What is the most appropriate next step in managing pain for a 42-year-old man with a gunshot wound to the left arm and a history of intravenous (IV) heroin and cocaine use, presenting with severe pain and normal vital signs, including a pulse of 90 beats per minute (tachycardia) and blood pressure of 145/90 millimeters of mercury (mmHg) (hypertension)?

From the Guidelines

The most appropriate next step in managing pain for this 42-year-old man with a gunshot wound to the left arm and history of IV drug use is to administer intravenous opioid analgesia, specifically morphine. This approach is supported by the most recent and highest quality study, which emphasizes the importance of efficient pain relief in acute care settings 1. The patient's severe pain, mild tachycardia, and hypertension justify the need for prompt analgesia. Some key points to consider in managing this patient's pain include:

• The use of multimodal analgesia, which combines different drugs and techniques to improve pain relief and reduce side effects 1
• The potential benefits of adding non-opioid medications like IV acetaminophen or ketorolac to the treatment plan, if not contraindicated 1
• The importance of closely monitoring the patient's vital signs and respiratory status while administering pain medication, particularly in light of their history of substance use disorder 2, 3
• The value of obtaining a pain management consultation to develop a comprehensive plan that addresses both the patient's acute pain needs and their underlying substance use disorder 2, 3. Given the patient's history of IV drug use, it is essential to balance the ethical obligation to treat pain with the complexities of managing analgesia in patients with substance use disorders, and morphine therapy is the most appropriate choice.

From the FDA Drug Label

If the level of pain increases after dosage stabilization, attempt to identify the source of increased pain before increasing the morphine sulfate tablets dosage Individually titrate morphine sulfate tablets to a dose that provides adequate analgesia and minimizes adverse reactions The most appropriate next step in managing pain for a 42-year-old man with a gunshot wound to the left arm and a history of intravenous (IV) heroin and cocaine use, presenting with severe pain, is Morphine therapy.

• Key considerations: + The patient has a history of substance use, which may impact pain management. + The patient is experiencing severe pain, which requires adequate analgesia. + Morphine sulfate tablets should be titrated individually to provide adequate analgesia and minimize adverse reactions 4, 5. It is essential to monitor the patient closely for signs of excessive sedation, respiratory depression, and other adverse reactions, as well as to assess for potential substance use disorders and provide appropriate treatment.

From the Research

Patient Assessment and History

• The patient is a 42-year-old man with a gunshot wound to the left arm and a history of intravenous heroin and cocaine use.
• He presents with severe pain 15 minutes after extensive debridement and application of multiple stitches.
• His vital signs are pulse 90/min and blood pressure 145/90 mmHg.
• Urine toxicology screening for opioids, cocaine, and alcohol was negative.

Pain Management Options

• Considering the patient's history of substance use, it is essential to weigh the risks and benefits of different pain management options.
• According to 6, pharmacologic management of acute pain should be tailored for each patient, and acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain.
• However, the patient's severe pain may require more potent analgesics, such as opioids, which should be used with caution due to the patient's history of substance use 6, 7.
• Alternative options, such as gabapentin and duloxetine, may be considered for neuropathic pain, but there is no indication that the patient's pain is neuropathic in nature 8.
• Peripheral nerve block may be an effective option for managing severe pain, but it may not be feasible in this scenario 9, 10.

Most Appropriate Next Step

• Given the patient's severe pain and history of substance use, the most appropriate next step in management would be to consider the use of opioids, such as morphine, while carefully monitoring the patient for signs of addiction or overdose 6, 7, 9, 10.
• Option C) Morphine therapy is the most appropriate choice, as it is a commonly used opioid for managing severe acute pain, and its use is supported by the evidence 6, 7, 9, 10.