, along with proper counseling on safe opioid use and disposal of excess medications. (Choice A) Transdermal opioids (eg, fentanyl) have similar pharmacodynamic properties as oral opioids and carry a similar risk of misuse and addiction. In general, transdermal and other long-acting opioid preparations are not recommended for acute pain in opioid-naïve patients. (Choice B) The patient is medically stable for discharge. Extending the hospitalization is unlikely to provide additional benefit, may increase harms (eg, iatrogenic infections), and represents inappropriate resource use. (Choice C) Benzodiazepines have negligible analgesic benefits and also carry a risk of addiction. (Choice D) Because this patient's family history of opioid use disorder involved a cousin rather than a first-degree relative, her personal risk of addiction is not significantly increased. Moreover, using only NSAIDs is likely to undertreat her pain; limited use of short-acting opioids for breakthrough pain is more appropriate. Educational objective: Most patients with acute pain (eg, trauma, post-operation) have significant improvement within 3-5 days and may be prescribed a brief course of opioid medication for breakthrough pain with low risk of addiction. Physicians should minimize opioid duration and dose, counsel patients on proper use, and maximize concurrent non-opioid therapies (eg, NSAIDs). __________ References: Prevention of opioid overdose (http://www.ncbi.nlm.nih.gov/pubmed/31167053)

A 35-Year-Old Woman Is Hospitalized Following a High-Speed Motor Vehicle