A 50-year-old man is brought to the emergency department after a motor vehicle collision. The patient was the restrained driver when a truck hit the side of his car. His head was not injured, and he did not lose consciousness, but he had severe chest, pelvic, and leg pain with intensity rated at 10 on a scale of 10. The patient has a history of injection heroin use but has not used illicit drugs since completing a methadone rehabilitation program 15 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. An open fracture of the left leg has some external bleeding. Wound debridement and external fixation of the fracture are planned. Rib and pubic rami fractures are being managed nonoperatively. The patient is given intravenous ketorolac and acetaminophen. An hour later, his pain is 7 on a scale of 10, and he appears visibly uncomfortable. The patient requests stronger pain control. Which of the following is the most appropriate analgesic pharmacotherapy for this patient?
Acute pain management in patients with opioid use disorder | |
Environment |
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Withdrawal |
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Analgesia |
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NSAIDs = nonsteroidal anti-inflammatory drugs. | |
Pain management in patients with opioid use disorder (OUD) is uniquely challenging and has 2 seemingly competing goals:
This patient with OUD in remission has severe, acute pain due to multiple traumatic injuries unrelieved by intravenous nonopioid analgesics (eg, acetaminophen, ketorolac). Other nonopioid strategies, including regional anesthesia and adjuvant medications (eg, ketamine), are often effective for mild to moderate pain but are unlikely to provide adequate analgesia in a patient with severe, widespread pain (eg, open fracture, polytrauma).
Therefore, intravenous short-acting opioids (eg, morphine) should be offered for moderate to severe pain. In addition to rapid pain relief, these can help facilitate treatment (eg, fracture stabilization) and may paradoxically help prevent relapse; just as unrelieved pain can cause worsening addiction in patients with active OUD, it is also a relapse risk factor for patients in remission.
All patients with OUD, including those in remission (who are particularly vulnerable), should be warned that relapse is a potential opioid-related adverse effect, and every pain-management decision should be made with clear and open patient collaboration. If opioids are used, they should be followed by a distinct relapse-prevention strategy, including reengagement with opioid treatment programs if necessary.
(Choices A and B) Gabapentin, indicated for postherpetic neuralgia and frequently used for neuropathic pain, can be helpful as an adjuvant for acute pain. Tramadol is a weak opioid agonist used for mild to moderate pain. However, their slower onset of action and weak (tramadol) or absent (gabapentin) opioid receptor activity make them inadequate to relieve severe, acute pain.
(Choice C) Methadone is used for maintenance therapy in patients with OUD and is typically continued during acute pain treatment to prevent withdrawal. Its pharmacodynamics (eg, long, unpredictable half-life) limit its usefulness to chronic, rather than acute, pain.
(Choice E) Asking the patient to simply endure the pain would violate the principle of beneficence; this decision can be made only by the patient. Also, fear of unrelieved pain could jeopardize the patient-physician relationship and even increase the risk of relapse. Untreated severe pain may also result in posttraumatic stress disorder.
Educational objective:
Management of acute pain in patients with opioid use disorder begins with maximizing nonopioid analgesics, adjuvant medications, and nonopioid strategies (eg, regional anesthesia). When severe pain remains uncontrolled, opioid medications are appropriate but should be used only after shared decision-making.