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April 2010, Volume 40 Number 4 , p 48 - 51


  • Yvonne D'Arcy MS, CRNP, CNS


Sam Jones, 62, has been admitted to your facility for low back pain radiating down both legs. For the past few months, he's been seeing a pain management specialist for chronic back pain, which suddenly worsened when he tried to move several heavy boxes. He rates the pain as an 8 on a pain intensity rating scale of 0 (no pain) to 10 (worst pain imaginable).The pain specialist had prescribed 80 mg of extended-release oxycodone twice a day plus 10 mg of oxycodone for breakthrough pain every 4 hours as needed. Mr. Jones had been using his breakthrough medication regularly before his admission for a potential daily maximum dose of 220 mg of oxycodone.After admission, Mr. Jones is prescribed hydromorphone via a patient-controlled analgesia (PCA) pump ordered at 0.2 mg every 10 minutes. No oral medications are prescribed for him. When you check the PCA pump settings at the 4-hour time period, you find that Mr. Jones has made 54 attempts and received 20 doses. He rates his pain as a 9/10.He tells you, "My back and legs hurt so much. I can't eat, sleep, or concentrate." What's wrong with Mr. Jones' pain management?This story is typical of what can happen to a patient being treated for chronic pain who's admitted to the hospital. Because of long-term opioid use, patients like Mr. Jones can become opioid-dependent. When admitted to an acute care setting, these patients may be prescribed less opioid medication than they normally take or be continued on their regular dosage even though their pain intensity levels have increased.Opioid-dependent patients undergoing surgery often don't receive enough medication to control acute postoperative pain. Dosages based on an opioid-naïve patient's medication tolerance won't be sufficient to relieve acute pain in patients accustomed to taking large opioid doses to manage chronic pain.Many healthcare providers are afraid that prescribing higher opioid dosages may lead to addiction which, in turn, can affect

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