A 40-year-old man is brought to the emergency department after a motor vehicle collision. He was the restrained driver when his car was hit on the side by a truck. He did not injure his head or lose consciousness but had severe left leg pain with intensity rated at 10 out of 10. The patient has a history of injection heroin use but has not used any illicit drugs since completing a methadone rehabilitation program 2 years ago. Temperature is 37.1 C (98.8 F), blood pressure is 147/86 mm Hg, pulse is 114/min, and respirations are 18/min. There is an open fracture of the left leg with some external bleeding but no other injuries. Wound debridement and external fixation of the fracture are planned. The patient is given a dose of intravenous ketorolac. One hour later, his pain is persistent. Which of the following is the most appropriate analgesic pharmacotherapy for this patient?

Question

A 40-year-old man is brought to the emergency department after a motor vehicle collision.  He was the restrained driver when his car was hit on the side by a truck.  He did not injure his head or lose consciousness but had severe left leg pain with intensity rated at 10 out of 10.  The patient has a history of injection heroin use but has not used any illicit drugs since completing a methadone rehabilitation program 2 years ago.  Temperature is 37.1 C (98.8 F), blood pressure is 147/86 mm Hg, pulse is 114/min, and respirations are 18/min.  There is an open fracture of the left leg with some external bleeding but no other injuries.  Wound debridement and external fixation of the fracture are planned.  The patient is given a dose of intravenous ketorolac.  One hour later, his pain is persistent.  Which of the following is the most appropriate analgesic pharmacotherapy for this patient?

Quizplus · Accepted Answer

This patient has acute nociceptive pain due to obvious trauma and has had no relief with an intravenous nonsteroidal anti-inflammatory drug (eg, ketorolac). In patients with current or recovering opioid use disorder, studies suggest that providers may undertreat pain in such circumstances due to fear of exacerbating the disorder. Initial management options for acute pain (including opioids) are generally similar for all patients (eg, starting with nonopioids such as ketorolac, a nonsteroidal anti-inflammatory drug), regardless of substance use history. However, patients with current or recovering opioid use disorder who are given opioid analgesics may need close follow-up care to monitor pain relief and avoid relapse. For this patient, intravenous morphine is an appropriate treatment option and should be offered following discussion of potential benefits and risks. (Choice A) Parenteral (intravenous or intramuscular) ketorolac is indicated for the short-term treatment of severe pain. It has peak effectiveness at 3 hours and can be given every 4-6 hours. More frequent dosing intervals are not recommended. (Choice B) Intravenous acetaminophen is primarily given to patients with mild or moderate pain who are unable to take oral or rectal preparations. For patients with severe pain, it is usually administered with opioid analgesics. (Choices D, E, and F) Transdermal fentanyl is indicated for long-term management of pain in patients who require daily, continuous pain relief. Methadone is used in maintenance therapy for patients with opioid use disorder and is occasionally used for its analgesic effects in patients with chronic pain. Gabapentin is indicated for postherpetic neuralgia and is frequently used as adjunctive therapy for other chronic (especially neuropathic) pain. The onset of action of these drugs is too slow for use in acute pain. Educational objective: Management options for acute pain (including opioids) will be similar for all patients regardless of substance use history, although those with a history of opioid use disorder who are given opioid analgesics may need close follow-up care to avoid relapse. References: Challenges in using opioids to treat pain in persons with substance use disorders. (http://www.ncbi.nlm.nih.gov/pubmed/18497713)

A 40-Year-Old Man Is Brought to the Emergency Department After