What is the best course of action for a patient with diffuse pain, normal lab tests (Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), lactic acid), and negative Magnetic Resonance Imaging (MRI) of the spine, who has previously been discharged with Dilaudid (hydromorphone) and now returns with severe pain?

Management of Recurrent Severe Diffuse Pain with Negative Workup

This patient requires immediate reassessment for missed serious pathology, discontinuation of repeated opioid discharges, and implementation of a comprehensive pain management strategy that addresses potential opioid-induced hyperalgesia and underlying psychosocial factors.

Critical Red Flags to Reassess Immediately

This pattern of recurrent presentations demands urgent re-evaluation for conditions that may have been missed:

• Vertebral osteomyelitis/discitis can be MRI-negative in early stages and requires high clinical suspicion with repeat imaging if infection is suspected, particularly given the diffuse nature of pain 1
• Stress fractures may not appear on initial MRI and can cause severe pain with normal initial imaging, requiring repeat MRI in 10-14 days if clinical suspicion remains high 1
• Cauda equina syndrome must be excluded with specific questioning about urinary retention (90% sensitivity), saddle anesthesia, bilateral leg weakness, or bowel dysfunction 2, 3
• Spinal malignancy should be reconsidered, especially if the patient has constitutional symptoms, night pain that doesn't improve with rest, or history of cancer 1, 3

The Problem with Repeated Dilaudid Discharges

Continuing to discharge this patient with Dilaudid is inappropriate and potentially harmful:

• The FDA label explicitly states Dilaudid should be "reserved for use in patients for whom alternative treatment options are inadequate" and "should not be used for an extended period of time unless pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate" 4
• Repeated opioid administration without addressing underlying pathology or implementing multimodal pain management violates the principle that opioids should be used "for the shortest duration consistent with individual patient treatment goals" 4
• Opioid-induced hyperalgesia may be developing, where the opioid itself paradoxically increases pain sensitivity, explaining why pain returns despite repeated opioid administration 1
• This pattern suggests either missed pathology, inadequate pain management strategy, or behavioral factors that require different intervention 1

Immediate Diagnostic Steps

Before any further opioid administration, obtain:

• Detailed pain characterization: Location, quality (aching vs burning suggests neuropathic), radiation pattern, exacerbating/relieving factors, and functional impact 1
• Comprehensive psychosocial assessment: Patient distress, psychiatric history, risk factors for aberrant medication use, and meaning of pain to the patient 1
• Inflammatory markers: ESR and CRP to evaluate for occult infection or inflammatory process that may not yet show on MRI 1
• Repeat MRI with contrast if any clinical features suggest infection (fever, recent infection, immunocompromised state) or malignancy, as initial MRI may have been too early to detect pathology 1

Appropriate Management Strategy

Implement a structured approach that does NOT rely on repeated opioid discharges:

Acute Pain Management in Hospital

• Multimodal analgesia: NSAIDs (if not contraindicated) combined with acetaminophen as first-line agents 5
• If opioids are necessary for severe pain, use scheduled dosing rather than PRN to prevent clock-watching behavior, but plan transition off opioids before discharge 1
• Consider non-pharmacologic interventions including physical therapy consultation while hospitalized 2

Discharge Planning

• Do NOT discharge with opioids alone - this has failed twice already and suggests either wrong diagnosis or wrong treatment approach 4
• Arrange urgent follow-up with pain management (within 1 week, not routine scheduling) for comprehensive evaluation 3
• Provide structured physical therapy referral with specific focus on functional restoration 2
• Consider psychiatric or psychology consultation if psychosocial factors are contributing 1

Alternative Diagnoses to Consider

• Sacroiliac joint dysfunction or piriformis syndrome can cause diffuse pain mimicking radiculopathy with normal MRI 2
• Myofascial pain syndrome may present with diffuse pain and normal imaging 2
• Central sensitization or chronic pain syndrome may be developing, particularly given recurrent presentations 1

Documentation and Communication

Critical for this admission:

• Document comprehensive pain assessment including psychosocial factors and medication use history 1
• Clearly communicate to the patient that repeated opioid use is not appropriate long-term management and discuss realistic expectations 2
• Check prescription drug monitoring program (PDMP) to assess for concurrent opioid prescriptions from other providers 4
• Establish clear discharge plan with specific follow-up rather than allowing patient to return to ED for pain management 3

When Opioids Are Contraindicated

This patient's pattern suggests opioids are NOT the answer:

• Three presentations with same complaint despite opioid treatment indicates treatment failure 1
• Risk of addiction, abuse, and misuse increases with repeated opioid exposure without addressing underlying cause 4
• Normal labs and imaging make serious pathology less likely, shifting focus to functional restoration rather than pharmacologic management 2, 3