Evaluation:
(1) severity of the pain
(2) monitoring for symptoms of withdrawal
(3) monitoring for psychiatric comorbidities
(4) evaluating adequacy of pain control
(5) enrollment in a drug control program, including methadone maintenance
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Pain Severity
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Pain Management
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mild
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NSAIDS, acetaminophen with codeine
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moderate
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NSAIDS, acetaminophen with opioids, cox-2 inhibitors; parenteral pain medications as needed
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severe
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parenteral opioids (preferably patient controlled analgesia, or scheduled parenteral opioids with as needed doses) then switch to long acting oral preparations as pain improves, followed by gradual tapering
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Abused substances with the potential for withdrawal include ethanol, barbiturates, benzodiazepines, amphetamines, cocaine, and opioids. Daily abuse and a history of previous withdrawal episode(s) can help identify a patient at increased risk for withdrawal.
A patient in a methadone maintenance program should be maintained on the current methadone dosage after verifying details with a physician in the program.
Complaints of persistent pain may reflect:
(1) inadequate pain control
(2) withdrawal symptoms
(3) psychiatric problems, especially anxiety and depression
With recovery from acute injury then the patient requires:
(1) substance abuse counseling
(2) psychiatric evaluation
