Management of Acute Pain and Opioid Addiction in the Emergency Department
Initial Pain Management Orders
This patient is experiencing opioid withdrawal, not just acute pain, and requires immediate aggressive multimodal analgesia with continuation of baseline opioid requirements before attempting to achieve additional analgesia. 1
Immediate Orders:
Verify current opioid regimen with the pain clinic and continue baseline opioid requirements (OxyContin 20 mg BID) to prevent worsening pain from withdrawal-induced hyperalgesia 1
Administer scheduled short-acting opioids at higher doses and shorter intervals than typical due to cross-tolerance—consider oxycodone 10-15 mg every 3-4 hours scheduled (not PRN), as allowing pain to reemerge causes unnecessary suffering and increases patient-provider tension 1, 2
Implement aggressive non-opioid multimodal analgesia: NSAIDs (ketorolac 30 mg IV if no contraindications), acetaminophen 1000 mg PO/IV every 6 hours, and continue Lyrica 100 mg which serves as an adjuvant analgesic 1, 2, 3
Antiemetic therapy: Ondansetron 4-8 mg IV (avoid metoclopramide initially due to extrapyramidal symptom risk with chronic use) 4
Monitor respiratory status and level of consciousness frequently when adding opioids, given the risk of respiratory depression 1, 5
Prescribe naloxone for home use given his substance use disorder history and increased overdose risk 2
Critical Pitfall to Avoid:
Do not use mixed agonist-antagonist opioids (buprenorphine, nalbuphine, butorphanol) as these will precipitate withdrawal in opioid-dependent patients 1, 2
Diagnosis of GI Symptoms
The patient's nausea, vomiting, diffuse abdominal pain, piloerection, and diaphoresis represent opioid withdrawal syndrome, not a primary gastrointestinal pathology. 5
Clinical Reasoning:
Opioid withdrawal symptoms include: nausea, vomiting, abdominal cramps, diarrhea, diaphoresis, piloerection, restlessness, anxiety, dilated pupils, tachycardia, and body aches 5
This patient has been without his prescribed opioids for 2 days after rapid consumption due to increased pain, creating the classic presentation of withdrawal 5
The timing (2 days without medication) and constellation of symptoms (GI symptoms plus piloerection and diaphoresis) confirm withdrawal rather than acute abdomen or other GI emergency 1, 5
Important Distinction:
While opioid-induced constipation and nausea can occur during opioid therapy, this patient's symptoms represent the opposite phenomenon—withdrawal-related GI hyperactivity 5, 6
Response to Methadone Request and Prescribing Authority
You cannot and should not prescribe methadone for opioid addiction treatment in the emergency department, as federal regulations restrict methadone for addiction treatment to certified opioid treatment programs only. 7, 5
Regulatory Framework:
Methadone for addiction treatment requires enrollment in a federally certified Opioid Treatment Program (OTP) with specific licensing and cannot be prescribed in typical outpatient or ED settings 7
As an AGACNP, you can prescribe methadone for acute pain management in the inpatient setting, but this does not address his underlying opioid use disorder and carries significant risks including QT prolongation, respiratory depression, and complex drug interactions 5
Methadone maintenance therapy does not provide analgesia for acute pain—it only addresses baseline opioid requirements for addiction treatment, requiring separate analgesic strategies 7, 2, 5
Appropriate Response to Patient:
Acknowledge his request positively as it demonstrates motivation for treatment 7
Explain that methadone for addiction requires specialized program enrollment, which you will facilitate through addiction medicine consultation 7
Reassure him that his pain will be aggressively treated and his admission will allow comprehensive addiction treatment planning 1
Consider buprenorphine as an alternative, which can be prescribed by qualified providers (with DATA 2000 waiver, though recent regulations have relaxed some requirements) and offers lower overdose risk with greater prescribing flexibility 7
Ethical and Professional Concerns
This ACNP colleague is practicing while impaired by opioid use disorder, creating immediate patient safety concerns and mandatory reporting obligations.
Immediate Ethical Obligations:
Patient safety is paramount—an impaired practitioner poses direct risk to patients under his care and cannot practice safely 2
Mandatory reporting to the state board of nursing and his employer is required in most jurisdictions when a healthcare provider is impaired 2
Duty to report supersedes colleague loyalty when patient safety is at risk—failure to report may constitute professional misconduct 2
Professional Concerns:
Diversion of controlled substances from his own prescriptions (using medications faster than prescribed) raises questions about potential diversion from workplace or patients 2
Prescribing to self or having inappropriate access to controlled substances through his ACNP role requires investigation 2
Impaired judgment and decision-making affects his ability to provide safe patient care, particularly in acute care settings 2
Compassionate Approach:
Frame reporting as facilitating treatment rather than punishment—most state boards have provider health programs offering confidential monitoring and treatment 2
Emphasize that addiction is a treatable medical condition and recovery is possible with appropriate intervention 7, 2
Prescription Drug Monitoring Resources
Utilize your state's Prescription Drug Monitoring Program (PDMP) immediately to assess this patient's controlled substance history and identify potential diversion or doctor shopping.
Available Resources:
State PDMP database: Check all controlled substance prescriptions filled in your state and increasingly across state lines through interstate data sharing 2
Real-time tracking: Most PDMPs update within 24-48 hours of prescription dispensing, showing dates, quantities, prescribers, and pharmacies 2
Red flags to identify: Multiple prescribers, early refills, overlapping prescriptions, high morphine milligram equivalents (MME), and dangerous drug combinations (opioids plus benzodiazepines) 2
Additional Monitoring Tools:
Urine drug screening: Order comprehensive testing including prescribed medications (to confirm use vs. diversion) and illicit substances 2
Treatment agreements: Document clear expectations for controlled substance use, including single prescriber/pharmacy, random drug testing, and consequences for misuse 2
Frequent follow-up: Evaluate benefits and harms within 1-4 weeks of any dose change when managing chronic pain with opioids 2
Emergency Department Referrals
Arrange immediate addiction medicine consultation and coordinate inpatient admission with integrated multidisciplinary care.
Essential Referrals:
Addiction medicine or psychiatry consultation: Initiate buprenorphine or arrange OTP enrollment for methadone maintenance therapy 7, 2
Pain management specialist: Address complex chronic pain with failed back surgery syndrome requiring multimodal non-opioid strategies 2, 3
Behavioral health/psychology: Treat comorbid depression (on Lexapro) and anxiety (on Xanax), which worsen pain perception and addiction risk 1, 2
Social work: Assess occupational disability, financial stressors, and coordinate outpatient addiction treatment resources 2
State board of nursing notification: Report impaired practitioner through appropriate channels (may be handled by hospital administration/legal) 2
Provider health program referral: Connect him with confidential monitoring and treatment programs for healthcare professionals with substance use disorders 2
Inpatient Coordination:
Integrated care team approach with frequent communication between addiction specialists, pain management, behavioral health, and primary team 2
Palliative care consultation may be appropriate for complex pain management in the context of addiction 2
At-Risk Populations for Addiction and Diversion
Healthcare professionals, particularly those with access to controlled substances, face elevated risk for opioid use disorder, along with patients having chronic pain, psychiatric comorbidities, and prior substance use history.
High-Risk Populations:
Healthcare workers (physicians, nurses, pharmacists, ACNPs) have higher rates of substance use disorders due to access, knowledge, and occupational stress 2
Chronic pain patients with inadequate pain control may escalate use seeking relief (pseudoaddiction) or develop true addiction 1
Psychiatric comorbidities: Depression, anxiety, PTSD, and personality disorders increase addiction risk and complicate pain management 1, 2
Prior substance use disorder: Personal or family history of addiction significantly increases risk 1, 2
Younger age at first opioid exposure and prolonged high-dose opioid therapy increase addiction risk 2
Pain Medication Diversion Risk Factors:
Financial stress or unemployment may motivate selling prescribed medications 2
Social networks with substance use increase diversion opportunities 2
Multiple prescribers or pharmacies (doctor shopping) indicates potential diversion 2
Hyperalgesia and Adverse Reactions:
Opioid-induced hyperalgesia: Paradoxical increased pain sensitivity from chronic opioid exposure, creating a vicious cycle of dose escalation 1, 2
Patients with addiction demonstrate lower pain tolerance than those in remission, creating a "syndrome of pain facilitation" 1, 2
Resources for Healthcare Providers with Addiction
State provider health programs offer confidential monitoring, treatment coordination, and advocacy for healthcare professionals with substance use disorders, with the goal of facilitating recovery while protecting public safety.
Primary Resources:
State provider health programs (also called physician health programs or professional assistance programs): Confidential evaluation, treatment referral, monitoring, and advocacy with licensing boards 2
Substance Abuse and Mental Health Services Administration (SAMHSA): National helpline (1-800-662-4357) provides 24/7 treatment referral and information 7
American Nurses Association Peer Assistance Programs: Specific resources for nurses and nurse practitioners with substance use disorders 2
Treatment Options:
Medication-assisted treatment with buprenorphine or methadone: Reduces mortality by approximately two-thirds, with methadone showing 11.3 vs. 36.1 deaths per 1,000 person-years in vs. out of treatment 7
Intensive outpatient programs (IOP) or residential treatment facilities specializing in healthcare professionals 7, 2
Peer support groups: Caduceus groups, International Doctors in Alcoholics Anonymous, and similar organizations for healthcare professionals 2
Return to Practice:
Structured monitoring programs allow many healthcare professionals to return to practice safely with ongoing accountability, random drug testing, and practice restrictions 2
Retention in treatment is essential—the 4 weeks immediately after treatment cessation carry mortality risk exceeding 30 deaths per 1,000 person-years 7